Vision Assessment and Treatment: Your One-Stop Shop

If you’ve already found your passion for all things vision in OT, it’s time to take a closer look at how you can incorporate vision into your practice. The next step will be to develop your skills assessing patients so you can feel more confident treating within the Occupational Therapy practice act and in turn grow your clinical program.

Vision Assessments

So you have a good foundation—now what?

You need to start building a core list of assessments to use. As with any assessment, having objective data to support your findings and mark milestones toward goal achievement will serve you best.

Fortunately, there are a number of great vision assessments to assist you!

Many of them do, however, have difficulty weeding out alternative issues (for example, unilateral attention/neglect and oculomotor issues, etc.), but I think most OT’s would agree that not often do our patients have one single identifiable impairment following a neurological event.

I have found that completing a wide variety of assessments provides me with a general idea on functional impairment and assists in formulating an initial treatment plan.

My Outline for Adult Rehab

Here’s an outline on what I find most helpful (please keep in mind this list is tailored toward adult rehab).

The Motor-free Visual Perceptual Test (MVPT) is a great test with subsections for visual memory, visual closure, spatial reasoning, figure-ground, and visual discrimination. This is the only standardized test I use for visual processing issues.

The MVPT is not appropriate for all, however. You may have strong difficulty completing it with a patient experiencing limited attention skills. It does require at least 20-30 minutes to complete and potentially longer if your patient really struggles with processing. Some years ago I did have one patient at the very end of the assessment look at me and say, “Oh, I don’t know, I’m just guessing!” I smartened up after that and now really don’t use it unless I know what I’m looking for.

Other options for visual processing include the Developmental Test of Visual Perception (DTVP) and the Test of Visual Perceptual Skills (TVPS). If you use either of these, please comment below and let me know!

Other popular tests are line bisection, letter cancellation (single or double depending on abilities of the patient), attention/unilateral neglect test such as the Star Cancellation test, the Bells test, and the Symbol Digit Modalities test (SDMT).

You might also consider “testing” simple and complex line tracing to determine figure ground ability, tolerance to extraneous stimuli, and ability to follow a line (preferably without the use of a finger) from one point to another. You will be able to formulate a variety of objective and functional goals from the results you garner with these tests.

Don’t forget to make the goals functional!

Quick Vision Screens

As part of any thorough visual assessment, you should also plan on completing several quick oculomotor screens. These are relatively quick to complete and should include ocular pursuits, convergence, saccades, peripheral field, and general ocular range of motion.

I would suggest attending a vision course (as mentioned previously many are offered by ODs) and learn how to complete these accurately as they are more subjective.

The NSUCO Oculomotor test guidelines can be used to determine ability, accuracy, and head/body movement during rotational pursuits. This assessment provides a number score that you can use to measure improvement.

Convergence is assessed to determine the distance your patient can maintain a simple image of a presented target. A measure of binocular vision, a “normal” near point of convergence is 10 cm or less. To be honest, many CVA, TBI, and concussion patients with visual difficulties have difficulty focusing on the target at all or even tolerating it in front of them in close proximity.

Saccades are the movement of the eyes between two targets. Consider testing this in all four visual quadrants.

Finally, test peripheral field in all quadrants to gain an idea of further limitations. You might also look at ocular range of motion as well to get an idea of how the eyes are moving individually.

You can find further visual processing assessments at Stroke Engine’s Assessments page here.  

Vision Treatments

So now you have an idea of what oculomotor and visual processing areas are most problematic. You are ready for treatment!

If you Google visual processing activities much of what you find, similar to fine motor activities, is child-oriented. These activities are still appropriate for adults, however you may preface your session by explaining this to your patient.

You probably have an assortment of cog-related activities at your facility that relate to visual processing (if you work inpatient, take a field trip to your outpatient facility and see if you can borrow some supplies or make some copies).

A quick list to get you started:

• Hidden pictures
• Spatial Reasoning games (Serpentiles, Cover Your Tracks, Square by Square, and other Spatial reasoning games on Amazon)
• Scanning a simple map for locations or following directions
• Scanning a menu or grocery ad for specific items
• Lay out a full deck of cards and locate each suit in order; shuffle and complete again
• Letter reversal grids

I am particularly partial to the grocery ad scanning task and often time how long a person takes to locate 10 or 15 items and use this number as a non-standardized measure of improvement for functional scanning. If your patient likes to use their phone or an iPad, you can recommend games such as bejeweled, tangrams, or my favorite, Mah-jong. For reference, a great website is Eye Can Learn.

Again, I highly suggest you take a course on vision to understand the best choices for treatment exercises regarding oculomotor dysfunction as it does require education and experience to recognize which oculomotor exercises are the most beneficial for a particular case.

Exercise options are HART Charts, 4 square saccades, a Marden ball, a Brock string, or technology such as Dynavision, Vision Coach, or BITS. You can find plenty of information on all of these with a quick Google search.

As much as I love rehab technology, low-tech options are sometimes the best choice as they are easily adapted to an HEP. You can easily design a similar setup to the Dynavision using post it notes on a wall surface to work on saccades—add use of an impaired arm to touch the notes and you have a nice visual-motor activity!

Quite a few vision apps now exist that you may enjoy using. I tend to primarily prescribe them as an HEP as I feel (for oculomotor skills, anyway) the size of a phone or a tablet is not as large as the functional environment (or even the windshield of a car). VisionTap is a great tool for oculomotor skills, and other options include Visual Attention Therapy, Vision Training, Eye movement training, Constant therapy, the list goes on.

Remember to Explain “Why” to the Patient

It’s really important to take the time to educate your patients on why you’re completing these visual tasks. If they have good insight and recognize that they are having issues that they did not experience pre-morbidly you may have an easier time with education.

You may consider creating a handout highlighting visual processing and oculomotor skills and providing an example of each in relation to a task. For example, visual closure is used to recognize road signs that may be partially hidden when driving. Pursuits are used to follow a person walking across the street.

I always feel it’s easier to be prepared rather than attempting to provide solid examples on the fly when discussing plan of care with your patients.

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I hope this provided you with a foundation or review of how you can treat visual issues. The more we educate ourselves and present occupational therapy as the natural expert in vision, the better we can continue to justify how important our services are and promote the quality of the skills we provide.

Comment below and let us know what other vision assessments and treatments you use!