This document discusses neuro-optometric rehabilitation (NOR), which provides coordinated visual care for patients with neurological insults. NOR addresses eye health, visual fields, refractive needs, and visual rehabilitative therapy through an interdisciplinary team. Common visual issues after brain injury include visual field deficits, visual spatial inattention, and post-traumatic vision syndrome. Treatments may include lenses, prisms, occlusion, scanning exercises, and vestibular therapy. Visual-evoked potentials can help evaluate disorders of the optic nerve and visual pathway.

1. Dr. Jennifer J. Kungle
The Center for Vision Development
Annapolis, Maryland

2. Outline
1. What is Neuro-Optometric Rehabilitation?
2. Interdisciplinary Approach to Treatment
3. Visual Field Loss Vs. Visual Spatial Inattention
4. Treatment with lenses/prisms/patching
5. The Vestibular Connection
6. Visual Perceptual Deficits
7. Visual Evoked Potential’s

3. What is Neuro-Optometric
Rehabilitation?
A service which provides, coordinates and manages
all of the visual needs of patients with
neurological insult
Neuro in NOR
 External Insults
 Closed or penetrating trauma
 Internal Insults
 Stroke (CVA), brain surgery

4. Neuro-Optometric Rehabilitation
Optometric in NOR
 Eye Health
 Visual Field
 Refractive Needs
 Prism
 Occlusion
 Low Vision
 Visual Rehabilitative Therapy

5. Neuro-Optometric Rehabilitation
Rehabilitation in NOR
 Multidiscipline Team
 Occupational Therapist, Physical Therapist, Vestibular
Therapist, Speech Therapist, Cranio-Sacral Therapist,
Physiatrist, Psychologist, Case Worker, Neurologist,
Cardiologist, Internist, Audiologist, Ophthalmologist,
Attorneys, Educators, Insurance Case Worker, Mobility
Specialist
 Communication with the entire team – ADVOCACY –
to help the patient rehabilitate

6. Right/Left Brain Generalizations
Right Brain Damage
1. Left Hemiplegia, hemianopia
2. Neglect of left side of self and/or space
3. Lack of recognizing objects, people, colors
(Agnosia's)
4. Spatial inaccuracies in judgments of speed of
motion
5. “Lost in Space”

7. Left Brain Damage
1. Right hemiplegia, hemianopia
2. Neglect of right side of space (rare)
3. Language difficulties, Aphasias

8. Neuro-Optometric Rehabilitation
Timeline of Care:
1. Acute Assessment in Hospital ER
2. Assessment in Rehab Facility
 Begin in-patient therapies
 May receive a vision evaluation/initial treatment
3. Outpatient care or homecare

10. Visual Field Deficits
 Extremely common following acquired brain injury
 Varies from small scotomas to a complete
homonymous hemifield
 Causes changes in perception of 3/D space
 Disrupts binocular vision; may cause double vision
 15% of patients with homonymous hemianopia experience
diplopia
 Shifts center of gravity causing balance and mobility
issues
 Right field loss near the fovea significantly impacts
reading as previewing next word in periphery is
hindered

11. Visual Field Deficits
 Visual field deficits occur in approximately 40%
of patients with a TBI; 67% of patients with a
cerebral vascular accident (CVA)
 Most deficits with CVA’s are homonymous
(30%); scattered (13%); nonhomonymous
(13%); or restricted visual field (8%)
 With TBI population, scattered deficits (22%),
homonymous (9%), restricted field (6%) and
nonhomonymous (1%)

12. Perimetric testing
 The normal visual field extends 60 degrees
nasally and 90 degrees temporally
 Standard visual field testing is performed on a
30 or 24 degree field; however for these types
of patients a 60 degree field test is ideal to
fully assess their visual function
 Perimetric testing is not always possible due to
physical, cognitive, behavioral or attentive states

13. Humphreys
Visual Field
Analyzer

14. FDT
Visual Field
Analyzer

15. Tangent Screen

16. Treatment
 Homonymous hemianopia will show some sign of
spontaneous resolution in 50-60% of patients
within the first 6 months
 Little has been shown to improve beyond this
time frame spontaneously; however improvements
can be made with specific rehabilitative techniques

17. Treatment – Quadrant field loss
Superior Field Loss
 Patients need warning about overhead lighting
and cabinets, and should be reminded to scan
new environments they enter
Inferior Field Loss
 Interfere with reading and mobility and should
be treated similar to a patient with a
hemianopic deficit

18. Treatments
Double Vision
 Treatment to restore binocular vision can be
employed with optometric vision therapy
 Assessment should be made as to whether the
loss of binocularity is helpful in overcoming a
visual field deficit by expanding the visual field.
If so, cling patches or occlusion foils can be
utilized to address the double vision in primary
gaze.
 Binasal Occluders
 Prism

19. Treatments
Perceptual Speed – critical for safety
 Tachistoscope training (Flash games)
 Computer programs
Scanning
 Practice large saccades into the blind field,
followed by smooth pursuit in opposite
direction
 Limit head movement (limit vestibular
input)
 Must also be practiced while moving

20. Treatments
Borderzone Stimulation
 Most field recovery happens at the blind
edge of the sighted field in homonymous
hemianopia
Peripheral Prism Application
 Gottleib prism mounted on peripheral edge
of lens
 Shifts blind field towards midline once you
look into the prism

21. Gottleib Prism

22. Treatments
Prism for Balance
 Yoked prism can be used to realign a patient’s
center of gravity and improve overall balance

24. Visual-Spatial Inattention
 Cognitive deficit that refers to a relative lack of
awareness to objects, people or visual stimuli
presented in the visual space contralateral to
the location of the cerebral lesion
 Also referred to as visual-spatial neglect,
unilateral spatial inattention (USI), visual hemi-inattention
or visual imperception
 Between 65-80% of patients with a stroke have
been reported to experience visual-spatial neglect

25. Visual-Spatial Inattention
 Frequently associated with hemianopia,
hemiparesis and other perceptual and
sensorimotor deficits
 Typically left visual-spatial neglect occurs
following a right hemispheric injury; this form is
more common and longer lasting than right side
visual-spatial neglect
 It will vary from person to person in severity

26. Visual-Spatial Inattention
 Patients with left visual-spatial neglect will veer
to the left when walking or bump their left
shoulder on door frames
 They will frequently lose their spatial orientation
and become confused even in familiar
environments.
 While eating they will leave food on the left side
of their plates; they will forget to comb or
shave the left side of their face; may be
startled by presence of their left arm

27. Visual-Spatial Inattention
The Parietal Lobe is the most common location
for the lesion causing visual-spatial neglect.
Other studies have found lesions in the frontal
lobe, parietofrontal white matter tracks,
subcortical regions (basal ganglia, pulvinar) and
the dopaminergic pathways.
The patient is unaware of the spatial loss and
denies that a problem exists

28. Testing for
Visual-Spatial Inattention
1. Extinction Test – via Confrontational Fields
2. Line Bisection Task
3. Letter Cancellation
4. Hart Chart
5. Picture Scanning
6. Picture Drawing

29. Testing for
Visual-Spatial Inattention

30. Hart Chart

31. Draw a clock Test

32. Interventions for
Visual-Spatial Inattention
Compensatory
 Draw a red highlighted line down the vertical
margin of each page; can use a red velcro strip,
ruler or reading guide
 Turn the page 90 degrees to avoid reading across
the body midline
 Trace underneath sentences with a pen to keep
track of what has been read
 Brightly colored T-square to help with tracking
and returning to the left margin

33. Interventions for
Visual-Spatial Inattention
Rehabilitative Activities
 Tracking exercises, visual search techniques
 Margolis eye throwing technique
 Involves proprioception and kinesthetic cueing to ensure
complete scanning of the environment
 Body Image Awareness
 Silhouette
 Body Lifts
 Prism Adaptation
 2 week trial minimum
 Alters perception of space

35. Post Traumatic Vision Syndrome
1. Convergence Insufficiency
2. Exotropia/High Exophoria
3. Accommodative Deficiencies
4. Photophobia
5. Low Blink Rate
6. Visual Spatial Distortions
7. Oculomotor Deficits (saccades, pursuits)
8. Difficulties with attention and concentration

38.  The physical lines of print appear to create an
irritating set of mirages in up to 50% of all
readers whose brains are hyper-reactive to
most sensory inputs.
 These illusions take a number of forms, but
most frequently make the print seem to
move on the page with a flowing, rippled look
or a swirling of the text in the periphery of
one’s vision.

40. Lens Treatments
1. Avoid multifocals *****
2. Always consider two pairs of glasses
3. May also require additional computer
Rx
4. Tints, polarization, anti-glare coatings
5. May require additional wrap around
sunglasses

41. Prism Treatments
1. Compensatory Prisms
 Fresnel Press-On Prisms (temporary)

42. Fresnel Prisms

43. Prism Treatments
1. Compensatory Prism - monocular
 Base Out for Esotropes
 Base In for Exotropes
 Vertical Prism for Hyper/Hypotropias
 Oblique axis
2. Therapeutic Prisms
 Yoked-Prism
 Shift spatial world to improve midline shifts, balance
and mobility, enhance stereopsis, eliminate visual-spatial
inattention

44. Occlusion Treatments
Elastic Patches
 avoid solid pirate patch, opt for a
translucent/frosted clear patch whenever possible
 great for patients who don’t wear glasses
 still allows for peripheral
awareness

45. Occlusion Treatments
 Cling Patches (Bangerter Occlusion Foils)
can vary from opaque (light perception) to
varying degrees of translucency
 Provide varying acuities, i.e. 20/50,
20/200, light perception

48. Occlusion Treatments
 Partial or spot patches can be used as immediate
treatment for double vision.
 Partial patches will allow the patient to maintain
peripheral awareness and facilitates their overall
coordination and balance.
 Occlusion Therapy without an assessment is NOT
recommended.

49. Superior Occlusion

50. Inferior Occlusion

51. Spot Occlusion

52. Streff
Wedge

53. Binasal Occluders
 Encourages divergence
 Eliminates cross fixation with esotropes

55. Bitemporal Occlusion
 Promotes convergence
 Helpful for some exotropes or high exophore’s

56. Where to find these products?
Bernell Vision Corporation
Bernell.com
 Wholesale prices to vision specialists
Optometric Education Foundation
Oepf.org

58. Visual-Vestibular Processing
There is an intimate relationship between vision,
vestibular and motor processing
 Stand on one foot: balance is achieved due to
input from vision, vestibular and proprioception
 Stand on one foot with eyes closed: you start to
lose your balance because visual information is lost
to provide motion stabilization

59. Visual-Vestibular Processing
 Dynamic Visual Acuity
 Use Snellen Chart; lateral head movements 2
cycles per second
 2 line drop in acuity – Abnormal Vestibular
Function
 Do lenses improve or reduce acuity?
 Watch for progressive lenses/bifocals

60. Vestibular-Ocular Reflex
 Reflexive eye movement in the opposite direction
to head movement in order to stabilize retinal
image and prevent BLUR
 One of the fastest reflexes in the body
 Stimulation of semicircular canals send impulse
along CN VIII; contralateral CN VI nuclei; lateral
rectus/opposite medial rectus (CN III) eye
muscles

62. VOR Gain
 Change in the eye angle divided by change in head
angle during head movement
 Ideally VOR Gain = 1
 It will vary if bifocals/progressive lenses are worn
 Low plus lenses will magnify and increase VOR
gain, thus decreasing dizziness; can eliminate need
for sunglasses
 Eye tracking exercises will increase VOR Gain

63. Dizziness –
Optometric Management
 Need to stress peripheral awareness and switch
from central (focal) to peripheral (ambient)
quickly to minimize dizziness
 Assess blink patterns, to aid refixation which will
decrease dizziness
 Encourage multiple fixations during
walking/turning, ‘visual anchors’

65. Visual Information Processing
 Active process of locating, extracting and
interpreting visual information from the environment
 These deficits can be academically, socially and
vocationally disabling
Symptoms:
 Difficulties with attention and concentration
 Memory deficiencies
 Decreased processing speed
 Poor spatial orientation

66. Visual Memory
“The true art of memory is attention.”
Samuel Johnson
 Memory deficits are one of the most persistent
effects of TBI.
 Reported to occur in approximately 70-80% of
victims.
 Impact day to day functioning.
 Prevent patients from returning to work.
 Prohibit independent living.

67. “Pooh looked at his two paws. He knew that one
of them was the right and he knew that when
you had decided which one of them was the right
then the other was the left; but he could never
remember where to begin.”
A.A. Milne

68. Visual Spatial Deficits
 Figure-ground discrimination
 Visual closure
 Form perception
 Right/left discrimination
 Visualization
 Visual thinking
 Visual logic/reasoning

72. Copyright © Diopsys, Inc. 2012. All Rights Reserved. Patent Pending.
How MUCH
How FAST

73. Clinical Indications for VEP
 Visual Disturbances
 Amblyopia
 Subjective Disturbances
 Double Vision
 Binocular Vision Disorder
 Visual Field Defect
 Color Vision Deficiencies
 Night Blindness
 Disorders of the Optic
Nerve & Visual Pathway
 Papilledema
 Optic Atrophy
 Glaucomatous Optic
Atrophy
 Drusen of the Optic
Disc
 Optic Neuritis
 Injury to Eye or Brain
 TBI
 Concussion

74. Additional Information
 www.nora.cc
Neuro-Optometric Rehabilitation Association
 www.covd.org
College of Optometrists in Vision Development
 www.marylandvisiontherapy.com
 drkungle@marylandvisiontherapy.com

75. Thank you!