FOTA Annual Conference 11/8-9, 2013

1. FOTA
Florida Occupational Therapy
Association
FOTA Annual Conference
November 8-9, 2013
Daytona Beach, FL
Attended by:
Laura Moritz & Elke Lacayo

2. Identifying Risk for Falls in the
Adult Client with Visual
Impairment: Strategies for
Prevention
Speakers:
• Sarah LaRosa, MOT, OTR/L, CLVT
• Bonnie Smith, OTR/L, CLVT

3. Condensed & modified
presentation
by Laura M. & Elke L.

4. Did you know?
• Visual impairment is one of
the primary contributions to
falls among elderly persons

5. CDC report
• Older adults with vision loss are more likely to
experience comorbid conditions than people without
vision loss
• Implication: Serious consequences for overall health,
ability to perform tasks, and to participate in social
roles
• Of people 65 years & greater in age vision loss is
expected to be 5.7 million

6. What is low vision?
• Impaired vision with a significant reduction in visual
function which is not correctable with conventional
glasses, contact lenses, surgery or other medical
treatment
• Encompasses individuals with less severe vision loss
as well as those who are legally blind
• Legal blindness is defined as: 20/200 or worse in
better eye or <20 degrees of visual field (or use
Snellen Chart)

7. Scope of Practice: OT Services for the
Client with Low Vision
• From AOTA’s resource manual: “Practice
Guidelines for Adults with Low Vision”
-Summary: “Expanding the role of
Occupational Therapy in low vision by helping older
adults use their remaining vision to participate in
desired occupations, supports their need for health
& productive lives. Similarly, modifying the home
environment to facilitate individual’s safe
participation in daily activities contributes to
overall health & wellness.

8. Scope of Practice: Role of OT
• Perform vision screening, lighting
assessments, glare assessment, balance
screening, home safety assessment:
– Modify home environment via lighting change,
use of contrast, obstacle removal, glare
management
– Training in the use of:
• Preferred Retinal Locus (PRL)
• Eccentric viewing
• Visual scanning, tracking, tracing

9. Scope of Practice: OT Services for the
Client with Low Vision
• Coverage by Medicare for OT in low vision since
1990
• Vision impairment was recognized as a physical
disability
• Must be provided under direction of Physician or
Optometrist (preferably a low vision specialist)
• Services must be “medically necessary and
reasonable”
– address lack of independence or safety
due to impairment

10. Key Concepts
• The brain sees, NOT the eyes! The eyes merely take a
photograph for the brain to process.
• Ocular visual impairment is the direct result of any lesion in
the anterior visual system.
• Cortical visual impairment is the direct result of any lesion in
the posterior visual system.
• The function of all eye movements is to keep images focused
on the fovea!
• It is the sum total of all lobes working together that allows a
person to visually process information and adapt to the world
around them.

11. Anatomy of the Eye

12. Anterior or Posterior?
• Where is the dysfunction?
– Is it the camera (the eye; anterior visual system)
– Or the computer/processor (the brain; posterior
visual system)
– Or both??

13. Functional Impact of Central Vision
Loss (i.e. ARMD, retinal tears)
• ADL problems most apparent
– Unable to recognize therapist’s face (mistaken for memory deficit)
– Unable to read (exercise programs, bathroom door signs, exit signs)
– Cannot identify colors (clothing)
– Difficulty with depth perception (stairs, curbs, uneven surfaces)
– Unable to see non contrasting objects (get up & go test with dark chair
against dark floor, pills on a counter top, sock on floor)
– Lighting may create glare causing increased difficulty with all visual tasks
(i.e., white table top, white linoleum floor)
– Difficulty at meal times (spilling, dropping items, inability to identify food
on plate, difficulty cutting bite size pieces)
– Slowed accommodation to changes in lighting (especially outside to
inside)
– Apparent memory deficits—related to inability to use visual memory
– Poor rehab motivation due to depression

14. Macular Degeneration
(central vision loss)

15. Diabetic Retinopathy Functional
Deficits
• Reading syringe, reading sliding scale, reading
glucometer
• Inspecting skin
• Working around the stove or oven (burns)
• Photophobia: indoors & outdoors
• Reduced activity & mobility levels
• Fluctuating acuities

16. Diabetic Retinopathy
(mixed vision loss)

17. Functional Impact of Mixed Vision Loss
• (i.e. Diabetic Retinopathy: Advanced Glaucoma)
• -fluctuating levels of vision (good general & task lighting, use contrast, manage
blood sugars, control intraocular pressure)
• -glare sensitivity (glare filters, sunglasses indoor & outdoor, curtain & blind use,
visors)
• -inability to perform skin inspection (good task lights & magnifying mirror)
• -difficulty reading insulin syringes (syringe magnifier, contrast, lighting,
magnification, prefilled syringes
• -reading & ADL problems as with central loss
• -mobility problems as with peripheral loss

18. Glaucoma
• “silent disease”, consider testing if family history
• increase intra-ocular pressure leading to optic
nerve damage
• “tunnel vision”
• Extreme contrast sensitivity loss (i.e. night
driving)
• Extreme photophobia
• Night blindness

19. Glaucoma (peripheral vision loss)

20. Functional Implications of Peripheral
Vision Loss
• (i.e. Glaucoma, Retinitis Pigmentosa, CVA)
-mobility problems most apparent
*walks into door frames or open doors (use protective techniques,
use cane, use scanning)
*does not see furniture or items on floor (improve lighting, tracing
techniques, scanning)
*does not see curb or stairs (use contrast, cane, scanning)
*walks into open cabinet doors and overhangs (protective
techniques, lighting, scanning, contrast)
*unaware of approaching people, cars, bikes (orientation & mobility training,
use of auditory cues, white cane/walker as symbol of vision deficits)
*difficulty locating doors, cars, bathrooms, objects (tracing, contrast use,
lighting)
*does not scan full sentence when reading/difficulty locating margins/reduced
comprehension (marginal cues, typoscopes, scanning techniques, CCTV)
*may be glare sensitive (glare filters, sunglasses)
*may have difficulties in low light (task lighting, increased general lighting, cane
use, night lights)

21. Retinitis Pigmentosa

22. Visual Field Loss

23. Functional Implications
• Problems as seen with field loss from disease
• Cognitive/perceptual component of
inattention, neglect
• May also have sensory or motor loss
• Balance & fall risk increased with multisensory
impairment

24. TBI
• Wide range of visual deficits including:
– Partial to total field losses
– Changes in acuity
– Perceptual changes
– Depth perception losses
– Diplopia
-Acquired strabismus
-Nystagmus
*Central Sign
*Multi-directional
-Photophobia

25. Common Optic Conditions
• Myopia- if the image falls in front of the retina, it is
referred to as nearsighted (+ power)
-corrected with concave/minus lens
• Hyperopia- if the image falls behind the retina it is
referred to as farsighted (- power)
-corrected with convex/plus lens
• Astigmatism- unequal curvatures occur along the
refractive surface such that the rays of light are not
focused on a single point on the retina
-creates a blur
-corrected using a cylindrical (toric lens)

26. Aging Eye
• Two types of prescription lens:
– Single vision: distance, near, intermediate (ex.
computer, piano, painting)
– Multifocal: bifocals, trifocals, progressive lens
• Bifocal & trifocal-see line
• Progressive- don’t see a line

27. Why does this matter?
• Wearing multifocal lens
– Eye has to focus through the correct lens for the correct distance or there is
blur
• Ex. Going down steps or curbs, chin tuck to see through top portion of
bifocals or trifocals
• Cognitive deficits may reduce correct use
• Visual deficits may already induce blur or scotoma
• Progressive lenses have zones of no correction in periphery of lenses-
smaller areas of correction than lined bifocals or trifocals

28. Research to Consider
• “Multifocal glasses impair edge-contrast
sensitivity & depth perception & increase the risk
of falls in older people”
– Lord, S., et al. (2002). Multifocal glasses impair edge
contrast sensitivity & depth perception & increase risk
for falls in older people. Journal of American Geriatric
Society, 50(11), 1760-6.
– Results of study: more than twice as likely to fall in
follow up period
– More likely to fall due to trip, when outside home or
walking up or down stairs

29. More Research
• Loss of edge-contrast sensitivity (steps, curbs,
cracks) may more accurately reflect capacity to
detect obstacles than acuity
• With recurrent falls, may consult with OD or MD
– Re: change to single vision lens
– Must have cognitive ability to remember to wear NVO
to read & DVO for mobility
*TIP for OT: find low vision Ophthalmologist or
Optometrist in your area to consult with and refer to

30. Cataract (foggy vision)

31. Slideshow: What Eye Problems
Look Like
• http://www.webmd.com/a-to-z-
guides/ss/slideshow-eye-conditions-overview

32. Importance of Vision Screening
• “one-third of community dwelling people over the age of 65 years fall at
least once a year”
– 3 categories of falls:
• Falls that result from interference with base of support: trips, slips
• Falls that result from externally applied push or self induced
displacement: bending, reaching, turning, or transfer
• Falls from physiological event disrupting posture control
mechanism
• (Salonen, 2012)

33. Impact of Vision Impairment for OT
• 21% of people over 65, by self report, have vision
impairment that impacts their ADLs
• If your patient has vision impairment as a
secondary problem, ignoring it will impede your
progress with their chief complaint
• Falls are a leading cause of hospitalization and
mortality in older adults
• Vision is a key component of balance
– Vestibular system
– Somatosensory system

34. Vision Screening: Methods & Tools
• Areas to assess include:
– Visual fields: central & peripheral
– Central distortions (metamorphopsia) or scotomas
– Loss of depth perception
– Loss of contrast sensitivity & color vision
– Response to glare & lighting needs
– Perceptual deficits
– Occular-motor control
– Acuity
– Appropriateness of AD such as magnifiers &
telescopes

35. • Obtain History
• Observation
• Assessments:
– Corneal & pupillary reflex
– Tracking/motor control
– Pursuits & saccade
– Ocular & vestibulo-ocular reflex
– Convergence
– Strabismus
– Eye dominance
– Visual fields
– Central or peripheral fields
– Facial fields
– Contrast sensitivity
– Color testing
– Depth perception
– Glare assessment
– Acuity screening
– “M” or Meter Measurement with Acuity
– Reading tests
– Multiple Testing tools

36. Screening to identify risk for falls in the
older adult with vision impairment
• Timed up and Go (TUG)
• Berg Balance Scale (BBS)
• Functional Reach Test
• Tinetti Falls Efficacy Scale (FES)
• UAB Center for Low Vision Rehabilitation:
Falls Efficacy Scale

37. Intervention Strategies
• After assessing visual function & assessing risk for falls, here are some
simple interventions to increase safety with mobility for the person with
visual impairment:
• Eccentric Viewing Training
• Visual Scanning Training
• Smooth Pursuit Training

38. Eccentric Viewing Training
• macular scotoma – blind, blurred or distorted spot in central field d/t damage in
the cone receptor cells responsible for detecting detail & color
• Fovea no longer serves as the point of fixation or retinal locus
• Must use a “pseudo fovea” or preferred retinal locus (PRL) for off center viewing to
identify objects
• AKA PRL training
– have client perform eye movements drifting in/out of scotoma at varied distances up to 5-8 ft (off
center focus & shifting back/forth, i.e. when cooking)
– Use a variety of functional objects (clock, face, building structure, street signs, etc.)
– Train in different environments (carry over of technique needs to be everywhere)
• Static
• Dynamic
• Home
• Community

39. Visual Scanning/Search
*Deficits:
– Visual field deficit (VFD)
– Visual Scanning: Hemi-inattention and/or Visual Spatial Neglect
*Strategies:
-Visual Scanning Training (VST)
-dynavision
-laser pointers
-scan course
-extrapersonal scan boards
-post-it notes on a wall
-lighthouse strategy
-video feedback

40. Dynavision

41. Smooth Pursuit Eye Movement
Training
• 2013 study published in Neurorehabilitation and
Neural Repair
• Randomized Prospective Trial
• Subjects; n=45
– Right CVA with left VSN & auditory neglect
• Effectiveness of VST vs SPT
• Pre-training, post-training, 2 week follow-up
• SPT group showed significant improvement at
post training & at 2 week follow-up vs VST group
which showed no significant improvement

42. AOTA tips: Living with Low Vision
• http://www.aota.org/~/media/Corporate/File
s/AboutOT/consumers/Adults/LowVision/Low
%20Vision%20Tip%20Sheet.ashx
• Patterson Medical Low Vision AE:
• http://www.pattersonmedical.com/app.aspx?
cmd=searchResults&sk=low+vision

43. Depth Perception: must teach
monocular cues (cues that can be processed by just one eye)
• Linear Perspective
– Parallel lines (i.e. outer edges of road appear to meet)
• Texture
– Grassy field appears less textured the farther away it gets
• Gradient
– i.e. sidewalk marked for textural changes, slope
• Apparent size of familiar objects
– Size of familiar objects
– When you see things far away they appear smaller, & when you are
closer they appear larger

44. Environmental Modifications
• Organize Environment
– Structure
– Simplify
– Reduce background pattern
• Enhance Contrast
• Ensure proper illumination
• Modify tasks

45. Referral Services
• Check to make sure the client is being followed by an MD to have
the health of the eye routinely examined; Ophthalmologist
• Orientation & Mobility Specialists
• PT
• Low Vision Optometrist
• Low Vision OT
• http://www.brookshealth.org/outpatient/locations/center-for-low-
vision/
-Sarah LaRosa email: sarah.larosa@brooksrehab.org
• http://www.lowvisionofcentralflorida.com/
-Bonnie Smith email: lowvisionrehabilitation@gmail.com

46. Low Vision Rehabilitation
of Central Florida (speaker’s handouts)
• Tips for working with visually impaired
• Sighted Guide Techniques
• Protective Techniques

47. FSCJ – ILAB
• http://www.fscj.edu/community-
engagement/independent-living-for-adult-
blind
• Vision Rehabilitation Services

48. THANK YOU