Low Vision & Visual

Perceptual
Dysfunction
Anatomical Review and Intervention
Strategies for the OTA
OTP Role
 OT practitioner’s have an important role in
the evaluation and treatment of visual
dysfunction.
 WHY?

◦ It’s not just what we see. Vision contributes to

posture, balance and motor control,
communication, cognition, and emotion.
◦ Can lead to deficits in ADL’s, reading, writing,
comprehension and play.
Visual Acuity
 The ability to see small visual detail,
“keenness or sharpness.”
Anatomy and System
 Acuity occurs through a multi-step process
◦ The lens, cornea, pupil, and vitreous body all work
together to bring light into the eye
◦ The retina (film in camera) processes the light &
records an image
◦ The macula and fovea make the image clear and
focused
◦ The image is initially upside down, electrical
impulses convert the image and send it to the
brain via the optic nerve.
◦ The picture is then interpreted by the brain as
right side up.
Development
 At birth, the baby has primary visual
fixation, tracking abilities and basic visual
acuity to see the mother’s face from 8
inches away.
 The visual acuity then develops rapidly

starting at 4 months stabilizing between 2

and 5 years of age.
 Reaches optimal functioning at 18 years

old.
Types of Acuity
 Visual acuity includes the ability to see
high-contrast, black on white optotypes and
low-contrast, beige on white optotypes.
 Low contrast acuity, is known as contrast

sensitivity function (CSF). E.g. human face

 2 forms of high-contrast visual acuity

◦ Distance acuity & Reading (near) acuity

 Reading acuity relies on Accommodation which
enables the eye to maintain clear focus on objects as
they come closer.
Visual Acuity Deficits
 Myopia (nearsightedness)

 Hyperopia (farsightedness)

 Astigmatism
Visual Acuity Assessment
 The Snellen chart- assesses near and distant
vision from 20 feet away, reading numbers and
letters decreasing in size from top to bottom.
◦ 20/20; The top number is based upon the smallest
line of optotypes the pt. can identify from 20 feet
away and the bottom number is the distance a
typical person can recognize the same
objects/letters/numbers.
◦ Example: 20/200 is considered legal blindness
because the typical person can recognize from 200
feet what a person with a visual deficit can only see
from 20 feet away.
Oculomotor Function
 Ensures that the object the person wishes to
view is focused on the fovea of both retinas
(to ensure a clear image) and that focus is
maintained as needed to accomplish the
desired goal.
 Also provides binocular vision which ensures

perception of a single image even though

the CNS is receiving two separate visual
images (one from each eye)- called sensory
fusion
 Diplopia- double vision
Deficits in Oculomotor Function
 Caused by paralysis of extraocular muscles or
disruption of central neural control of the
extraocular muscles
 Functional results: decreased speed, control and
coordination of eye movements.
 Cranial Nerves (CN) that control eye muscles: CN III
(oculomotor), CN IV (trochlear), and CN VI
(abducens).
 CN control 7 pairs of eye muscles that control eye
movement.
 When a lesion occurs, muscles controlled by the CN
are weakened or paralyzed (paralytic strabismus)
Muscles of the Eye
 Eye has 7 muscles that work together to
allow full ROM for scanning the environment
to bring information to the brain.
◦ Superior rectus, Lateral rectus, Inferior
oblique, Inferior rectus, Medial rectus,
Superior oblique, Levator palpebrae
 ROM will be affected if one muscle is
impaired OR if the muscle is not receiving
the message from the brain because of a
nerve injury
Visual Field
 This is the external world that can be seen when a
person looks straight ahead.
 Normal visual field extends ~ 65 degrees
superiorly, 75 degrees inferiorly, and 95 degrees
outward.
 Functionally, it is the area that can be seen when
eye is looking straight ahead (~180 degrees
horizontally and 125 degrees vertically)
 Each eye can be divided into superior and inferior
halves which are subdivided into L/R quadrants.
 Binocular- vision seen by both eyes
 Monocular- vision seen by one eye
Visual Field Deficits (VFDs)
 Blind spots in a portion of the visual field.
 May occur based on the location of injury in

the brain.
 VFDs include:

◦ Hemianopia
◦ Homonymous hemianopia
◦ Quadrantanopia
Visual Field cont.
 H- Vision loss in one
half of the visual field
in one eye.
 HH- Vision loss in one
half of the visual field
on the same side of
both eyes
◦ Caused by TBI or Stroke
◦ Results in deficits in
reading, writing, and
mobility.
Hemianopia vs.
Visual Field Homonymous Hemianopia
Visual Field Assessment
 Confrontation Testing- provides a gross
indication of field loss (static or kinetic)
◦ Static: Therapist sits in front of the client at a
meter distance and has client fixate on a centrally
placed target. Therapist holds up 2 targets in
each of the four quadrants of the visual field. The
client indicates whether the targets are seen.
◦ Kinetic: Therapist stands behind client and
moves a target (pen light) in from the periphery
while client fixates on a central target. Client
indicates as soon as the target is noticed.
◦ [Link]
Visual Attention &
Scanning
 Visual attention- the ability to observe objects
closely and carefully to discern information about
their features and their relationship to oneself
and other objects in the environment.
◦ Requires ability to sustain focus for several seconds to
several minutes and ability to shift focus from object to
object in organized way (left to right, top to bottom).
◦ Focal (selective) and Ambient (peripheral)
 Hemi-inattention- avoidance in searching left
half of visual space (associated with R hem.
injuries)
Other Visual Disorders
 Retinopathy-Most common visual disorder seen in children. ROP
occurs in many pre term infants and is the leading cause of
blindness in preterm infants. The vessels of the eye to turn away
from the retina towards the center of the eye causing abnormal
blood flow. There may be no functional limitation to total
blindness.
 Albinism-Reduction or absence of melanin pigment. Reduced
visual acuity ,photophobia, nystagmus, and strabismus (cross
eyed)
 Macular degeneration-Is a progressive vision disorder that
effects a patients central vision. There is wet and dry MD. Wet is
the more aggressive.
 Glaucoma- a group of diseases that are progressive with gradual
vision loss due to abnormally high pressure on the optic nerve
causing damage. Patchy blind spots in your side or central vision
in both eyes. Tunnel vision at end stages and then total blindness.
Visual Disorders Cont.
 Binoculardisorders-eyes
working together
◦ Strabismis (ex. Esotropia, exotropia and
hypotropia)
◦ Convergence insufficiency
◦ Stereopsis-also known as depth perception
◦ Amblyopia (lazy eye) decreased visual
acuity in one eye may develop as a result of
strabismus.
Visual Terms
 Depth Perception-ability to judge depth or the
relative distance of objects in space and to orient
one’s position in relation to them.
 Fixation-to maintain visual gaze on an object
 Occlude-to cover up one or both eyes to restrict
vision. Usually done by practitioner during
assessments
 Peripheral fields-vision that occurs outside the
center of gaze
 Convergence-a simultaneous inward movement
of both eyes toward each other in an effort o
maintain binocular vision to view an object
Visual terms cont.
 Tracking-the process of measuring either the point of
gaze or the motion of an eye relative to the head.
 Saccades-Fast movement of the eye toward object of
interest.
 Visual perception- the ability to turn the raw data
supplied by the retina into cognitive concepts of the
perception of space and objects that can be manipulated
and used for decision making.
 Visual cognition- the ability to manipulate and integrate
visual input with other sensory information to gain
knowledge and make decisions.
 Visual memory- the ability to create and retain a picture
of the object in the mind’s eye while visual analysis is
being completed.
Visual Terms Cont.
 Pattern recognition- identifying the salient
features of an object and using these features
to distinguish the object from its surroundings.
 Visual scanning- organized and thorough
scanning of the visual array, accomplished by
using saccadic eye movements.
 Visual attention- visual focus on an object or
information.
 Oculomotor control-enables eye movements
to be completed quickly and accurately and
ensures perceptual stability.
Treatment Strategies
 Remedial- decrease or increase arousal, word
searches, copying tasks, computer games
 Compensatory strategies-mnemonics,
rehearsal, imagery, planning and sequencing
tasks. Time requirements and how the info is
provided, finger pointing. Audio books, talking
watch.
 Modifying or adapting the environment-
matching, increasing contrast black lettering over
yellow background, mark steps with color in
child’s physical environment, use tactile templates
for staying on lines when righting.
Hierarchy of Perceptual
Development in CNS
Reversible Figures