FOTA
Florida Occupational Therapy
Association
FOTA Annual Conference
November 8-9, 2013
Daytona Beach, FL
Attended by:
Lau...
Identifying Risk for Falls in the
Adult Client with Visual
Impairment: Strategies for
Prevention
Speakers:
• Sarah LaRosa,...
Condensed & modified
presentation
by Laura M. & Elke L.
Did you know?
• Visual impairment is one of
the primary contributions to
falls among elderly persons
CDC report
• Older adults with vision loss are more likely to
experience comorbid conditions than people without
vision lo...
What is low vision?
• Impaired vision with a significant reduction in visual
function which is not correctable with conven...
Scope of Practice: OT Services for the
Client with Low Vision
• From AOTA’s resource manual: “Practice
Guidelines for Adul...
Scope of Practice: Role of OT
• Perform vision screening, lighting
assessments, glare assessment, balance
screening, home ...
Scope of Practice: OT Services for the
Client with Low Vision
• Coverage by Medicare for OT in low vision since
1990
• Vis...
Key Concepts
• The brain sees, NOT the eyes! The eyes merely take a
photograph for the brain to process.
• Ocular visual i...
Anatomy of the Eye
Anterior or Posterior?
• Where is the dysfunction?
– Is it the camera (the eye; anterior visual system)
– Or the computer/...
Functional Impact of Central Vision
Loss (i.e. ARMD, retinal tears)
• ADL problems most apparent
– Unable to recognize the...
Macular Degeneration
(central vision loss)
Diabetic Retinopathy Functional
Deficits
• Reading syringe, reading sliding scale, reading
glucometer
• Inspecting skin
• ...
Diabetic Retinopathy
(mixed vision loss)
Functional Impact of Mixed Vision Loss
• (i.e. Diabetic Retinopathy: Advanced Glaucoma)
• -fluctuating levels of vision (g...
Glaucoma
• “silent disease”, consider testing if family history
• increase intra-ocular pressure leading to optic
nerve da...
Glaucoma (peripheral vision loss)
Functional Implications of Peripheral
Vision Loss
• (i.e. Glaucoma, Retinitis Pigmentosa, CVA)
-mobility problems most app...
Retinitis Pigmentosa
Visual Field Loss
Functional Implications
• Problems as seen with field loss from disease
• Cognitive/perceptual component of
inattention, n...
TBI
• Wide range of visual deficits including:
– Partial to total field losses
– Changes in acuity
– Perceptual changes
– ...
Common Optic Conditions
• Myopia- if the image falls in front of the retina, it is
referred to as nearsighted (+ power)
-c...
Aging Eye
• Two types of prescription lens:
– Single vision: distance, near, intermediate (ex.
computer, piano, painting)
...
Why does this matter?
• Wearing multifocal lens
– Eye has to focus through the correct lens for the correct distance or th...
Research to Consider
• “Multifocal glasses impair edge-contrast
sensitivity & depth perception & increase the risk
of fall...
More Research
• Loss of edge-contrast sensitivity (steps, curbs,
cracks) may more accurately reflect capacity to
detect ob...
Cataract (foggy vision)
Slideshow: What Eye Problems
Look Like
• http://www.webmd.com/a-to-z-
guides/ss/slideshow-eye-conditions-overview
Importance of Vision Screening
• “one-third of community dwelling people over the age of 65 years fall at
least once a yea...
Impact of Vision Impairment for OT
• 21% of people over 65, by self report, have vision
impairment that impacts their ADLs...
Vision Screening: Methods & Tools
• Areas to assess include:
– Visual fields: central & peripheral
– Central distortions (...
• Obtain History
• Observation
• Assessments:
– Corneal & pupillary reflex
– Tracking/motor control
– Pursuits & saccade
–...
Screening to identify risk for falls in the
older adult with vision impairment
• Timed up and Go (TUG)
• Berg Balance Scal...
Intervention Strategies
• After assessing visual function & assessing risk for falls, here are some
simple interventions t...
Eccentric Viewing Training
• macular scotoma – blind, blurred or distorted spot in central field d/t damage in
the cone re...
Visual Scanning/Search
*Deficits:
– Visual field deficit (VFD)
– Visual Scanning: Hemi-inattention and/or Visual Spatial N...
Dynavision
Smooth Pursuit Eye Movement
Training
• 2013 study published in Neurorehabilitation and
Neural Repair
• Randomized Prospect...
AOTA tips: Living with Low Vision
• http://www.aota.org/~/media/Corporate/File
s/AboutOT/consumers/Adults/LowVision/Low
%2...
Depth Perception: must teach
monocular cues (cues that can be processed by just one eye)
• Linear Perspective
– Parallel l...
Environmental Modifications
• Organize Environment
– Structure
– Simplify
– Reduce background pattern
• Enhance Contrast
•...
Referral Services
• Check to make sure the client is being followed by an MD to have
the health of the eye routinely exami...
Low Vision Rehabilitation
of Central Florida (speaker’s handouts)
• Tips for working with visually impaired
• Sighted Guid...
FSCJ – ILAB
• http://www.fscj.edu/community-
engagement/independent-living-for-adult-
blind
• Vision Rehabilitation Servic...
THANK YOU
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Fota conference 2013

  1. 1. FOTA Florida Occupational Therapy Association FOTA Annual Conference November 8-9, 2013 Daytona Beach, FL Attended by: Laura Moritz & Elke Lacayo
  2. 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. 3. Condensed & modified presentation by Laura M. & Elke L.
  4. 4. Did you know? • Visual impairment is one of the primary contributions to falls among elderly persons
  5. 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. 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. 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. 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. 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. 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. 11. Anatomy of the Eye
  12. 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. 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. 14. Macular Degeneration (central vision loss)
  15. 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. 16. Diabetic Retinopathy (mixed vision loss)
  17. 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. 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. 19. Glaucoma (peripheral vision loss)
  20. 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. 21. Retinitis Pigmentosa
  22. 22. Visual Field Loss
  23. 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. 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. 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. 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. 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. 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. 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. 30. Cataract (foggy vision)
  31. 31. Slideshow: What Eye Problems Look Like • http://www.webmd.com/a-to-z- guides/ss/slideshow-eye-conditions-overview
  32. 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. 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. 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. 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. 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. 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. 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. 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. 40. Dynavision
  41. 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. 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. 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. 44. Environmental Modifications • Organize Environment – Structure – Simplify – Reduce background pattern • Enhance Contrast • Ensure proper illumination • Modify tasks
  45. 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. 46. Low Vision Rehabilitation of Central Florida (speaker’s handouts) • Tips for working with visually impaired • Sighted Guide Techniques • Protective Techniques
  47. 47. FSCJ – ILAB • http://www.fscj.edu/community- engagement/independent-living-for-adult- blind • Vision Rehabilitation Services
  48. 48. THANK YOU
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