1. Visual Assessment in Acute Care
Why we contacted Dr. Cohen
Vision Toolkit
Possible interventions
Case study (if enough time)

2. Why did we contact Dr. Cohen?
We frequently noticed visual impairments. What do we assess? How? How do we describe what we see? How do we intervene?
Questions- besides the very basics, we lacked the language and understanding to properly describe visual phenomena
We contacted Dr. Cohen after finding out her specialty and were so happy to find that she was open to working with us. She provided an in-service to our entire staff, met with our Neurology team for further discussion, and is now collaborating with us to develop screening and intervention ideas

3. What did we learn? How to better assess vision in acute setting
Assessment priorities for Neuro and Trauma populations
Developed Vision Toolkit

4. Vision Toolkit Quick and accessible reference
Describes how to assess and how to intervene
(Appendix A)
Basic assessment- subjective report, visual acuity, extraocular muscles (EOM), visual fields, and inattention
Advanced assessment- eye alignment, fusional vergences, saccades, and visuoperception
Important to create assessment with clear directions for large, fluctuating staff with various levels of experience
Visuoperception- includes visuospatial awareness, visual closure, visual discrimination, visual memory, and figure-ground; most often assess with Motor-Free Visual Perception Test (MFVT) at UNMH

5. Visual Acuity Interventions
Increase contrast
Compensate with tactile or auditory cues
Teach navigational skills
Advocate for environmental consistency
Impairments- may be due to lesions to eye or optic nerve
Contrast- color, black-white, shape

6. EOM Interventions Compensatory head movements
Increase visual attention to affected area
Adaptive equipment
Sorting tasks if difficulty with smooth pursuit
Compensatory head positioning if nystagmus
Cranial nerve glides if impaired quality of movement?
Oculomotor impairments- may be due to lesions to any of 5 separate neural control centers with common final pathway: saccadic eye movements, smooth pursuit movement, optokinetic movement, vestibulo-oculomotor reflex, and vergence movement
Compensatory head movements- in direction of affected EOM line of pull
AE- “window” templates for reading, writing checks, filling out envelopes
Head positioning- in gaze position of least eye movement (null point)
CN glides- evidence-based?

7. Visual Fields Interventions
Compensatory head movements
Increase visual attention to affected area
Dynamic overhead reach tasks
Obstacle avoidance during mobility tasks
Reading comprehension or functional pen-and-paper tasks
Impairments- may be due to lesions to retinal receptors or visual pathway from optic nerve to occipital lobe
Dynamic reach- if superior quadrants affected
Obstacle avoidance, reading, and pen-and-paper tasks- if inferior quadrants affected

8. Inattention Interventions
Present stimuli in affected area
Teach systematic scanning
Increase visual attention to affected area
Increase sustained attention
Recalibrate midline
Stress physical interaction with blind side environment
Cover intact half-field of lenses
Important to assess all spaces- personal, arm’s reach (near extrapersonal), and beyond arm’s reach (far extrapersonal); cancellation tests often more sensitive than line bisection tests at near extrapersonal space level, Catherine Bergego Scale (CBS) and Behavioral Inattention Test (BIT) appropriate for near and far extrapersonal space levels
Systematic scanning- begins on affected side
Recalibrate midline- rotate trunk-on-head 15 degrees, use visual landmarks
Lenses- use semi-opaque material (e.g., clear tape); goal is to facilitate attention shifts away from intact side and towards impaired side

9. Case Study, Background
J.K. is a 53-year-old male, married, with a 12-year-old son, and no longer able to work.
History of pituitary mass, skull base mass with C2 spinal cord compression, recent fall in bathroom, and cerebrospinal fluid leak requiring placement of ventriculoperitoneal shunt
Presenting with recent blindness, minimal bimanual sensation, impaired activity tolerance, dependence on wheelchair for mobility, and frustration and anxiety related to situation
Pituitary mass- detected 2004, treated 7 operations including 2 subtotal resections and radiation therapy
Skull base mass- treated with craniotomy and hemilaminectomy of C1-2 complicated by CSF leak requiring eventual VPS
Blindness- gradual onset to February 2016, has yet to complete white cane training
Impaired sensation- including loss of protective sensation in dominant RUE
Impaired activity tolerance- due to headache pain, abdominal pain at VPS surgical site, and lightheadedness

10. Case Study, Interventions
Customized dining tray
Built-up handles for utensils
Education in clock-based orientation system
Progressive positioning for activity tolerance
Emphasis on self-efficacy and problem solving
Dining tray- with high-friction liner, tactile cues along perimeter, and diagrammed locations for dinnerware and utensils
Built-up handles- with tactile cues to distinguish orientation and individual utensils
Clock system- later expanded to additional activities

11. Case Study, Outcomes
Following 3 sessions and with lots of encouragement:
Set-up assistance to eat while sitting for at least 15 minutes
Stand-by assistance with verbal cues for navigation to ambulate 150 feet with front-wheeled walker
Markedly more positive mood

12. References
Gutman, S.A. & Schonfeld, A.B. (2009). Screening adult neurologic populations: A step-by-step instruction manual, (2nd ed.). Bethesda, MD: AOTA Press.
Hamby, J.R. (2011). The nervous system. In H. Smith-Gabai (Ed.), Occupational therapy in acute care (pp ). Bethesda, MD: AOTA Press.
Luauté, J., Halligane, P., Rodea, G., Rossettia, Y., & Boisson, D. (2006). Visuo-spatial neglect: A systematic review of current interventions and their effectiveness. Neuroscience and Biobehavioral Reviews,
Zoltan, B. (2007). Vision, perception, and cognition (4th ed.). Thorofare, NJ: SLACK Incorporated.

13. Appendix A

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19. Questions?