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The Role of Neuro-Optometric Rehabilitation

  • M. H. Esther Han
Chapter

Abstract

Neuro-optometric rehabilitation is a specialized field within optometry, involving the evaluation and management of visual sequela secondary to neurological events affecting and interfering with normal visual information processing. These sequelae adversely impact the patient’s ability to perform many activities of daily living (ADLs). The most common etiologies are mild traumatic brain injuries (mTBIs), such as concussion and cerebrovascular accidents (CVAs). However, systemic conditions with associated neurological consequences, such as vestibular dysfunctions, autoimmune diseases, and/or viral infections, can also adversely affect the visual system in ways other than visual clarity.

The visual sequela affects the input of visual information: it may prevent the patient from having clear and single vision at all distances. Poor visual input will undoubtedly affect visual information processing. Given the diffuse axonal injury often occurring with mTBI, damage to neurological pathways involving vision will impact negatively on the speed, accuracy, and sustaining ability to process and integrate visual information within a multisensory context.

Management may include spectacles to correct the refractive state (myopia, hyperopia, astigmatism, and/or presbyopia), prisms (fusional and/or yoked) to reduce symptoms, such as double vision and disequilibrium, tinted lenses to reduce photosensitivity and/or visual discomfort, and occlusion (full or partial) to reduce double vision and/or posturally related symptoms. An optometric vision therapy program is highly recommended to improve sensorimotor and visual processing integration deficits, which cannot be resolved with spectacle lenses alone. Thus, the goal of neuro-optometric rehabilitation is to maximize the patient’s ability to function within a multisensory environment.

Keywords

Accommodation Binocular Oculomotor Contrast sensitivity Diplopia Light sensitivity Hemianopia Visual vestibular deficits Visual perceptual deficits Dorsal stream deficits 

Notes

Glossary of Clinical Terms (Cline, Hofstetter, & Griffin, 1989; Han, 2007; Kapoor & Ciuffreda, 2005)

Accommodation

The ability to change focus and maintain a clear image of an object (when looking from far to near and vice versa), using the eye’s crystalline lens-based mechanism.

Accommodative amplitude

The closest point of clear vision that is typically measured monocularly.

Accommodative infacility

A condition in which slow or difficult accommodative responses are observed in response step changes in lens power.

Accommodative insufficiency

A condition in which the measured amplitude of accommodation is less than expected given the patient’s age.

Astigmatism

Unequal refractive error in orthogonal meridians of the eye. Rays of light from infinity come to a focus at two different distances relative to the retina, with accommodation minimally stimulated.

Binocular

Viewing with two eyes at the same time.

Contrast sensitivity

The ability to detect threshold contrast targets. Measuring contrast sensitivity measures the ability to resolve spatial properties across a range of spatial frequencies and levels of contrast (Warren, 1993).

Convergence

The turning inward of the eyes toward each other.

Convergence excess

A condition in which esophoria is greater at near than far.

Convergence insufficiency

The condition in which exophoria is greater at near than far, with a receded near point of convergence and reduced relative fusional convergence at near.

Diplopia

The condition in which a single object is perceived as two objects rather than one; double vision.

Divergence

A deviation or relative movement of the two eyes outward from parallelism.

Divergence excess

A condition in which exophoria is greater at distance than near and often associated with an exotropia.

Divergence insufficiency

A condition in which there is greater esophoria at distance than near, and is often associated with esotropia.

Emmetropia

Essentially no refractive error present.

Esophoria

A condition in which the two eyes intersect in front of the plane of regard when fusion is disrupted.

Exophoria

A condition in which the two eyes intersect beyond the plane of regard when fusion is disrupted.

Exotropia

A type of strabismus in which the nonfixating eye is turned outwards.

Fixation

Ocular alignment with the image of the fixated target falling on the fovea; may be performed one eye at a time (i.e., monocularly) or with both eyes at the same time (i.e., binocularly).

Fusion

Single, cortically integrated vision under binocular viewing conditions.

Fusional prism

The amount of prism an individual can fuse.

Fusional range

The range over which the vergence system can be stimulated by the addition of prisms binocularly and still maintain single, binocular vision at both distance (6 m) and near (40 cm). Three parameters are recorded: the first is the amount of prism at which the patient reports blurred vision; the second is the amount of prism at which the patient reports diplopia; and, the third is the amount of prism at which the patient regains fusion.

Hemianopia

Hemi-field visual field defect, which may be unilateral or bilateral (i.e., homonymous or bitemporal).

Hyperopia

Far-sightedness; when rays of light from infinity come to a focus behind the eye, with accommodation minimally stimulated.

Monocular

Viewing with one eye at a time.

Myopia

Near-sightedness; when rays of light from infinity come to a focus in front of the eye, with accommodation minimally stimulated.

Nystagmus

Rapid involuntary oscillation or movement of the eyes, the presence or absence of which may be diagnostic of neurological and vision disorders.

Oculomotor

When the eyes move (includes fixation, pursuit, and saccade) to follow targets moving laterally, vertically, or obliquely in one plane, with no change in depth.

Oscillopsia

Illusory movement of the world generally related to vestibular dysfunction.

Presbyopia

Normal age-related, physiological loss of focusing ability.

Prism

A lens that deviates the path of light as it passes through it. A prism is characterized by the base and the apex and is described by the direction of the base. Prisms move images away from the base and towards the apex. Prisms are measured in units called prism diopters. One prism diopter indicates that the image is moved by 1 cm at a distance of 1 m (Brooks & Borish, 1996).

Pursuit

Slow, continuous, and conjugate eye movement used when the eyes follow an object as it is moved slowly and smoothly.

Refractive status

The degree to which images on the retina are not focused.

Saccade

Rapid, step-like conjugate eye movement that redirects the line of sight from one position to another.

Strabismus

An anomaly of binocular vision in which one eye fails to intersect an object of regard.

Stereopsis

Relative depth perception based on horizontal retinal image disparity.

Vergence

When the two eyes move to track targets moving in depth.

Versional eye movements

When the two eyes move (includes fixation, pursuit, and saccade) to follow targets moving laterally, vertically, or obliquely in one plane, with no change in depth.

Vestibulo-ocular reflex (VOR)

Rapid, reflex movement of the eyes, which functions to counteract head movements and maintain stable gaze on an object.

Yoked prism

Prisms with bases oriented in the same direction.

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Authors and Affiliations

  • M. H. Esther Han
    • 1
  1. 1.SUNY College of Optometry, Vision Rehabilitation ServiceNew YorkUSA

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