Page 39 - BOAF Journal 1 2012:2707

Behavioral Optometry
BOAF
Volume1 Number1 2012
The patients, the physiatrist, all other members of the rehab team and you the optometrist can all have different goals. Of- ten you can help the other pro- fessionals by suggesting modi- fications in their therapy based upon your evaluation. By work- ing together, you can help the patient improve with less frus- tration and help them to reach their highest potential in the least amount of time.
The key basis to successful teamwork is education. Each of us as professionals can bring our experiences and knowledge to the team. An example of a patient who needed optometric intervention is a one with a ves- tibular concussion. The patient may be evaluated by the otolo- gist or neuro-otologist and found to need vestibular ther- apy. The physical therapist will generally provide gaze stabiliza- tion activities that may help the patient some to some degree, but sometimes the patient may also feel worse due to the in- creased vestibular-visual symp- toms. It is recommended that all vestibular patients have a full optometric functional examina- tion. This is especially true with patients who do worse or no better with traditional gaze sta- bilization therapy. The optome- trist may find visual blur secon- dary to a poor gain of the vesti- bular ocular reflex. The optome- trist may then prescribe low plus lenses or consider proprio- ceptive support for the therapy procedures. The patient would then be ready for more effective
and successful vestibular ther- apy with the physical therapist. In this example, the outcome for the patient would likely be bet- ter. Many times I’ve had these patients rehabilitate to the point where they may only need low plus lenses on a part time basis to maintain a good visual- vestibular relationship. For fur- ther information on vestibular dysfunction, please the book by Susan Herdman.
Basic Visual Skills
Following an ABI many pa- tients are found to suffer diffi- culties with basic visual skills. There are commonly concerns in the area of accommodation, binocularity, extra ocular motor (EOM) control and overall proc- essing speed. Politzer and Suter describe many of these conditions in their chapter on “Vision Examination of Patients with Neurological Disease and Injury. Often patients are evalu- ated by the speech therapist for reading abilities or the neurop- sychologist for information processing and overall cognitive function. Many patients who are evaluated may have poor performance because of any of the areas noted above. In some cases the patient may have de- veloped a dysfunction or have lost the resiliency to compen- sate for a preexisting condition. An example could be a dys- function of accommodation or the loss of the ability to com- pensate for prepresbyopia. The patient’s difficulty reading or performance on the neuropsy-
chological testing may not ac- tually be a speech or neuropsy- chological problem, but simply an undiagnosed visual deficit that interferes with the attempt at performing the task.
The inability to track during reading may be recovered with the use of lenses, prism, selec- tive occlusion, vision rehabilita- tion and/or compensatory strategies. For example one might use low plus lenses or base in prism to help the patient to handle the spatial demands of the reading task. The patient may also benefit by the use of his fingers to anchor the begin- ning of the line of reading so he can locate the next line of print with less effort and distress. This proprioceptive compensa- tory strategy can be used until further recovery and improve- ment is made in ocular motor processing.
Paresis/Palsy of Extra Ocular Muscles
ABI may present with corti- cal and/or subcortical insults that prevents or limits the pa- tient’s ability to scan binocularly and/or monocularly. Cortical lesions may present with gaze palsies and/or gaze prefer- ences. Wong describes these well in her book, Eye Movement Disorders. This may not allow the patient to scan across the midline to one side and thus prevent an appropriate scan- ning and interpretation of one’s visual space. This may also be related to unilateral spatial inat- tention. Subcortical lesions
- 39-