Adults Final 2015: Vision Flashcards
What are the foundational skills in Warren’s Hierarchy for Visual Perceptual Development?
oculomotor control: ability to move the eyes in tandem to produce single visual image (binocularity)
visual field: what you see without moving your head
visual acuity: sharp vision; function of fovea in retina
Why is Warren’s Hierarchy useful?
It is a development framework for eval/tx of visual-perceptual deficits. Higher skills build on lower ones and are impacted by disruption of lower skills. Tx addresses lower skills to help restore higher ones.
Diplopia:
- double vision, often due to problem w oculomotor function
- usually resolves on its own but improves faster w eye patch on weaker eye, and hemi-taped glasses
What are the six extra ocular muscles and their functions on the eyeball (from neutral)?
- medial rectus - adduction
- lateral rectus - abduction
- superior rectus - elevation
- inferior rectus - depression
- superior oblique - intorsion (superior part of eyeball toward nose)
- inferior oblique - extorsion
Visual acuity deficits:
- inability to focus image on retina (trauma)
- inability of retina to process image (disease)
- inability of optic nerve to transmit image (trauma, disease)
►7 visual acuity interventions:
- increase: background contrast, lighting (2)
- reduce: background patterns, clutter (2)
- enlarge objects, organize materials, use community resources for compensatory strategies (3)
Visual field deficits:
loss of vision in part of normal field of view:
- anopsias such as hemianopsias (most common w stroke) and quadrantanopsia
- scotoma (blind spot)
What is hemianopsia?
a deficit in which each eye loses half its visual field
Three types of hemianopsia:
Binasal: loss of nasal half of vision in both eyes
Bi temporal: loss of temporal half of vis. in both
Homonymous: loss of same half of each eye
VFD cause and impact:
Cause: often stroke/tbi
Impact: client gets dependent on perceptual fill-in (AKA perceptual completion) so is unaware of what’s really there; visual search function slow and delayed; can produce anxiety
►VFD intervention using mobility:
- help client increase distance, speed, frequency of head turning (for vis. search)
- organize the scanning strategy
- encourage detection of objects in the VFD
- encourage attention to objects
- practice shift of attention from central to peripheral fields, esp. in VFD area
►scanning activities for mobility:
- “I see something (color)”; client has to find it
- “narrative walk” - describe what you see on client’s blind side
- mall walks
- hazard identification (steps, curbs, holes in the street, etc.)
- landmark identification
►VFD intervention: reading
- pre-reading exercises to adapt saccade strategies
- practice reading w large-print text
- visual cues to identify L or R margin
- use of fingertip or pen to follow the line
- tracing the line
- practicing writing checks or addressing envelopes with new strategies
- increase lighting, contrast
- reduce patterns in background, clutter
- organize reading environment
Unilateral neglect (UN):
- attentional disorder, often after stroke & on L
- reduced perception of stimuli contralateral to brain lesion
- associated neglect of limbs, sensory input
- high correlation w parietal lesions
- poor rehab outcomes
effects of neglect
- asymmetrical visual search patterns
- client misses info on L side
- fixates on most peripheral vis. stimuli on R side
- client doesn’t re-scan independently
UN severity level/ways of classifying:
- by what behavior is manifested: hemi-inattention, hemi-sensory inattention, visuo-spatial neglect, representational neglect
- by WHAT is being neglected: peri-personal inattention/neglect, peri-spatial inattention/neglect
►behavioral indicators of neglect
- unsymmetrical weight-bearing
- difficulty initiating movement on L or turning to L
- bumping into things on L
- reduced L arm swing
- failure to check placement of limbs before transfer
- Pusher syndrome
evaluating neglect:
Specialist needed for neuro-opthalmic evals, but these OT screens can determine referral needs:
- visual attention, field, acuity
- oculomotor control, ocular ROM
- fixation, vergence, alignment
- visual pursuit, tracking, saccades
►Cancellation tests (to evaluate neglect)
multiple variations, including:
- star cancellation from multiple symbol chart
- double letter cancellation from random letters list (e.g. find all Es AND Rs)
- line bisection tests
other ways to evaluate visual-perceptual problems:
drawing and copying designs such as flower, house, tree, clock
►Interventions overview (for neglect):
- saccadic eye movement training
- neck muscle vibration (TENS)
- trunk rotation
- proprioceptive input
- optokinetic stimulation
- limb activation - visuo-motor cueing with tool use
- patching/occlusion
- prism use & adaptation
- scanning
- imagery (?)
- common visual and auditory spatial origination
- other assistive technologies
saccades evaluation:
King-Devick test, in which pt. performs functional tasks dependent on visual-spatial organization
training saccadic movement
- scan boards
- eye charts
- large-print shapes/letters on table or wall
- “follow the flashlight”
- your own ideas…
trunk rotation:
Rotating trunk, head and neck to affected side reduces symptoms of neglect.
*Think of activities that produce trunk rotation in high- and low-tone situations.
proprioceptive input:
Grade input: gentle joint compression to supported wt. bearing on soft surfaces, then hard surfaces, then w/ weights/bands, etc.
*Pay attention to painful shoulders!
limb activation:
- small, volitional movements w body part on L
- grade for + movement, concentration, volition
- consider “yoked” movement w functional use, where therapist wraps her LUE to client LUE
visuo-motor cueing and tool use:
- a form of limb activation
- evidence shows that adding object in affected extremity increases att’n to affected side
patching/occlusion:
- evidence shows patching unaffected hemi-field increases att’n to affected hemi-field
- partial lens occlusion in avail. field promotes scanning in affected field
►prism use:
- prisms found to be one of the most successful methods for reducing neglect
- prisms are prescribed by the optho or neuro-optho
- OT accompnay client to optho/neuro-optho eval when possible
- conduct activities with prisms
- caution: mobility, transfers, standing
visual scanning training (VST):
beneficial in short run for reducing neglect but effects don’t last; combine w/ other interventions
scanning strategies:
- lighthouse strategy
- Dynavision 2000
- neuro-vision technology (effectiveness still in question)
- also: anchoring, border scan, perimeter scan, visual sweep (L to R)
imagery:
- imagined limb activation shown to reduce symptoms of neglect
- challenge: create imagined limb activation (could imagine activities using both sides of body, i.e. swimming, playing piano, etc.)
common visual and auditory spatial origination:
- music/object on affected side to increase att’n
- therapist stand and talk in pt.’s affected field (for mild neglect)
►other treatment considerations for hemi-inattention:
- interaction with the target once located
- conscious attention to visual detail, careful exploration of the object
- practice of search strategies in context: Recheck work
- client and family education
►What is the difference between hemianopsia and hemi-inattention?
Hemianopsia (VFD):
- a sensory deficit, lower on Warren’s hierarchy
- with help, client will compensate by using visual attention
- eye movement directed to L side
- less effect on task performance
Hemi-inattention:
- a “consciousness” deficit, higher on Warren’s hierarchy
- no attentional mechanisms engaged
- little to no eye or head movement to left to search visual field
- more severe effect on task performance
Will a problem with eye tracking be problematic for pattern recognition? Why or why not?
Yes. Tracking is lower on Warren’s hierarchy, and higher visual-perceptual skills (like pattern recognition) depend upon it.
Name 3 interventions you should always consider for any vision-related problem
INCREASE: lighting, contrast and size (magnification)
Why is use of mirrors a questionable intervention for addressing hemi-inattention?
Hemi-inattention is not just a visual problem, but a visual-perceptual one. It is hard for those with hemi-inattention to understand what is happening with the mirror, and therefore it isn’t always effective. (remember video of doc. trying it with pt)
Self-management for low vision (or any long term disorder) IS:
- an individual’s ability to manage:
- symptoms
- treatment
- physical, psychosocial, and lifestyle changes
… related to living with their disorder.
- an individual’s engagement in:
- health-promoting activities
- monitoring/managing symptoms
- managing related functional, emotional, and interpersonal impacts
- adherence to tx regime
Self-management for low vision (or any long term disorder) IS NOT:
- self-helps groups
- elimination of need to healthcare pro’s
- group therapy
Self-management enables:
- making informed choices
- applying general skills to specific problems
- collaborating with healthcare pro’s/systems
- practicing new health perspectives/behaviors
- regaining/maintaining emotional health
Self-management is grounded in social science theory:
- Transtheoretical Model (Stages of Change: precontemplation, contemplation, prep., action, maintenance, relapse)
- Social Learning Theory: Self-efficacy results as confidence and belief in ability to execute an action or thought process leads to personal mastery.
- Also CBT
3 skillsets that lead to good self-management:
- skills to deal w/ chronic illness
- skills to continue normal lifestyle
- skills to deal w/ emotions
5 core skills to develop for self-management:
- problem-solving
- decision-making
- resource-utilization
- paretnering w health pro’s (MD/ nurse, OT/PT, counselor/psych)
- taking action
CDSMP is:
Chronic Disease Self-Management Programs
CDSMP guides the mastery of skills via:
- action-planning
- feedback on progress
- modeling self-management behaviors
- modeling problem-solving strategies
- social persuasion through group support
- individualized guidance
How can occupation be used to refocus self-management?
A client-centered, occupation-focused approach to self-management emphasizes lifestyle and emotion-based skills.
CDSMP outcomes:
- improved health status, slowing of decline
- positive health behaviors, improved self-efficacy
- better utilization of health services (fewer ER and doctor visits)
- improved quality of life
Evidence for CDSMP:
It is used internationally and for several decades. Effectiveness has been demonstrated for:
- diabetes
- arthritis
- chronic pain
- heart and lung disease
- stroke
- low vision
What does this describe, visual history or peripheral field?
Find out if there is PMH of visual deficits; Refer pt to vision specialist if anything is odd in screening; If you can, accompany pt to ophthalmology or neuro-ophthalmology eval (if you can’t, read the report and call specialist to get details); begin functional application of visual evaluation
Visual History
What screening does this describe: central field/central fixation or peripheral field?
Hold object about 16 inches from person’s face at midline and about nose level; observe pupils to determine whether both are fixed on the object; move the object within the central 30 degrees of the visual field; note if person turns his/her head to look
Central field/central fixation
What screening does this describe: depth perception or peripheral field?
hold the object outside the peripheral visual field in superior fields (at 11 o’clock and 1 o’clock), horizontally (at 3 o’clock and 9 o’clock), and inferiorly (at 5 o’clock and 7 o’clock); instruct person to say when they see the object
peripheral field
What screening does this describe: oculomotor ROM or double simultaneous stimulation?
this is only done on a pt with a normal field of vision to evaluate unilateral inattention; move two objects, one in each hand alone or together (i.e. R, L, or BOTH in random order); if inattention exists, the person will not detect BOTH movements and will reply R instead
double simultaneous stimulation
What screening does this describe: oculomotor ROM or depth perception?
have pt cover his/her R eye with the R hand, then the L eye with the L hand, then do the activity with both eyes uncovered. Move the object in an H pattern; observe for full ROM of the pupils
oculomotor ROM
Is the screening for double simultaneous stimulation done on a person with a normal field of vision? Yes or No
Yes - only done on a person with a normal field of vision
What screening does this describe: peripheral field or depth perception?
hold one pencial about 16 inches in front of pt; occlude the R eye with the R hand; have pt take a pencil in the L hand, bring it over the head, and touch it to the tip of your pencil; repeat L eye occluded with L hand; note if there is an obvious deviation of pupils from the center.
Depth perception
LVSM (P):
Low Vision Self Management (Program)
What does this describe?
Problems discriminating hues; pt must discriminate between color perception and color agnosia, so do a screening that does not NAME colors, but SORTS them; problems indicate possible visual organization problems and/or color blindness
Color Perception
True or False: color is an important influence on quick perceptual procesing
True
True or False: the King-Devick Test of Visual Scanning involves a functional task that does not need visual-spatial organization to perform
False - you DO need visual-spatial organization to perform this!
What is LVSM?
A group intervention for low vision, focusing on psychological issues. It was developed into its current 10-session form over about 10 years.
What is the primary theoretical focus of LVSM?
CBT (cognitive-behavioral therapy)
What methods do LVSM groups use?
- educational presentations/materials
- problem-solving
- CBT skills training
- exercise
LVSM results:
- significant change in negative affect
- increased self-efficacy
- improved function and quality of life
- inprovement in knowledge, skills and problem-solving
- improved sense of security in daily occupations
- improvement sustained 28 months later
Obstacles to LVSM (and any program):
- transportation/attendance
- number of sessions needed to address needs
- participant recruitment
- hard to get people to attend ALL the sessions
- hard to get new program off the ground
“LVSMP: A 10-session program” does the following:
- acknowledges vision impairment as a chronic, progressive condition
- addresses general self-management for chronic condition
- focuses on specific low vision issues
- is intended as a group intervention but can be used with individuals who are uncertain a) about attending 10 sessions or b) about reimbursement for the group
All 10 LVSMP sessions contain:
- welcome and intro
- follow-up from last session
- info and resource sharing (peer or professional)
- problem-solving discussion and/or modeling activity
- “take action” project in home or community
Outcomes: conditions and measures
- mood: Profile of Mood States (POMS)
- clinical depression: Center for Epidemiological Studies Depression Scale (CES-D)
- visual function: Melbourne Low Vision ADL Index (MLVAI)
- participation: Activities Card Sort
- self-efficacy: Low Vision Self-Efficacy Scale (LV-SES)
LVSMP sessions
- Understanding Vision Loss
- Coping with Vision Loss
- Using Available Vision and Using Other Senses
- Communication
- Personal Care
- Household Management
- Getting Around
- Leisure and Recreation
- Advocacy
- Your Family and Friends
Good LVSMP takeaway:
From Session 3, Using Available Vision:
The Four B’s:
- Bigger
- Brighter
- Bolder
- Be Organized
“Take home messages” re: LVSMP:
- Self-management works well for the low vision population with acquired eye disease or neurovisual deficits (with minimal cognitive impairment)
- Sessions can be group or individual
- You can customize interventions for client-centeredness
Two intervention areas to emphasize:
- work with ADLs that are reading and “way-finding” dependent
- work with envoronmental adaptation with attention to lighting, magnification and contrast.
►Warren’s Heirarchy:
foundational skills: oculomotor control, visual fields, visual acuity
1st level: Attention: alert and attending
2nd level: scanning
3rd level: pattern recognition
4th level: visual memory
5th level: visuocognition
6th level: adaptation through vision
other suggestions for hemi-inattention:
- reduce background patterns
- proper lighting of room and task
- increased contrast
- many of the interventions for acquired eye disease can work for clients w neurogenic visual problems, depending on the severity
