1. How Vision impacts Memory:
The visual connection in the adult neurological population
Alicia M. Reiser, MS OTR/L
Physical Therapy at St. Luke’s

2. Vision and Visual Perception
Rowe et al (2009) up to 92% stroke survivors had some visual impairment
Visual Deficits can be mistaken as cognitive or physical deficits
Vision
Primary way we acquire information
Alerts us to danger, pleasure
Enables anticipatory actions
Plans for situations and reactions
Visual Perception
“Applying cognitive concepts of space and form to understand the visual world by transforming raw data form the retina into cognitive concepts”
Eye Sight vs. Vision: What’s the Difference?

3. Mary Warren’s visual hierarchy and the 4 circles of vision
Magnacellular Parvocellular
Ambient (peripheral) vision Focal vision
Doesn’t go to occipital lobe occipital/temporal lobes
Visual language processing visual spatial processing
Directs motor movement of eyes/hands object identification
Gross Motor fine motor
Visual cognition
Visual memory
Pattern recognition
Scanning
Visual attention
Oculomotor control, visual fields, visual acuity
Centering:
Where is it?
Identify:
What is it?
VISION
Antigravity:
Where am I?
Speech/auditory:
What do I
know about it?
(Hillier and Kawar, 2013)
(Warren, 1993)

4. What does the hierarchy mean?
Visual cognition: ability to mentally manipulate visual info and integrate it with other sensory info to solve problems, form plans and make decisions (executive functioning)
Visual memory: store and retrieve a mental image of object in the mind’s eye, apply new patterns to solve problems by comparison
Pattern recognition: identify the salient features of an object in order to visually remember it (shape, color, texture). This determines if the memory is laid down. Frontal Lobe looks for as many attractors as possible- what makes an object different. CVA and TBIs tend to use more generic attractors.
Scanning: the ability of the fovea to fixate and take in the environment in a sequential pattern by using saccades automatically by the brain stem and voluntarily by the frontal lobes. Reading is usually linear, non structured shape is circular.

5. Hierarchy: works together at all levels- think developmentally
Visual attention: 3 step cognitive process (disengage, move and compare). Critical step in visual processing using both global and focal attentions
Oculomotor control, visual fields, visual acuity: together allows for efficient conjugate movement, registering the entire scene and eyesight, including contrast. Oculomotor control provides perceptual stability, acuity provides clarity of detail and color, and field allows for awareness of objects in environment (Warren, 1993)
Hierarchy: works together at all levels- think developmentally
Following brain injury:
Visual field, acuity, control and visual attention impacted
OT screens for this deficits and identifies limitations in occupational performance (Warren, 2014)
Oculomotor control affected by disruption of CN function or disruption of CNS control
Exotropia, high exophoria, accommodative dysfunction (Blurry vision), convergence insufficiency (diploplia), low blink rate, spatial disorientation (the inability of a person to determine his true body position, motion, and altitude relative to his surroundings), poor fixation, irregular eye pursuit movements and unstable ambient vision
Diploplia, illusion that objects are moving in the environment, poor concentration and attention, staring, poor visual memory, eye pain, neuromotor deficits including balance, coordination and postural control (Kane)

6. Team Introduction
Neuro opthomologist: diagnose and prognose- what caused the impairment?
Neuro or behavioral optomotrist: diagnose, prognose and interventions to improve
Certified Vision Rehab Therapist: if vision is significantly impaired to teach blind tech
Occupational Therapist: screen and identify strategies to improve occupational performance

7. Primary changes after brain injury:
Visual field, visual acuity,
oculomotor control, visual attention

8. ADL performance affected
Reading
Writing
Employment
Role of parent, child, spouse, worker
Functional Directional Skills
Driving
Topographical orientation
Personal space

9. Vision Screen Performed by OT

10. Screen for Acuity
Deficits due to optic nerve damage or bilateral damage to the occipital lobe
High Contrast Acuity: distance and near, low contrast
Distance Snellen Chart
Reading acuity chart
Mars Chart, LeaNumbers Chart or Glass Test
Glass test: clear glass water to within ½”, then black mug with milk to within ½”

11. Treating acuity dysfunction
Clean glasses
Check med side effects: seizure, spasticity
Refer to optometrist/opthomologist for refraction update
Improve accommodation
Use contrast on stairs, with meals, in bathroom, minimize patterns and clutter, increase lighting, LED lighting, enlarged adaptive equipment, organize environment, simplify tasks, manage glare
Electronic Magnifiers

12. Visual pathway to the brain
Left honomonous hemianopsia
Right hemianopsia
Binasal occlusion
Tunnel vision

13. Screen for Visual Field
Deficits due to MCA, PCA (75% result in homonymous hemianopsia) or occipital lobe brain injury
Diagnosed by opthamologist or optometrist, usually after 5 months
Perimetry testing: central and peripheral, manual or computerized
Confrontation test: shown unreliable
Tangent Screen: results given in isopter, absolute scale or gray scale diagrams
Visual Skills for Reading Test (Pepper), Telephone number copy
Trail making test, clock drawing test, single letter cancellation test, line bisection test

15. Behaviors seen with HH
Don’t cross visual midline therefore filling in the blanks with previous visual memories, safety imparied
Scan slowly to affected side impacting rate of ADL completion
Miss detail on blind side with reading, small detail tasks
Reduced hand monitoring with function
Decreased mobility: slowed, looks down, stops to search, gets lost
Writing: drifts
ADLS: driving, shopping, yard work, meal prep, money mgmt, communication, homemaking, self-care
Reading: word recognition due to limited fovea previously 19 characters, unable to preplan saccade
Right: affects saccade, can’t preplan next word
Left: omits words, skips lines

16. Treating Hemianopsia
Recovery rare after 6 months (Zhang, et al, 2006): Compensation is Key
Computerized Light boards: Dynavision, Wii
Laser pointer: flashlight tag
Reading: Pre-Reading tasks to increase saccade length, large print familiar text, occupation based text. Maybe not bifocals
Writing: illumination, contrast, bold lines and black pen
“Scan the environment” tasks
Wider head turns
Increased head movement for scanning
Faster rate of head movement
Improved search pattern
Wide scanning tasks
Approach from the affected side during divided attention tasks
Modify the environment
Prisms from neuro optomotrist

17. Visual Attention
Skills to attend: filter out, balance all perceptions, become salient, termination
Monitor central field (cones- what is it?) and peripheral field (rods-where am I?)
Constant communication through cortex, brainstem and cerebellum orchestrated by the frontal lobe
Mass practice , experience and context can all improve recovery

18. Types of Attention Focused attention: responding to specific element
Sustained attention: maintaining response over period of time
Selective attention: free from distraction of environment
Alternating attention: shift from one task to another
Divided attention: simultaneous engagement in more than one task, multitasking

19. Neglect If vestibular cortex: pusher syndrome
Due to deviation in normal search pattern
Disorder in:
spatial cognition
No concept of space….no insight
spatial orientation
Left sided space doesn’t exist
spatial exploration
Difficulty crossing visual midline
Difficult disengaging search pattern from right
80% result from damage in right parieto-temporal-frontal circuitry (Warren)
If vestibular cortex: pusher syndrome

20. Behaviors Decreased ADLS: reading, WC mobs, driving Limited insight
Decreased task initiation
Decreased sustained attention
Decreased working memory
Perseverates
Decreased alternating attention

21. Evaluation for Visual Attention
Why is there inattention?
Spatial bias
Impaired conceptualization
Non lateralized inattention
Tests: Cancellation tests (assesses search pattern), Telephone number copy, Reading performance, Design Copy, Scan Board, ScanCourse, Dynavision, ADL observation
Spatial bias: can’t initiate to left side
Conceptualization: decreased response to cuing to fix it
Inattention: no sustained attention, task initiation, search pattern
# Copy: look for errors on left, can’t find errors, fast completion time
Reading: look for start in middle of page, unaware makes no sense
Scan Board: like King Devick

22. Search Patterns (Warren)
Left Hemianopsia
Hemi- inattention
Abbreviated search pattern- omissions on left
Pattern is organized
Re-scanning to check accuracy
Sustained attention measured by completion time appropriate
Improves with cuing
Abbreviated search pattern- omissions on left
Pattern is random
Revisitng on right
Reduced sustained attention, shorter completion time
Cue meaningless

23. Interventions for Visual Attention
Modify Environment to support participation
Decrease pattern, increase contrast, reduce glare, lighting
Improve attention through language to assess performance, activity based
Visual Scanning Training
Focus on: Left to right, symmetrical scanning, completing search to left, observe detail, anticipate, rapidly shifting R v L
Visuospatial Training Tablet

24. Treating Visual Attention
Multimatrix tasks: categorization, spelling
Shapes and grid tasks
Pencil and Marsden ball tasks with patch
Cognitive load tasks
Go-no-go: flash pen light a number of times, hold fingers up how many seconds to wait, then pt taps table equal to amount of flashes

25. Treatment Meaningful occupations Salient tasks: babies, pets, family
Multimatrix Game, Tracking Tube
Refer to developmental or neuro optometrist for prisms, lenses
Sensory Input: Incorporate auditory, visual (prisms or partial occlusion) and vestibular treatment with cognitive load

26. Oculomotor Impairment
Caused by closed head injury, facial trauma, Cranial nerve trauma or Brainstem injury; damage to cortical areas that use eye movements to shift attention (Warren), PD, MS
Saccades: bring taret to fovea after activated by attention, uses scan and search with quick movements
Smooth pursuits: triggered by movement and hold a moving image on the fovea
Cervical VOR
Remember that eye movement is complex combination of cortical, brainstem and cerebellar control

27. Accomodative dysfunction
Convergence insufficiency
Treated by optometrist
OT uses larger print or magnifiers
Binocular insufficiency
Convergence excess
Divergence excess
Divergence insufficiency
23 kinds of nystagmus
Ocular dysmetria: over/under shoots with saccades, slows down identification

28. 3 steps to accommodate Converge to target and stimulate photoreceptors
Lens thickens to refract light
Pupils constrict to reduce scatter of light

29. Behaviors
Difficulty focusing, altered perception, disruption of balance
OT cannot fix oculomotor dysfunction
Modify and Adapt
Manage condition until resolves
Eliminate stress for improved ADLS
Most clears up within 6 months (Park, Hwang, Yu, 2008)

30. Altered Perception Diploplia Acquired paralytic strabismus
Doubled images
Blurred images
Ghosting images
Distorted images
Acquired paralytic strabismus
Due to paralysis or weakness of CN 3,4,6

31. Cranial Nerve Review:
CN 3 (Oculomotor nerve) lesion: exotropia, vertical or medial movements difficult, lateral diploplia, ptosis, dilated pupil, due to severe TBI
CN 4 (Trochlear Nerve) lesion: bilateral lesions common, vertical diploplia near vision, head tilt contralateral side
CN 5 (Abducens Nerve) lesion: esotropia, lateral diploplia for far vision

32. Screening for binocularity
What and how to screen:
What does it mean?
Unilateral Cover test: phorias near and far
Broch string: convergence, suppression near vs far, alignment, accommodation
Red/Green Fusion test: suppression right vs left eye
Near point of convergence
Behaviors with phorias: headache, blurred vision
Convergence insufficiency: poor recall of what read, decreased reading, look out window
Convergence excess: love to read, get close to notes to write
Suppression: poor sports skills
Accommodative infacility: poor concentration, poor sustained attention

33. Screen for diploplia Screen if binocular or monocular diploplia
Only when both eyes open: binocular diploplia
Patching can be useful
Even when one eye shut: Monocular diploplia
patching doesn’t help: requires sx, vision rehab or prisms
Screen where the diploplia is?
Move eyes around from 12 to 6 to 12
Where is the double vision worse? Better?
Tilt head right, left. Worse, better?
Patching: complete occlusion
Can lead to monocular vision, eye fatigue and strain
Must alternate patch- poor pt compliance
Decreased depth perception / increase fall risk
Strengthen the oculomotor deficit
Occlusion:
Binasal occlusion forcing peripheral vision
Nasal portion of dominant eye
Need MD consent

34. Diploplia cont….
Prisms from optomotrist when peripheral or central nerve injury (Hilliar, 2014) Used with phorias to achieve fusion.
Multimatrix games
Fusion tasks with scanning
Convergence activities
Reading
Broch string
Pencil push ups
Add an auditory component with a metronome
Add a cognitive load by converging on every 3rd beat

35. Other Disturbances in Visual Perception
Visual discrimination: ability to discriminate one thing from another allowing for pattern recognition
Pattern recognition: spatial patterns (shape of the letter), sequential patterns (q is a spatial pattern in a sequence of letters to form a word) and movement patterns (magnocellular through gestures, expression)
Behaviors include not recognizing patterns, sequences, difficulty with symbolic literacy, difficulty organizing space and time

36. Visual Memory Semantic Declarative Memory: info heard or read
Episodic Declarative Memory: remembering what did or what happened
Implicit Procedural Memory: long term memory for motor learning task (tying shoe, handwriting)
Working Memory: metacognition…think while we are thinking! Reading, writing, lecture

37. Visual Imagery
Manipulating images in minds eye

38. Perceptual Midline Shift
Perceived midline of body is not the actual midline of the body
Auditory
Visual
Vestibular
Due to dysynchrony of sensory integration at midbrain with major contributions from ambient visual pathway causing poor sports performance, social insecurity and difficulty driving (Hillier and Kawar)
Benefit from yoked prisms

39. Treating Tunnel Vision
Bimanual circles
Mimicking gross motor movements while fixated straight ahead
Flashlight tag
Scarf juggling

40. Therapeutic strategies after trauma
Adapt: make plastic changes in the cerebellum and brainstem neuronal responses to head movement
Decrease retinal slip/oscillopsia
Improve postural control and gaze
Decrease vertigo
Use for those with unilateral lesions with high velocity head movement or central lesion
Habituate: minimize sensitivity to aggravating stimuli
Use for those with unilateral lesions causing asymmetry and visual vestibular mismatch
Substitute: enhance visual and somatosensory cues to compensate
Use for those with bilateral lesions and high velocity unilateral lesions with gaze stability and somatosensory training

41. References
Hillier, Carl and Kawar, Mary. (continuing education PDP, 2013). Eyesight to Insight: Visual/Vestibular Assessment and Treatment. Pittsburgh, PA.
Hillier, Rita and Tarbutton, Natalie. Vision Deficits following Stroke: Implications for Occupational Therapy Practice. OT Practice, 19 (21), 13-16
Lane, Kenneth (2012). Visual Attention in Children: Theories and Activities. SLACK Publishers, New York.
Park, UC; Kim S. J.; Hwang, J. M. & Yu, Y. S. (2008). Clinical features and natural history of acquired third, fourth, and sixth cranial nerve palsy. Eye (Lond) May;22(5): Epub 2007 Feb 9.
Rowe, F., Brand, D., Jackson, C. A., Price, A., ….Freeman, C. (2009). Visual impairment following stroke: Do stroke patients require visual assessments? Age and Ageing, 38,
Rummell, Errol. (2012, September 17). Vision Rehab for Hemianopsia: How VRT can improve vision loss from a neurological origin. Advance for Occupational Therapy Practitioners

42. Warren, Mary. (1993). A Hierarchical Model for Evaluation and Treatment of visual Perceptual Dysfunction in Adult Acquired Brain Injury, Part 1. AJOT, 47,
Warren, Mary. (continuing education vis ABILITIES Rehab Services, inc. 2014). Visual Processing Impairment I: Evaluation and Intervention for Adult Acquired Brain Injury. JFK Johnson Rehabilitation Institute, Edison, New Jersey.
Zhang, X., Kadar, S., Lynn, M. J., Newman, N. J. & Bouisse, V. (2006). Homonymous he,ianopsia in strole. Journal of Neuro-opthomology, 26,

43. Appendix

44. Eye Terms Mobility: the ability to move eyes full range
Motility: skill with which the eyes move (smooth, slightly jerky, jerky)
Pursuits: tracking of moving object with body still or stationary object with body moving
Steady fixation: ability to keep eyes from moving off moving target
Saccades: quick eye movement for scanning environment, reading (visual memory, comprehension based here)

45. Eye Terms Binocularity (teaming or alignment)
Phoria “the tendency to” or weakness
Orthophoria: tendency to stay in alignment
Exophoria: tendency to drift out, therefore a shift inward when contralateral eye occluded
Esophoria: tendency to drift in, therefore a shift outward when contralateral eye occluded
Hyperphoria: tendency to drift upward, therefore a shift downward when contralateral eye occluded
Results in intermittent diploplia
REFERRAL to Dev/Neuro Optomotrist if eso or hyperphoric

46. Binocularity Tropia “is out of alignment” or paralyzed/ Strabismus
Exotropia: eye is turned out
Esotropia: eye turned in
Hypertropia: eye turned up
Cyclotropia: eye is rotated
Results in constant diploplia of gaze
Strabismus is acquired from TBI or developmental