CLINICAL OBSERVATIONS INDICATING VISUAL IMPAIRMENT

Brain Injury Visual Assessment Battery for Adults page 1 CLINICAL OBSERVATIONS INDICATING VISUAL IMPAIRMENT Client: Examiner: Date: Diagnosis: VISUAL ACUITY Ask the client to read a line of standard size print (10 point or 1M) in a newspaper, magazine, or book. complains that the print looks fuzzy or blurry complains of inability to bring the print into focus continuously adjusts focal length of the page as if trying to bring the print into focus complains that the print is too small or too faint to read brings the page of print in very close (less than 16 inches) to try to read it shifts the page of print to one side of midline (up, down, left, right) to read it views the print out of the corner of the eye or by looking above or below the line of print General Observations complains of an inability to recognize faces states that he/she can see better out of the corner of an eye or eyes states that vision fluctuates throughout the day states that colors are difficult to distinguish (especially dark colors: black, navy, purple) uses a flashlight to view objects and/or states that additional light is needed for tasks CONTRAST SENSITIVITY FUNCTION Ask the client to fill a clear glass with water from the tap or a pitcher to within 1/2 inch of the brim. complains that he/she can t see the level of water as it rises in the glass over fills the glass uses the tip of a finger over the brim of the glass to tactually determine the water level moves in very close to the glass to view the water level tilts the glass back and forth to create movement to determine the water level

bivaba Clinical Observations Indicating Visual Impairment page 2 Ask the client to fill a black cup with milk to within 1/2 inch of the brim and compare with his/her performance using the clear glass and water. Observe the client ambulate in environments with low contrast features such as unmarked curbs, subtle changes in the support surface, areas with poor illumination, furniture that does not contrast from surrounding features, door frames that do not contrast from doors etc. hesitates when approaching curb or subtle change in support surface misses curb or does not see it until directly on top of it trips when transitioning between support surfaces of similar color bumps into or comes very close to low contrast obstacles (furniture etc.) uses hands to guide self around an obstacle General Observations complains of an inability to recognize faces performance on tasks or ambulation declines in dimly lit surroundings is unable to accurately distinguish colors of similar hues such as dark blue from black, purple from dark blue or black, white from beige etc. requests additional illumination when performing a task VISUAL FIELD DEFICIT Observe the client ambulate through crowded areas with moving obstacles. collides or comes very close to obstacles consistently on one side in an unfamiliar environment stares straight ahead at the floor immediately in front of him/her and/or consistently stares to one side stays very close to one side of the wall when ambulating down a hallway uses fingers to trail wall to tactually guide self refuses to take the lead when ambulating, preferring to walk behind others appears anxious or uncertain in crowded areas stops walking when approaching or passing by another moving person or object complains of feeling off balance particularly to one side

bivaba Clinical Observations Indicating Visual Impairment page 3 Ask the client to read outloud a paragraph of 10 point (1m) or larger text printed on an 8.5 x 11 inch piece of paper. transforms words by omitting or misreading letters on one side of the word(s) abbreviates scan to one side of the page, omitting word(s) on that side uses finger to direct scan across the line of print and maintain place on the page consistently loses place on one side of the page hesitates reading a word, or misreads a word initially then corrects self; reads very slowly General Observations avoids crowds and crowded environments such as shopping centers avoids obstacles in familiar environments but collides with obstacles in unfamiliar environments complains of disorientation when riding in a car or a wheelchair reads only half of a wide sign or misses signage on one side transforms numbers, for example, reads an 8 as a 6 or a 3 displaces writing to one side when completing a form such as a check handwriting drifts up or down when writing on line or addressing an envelope complains of being unable to follow what is happening on television particularly when viewing a dynamic sporting event (football, basketball, etc.) or a show with a lot of action makes mistakes dialing a telephone; such as pressing a similar but incorrect number scans shelves or counters very slowly to find items and often is unable to locate an item has become very particular that items be returned to a specific location following use and becomes upset with others who leave items out or return them to a different location HEMI INATTENTION only comments on objects or visual details on one side of a visual scene initiates and confines search to the right side of an array is hesitant to shift eyes across midline towards left side; unable to maintain fixation on an object placed to the left of midline is reluctant to turn towards the left and/or avoids left turns during ambulation

bivaba Clinical Observations Indicating Visual Impairment page 4 fails to search the environment for information needed to adapt, such as looking at a clock or a wristwatch when asked what time it is fails to rescan or check work for errors when completing a complex task demonstrates reduced effort on tasks which require visual discrimination is easily distracted by motion occurring on the right side; directs attention to the right visual field frequently during tasks is unable to maintain concentration on a task which requires sorting through visual information or attention to visual detail; forgets what he/she is looking for or makes mistakes in identification COMBINATION OF HEMI INATTENTION AND VISUAL FIELD DEFICIT These behaviors represent exaggerations of those observed in clients with either hemi inattention or visual field deficit. The client usually requires repeated physical cues to correct behavior or redirect attention. veers off towards the right side when propelling a wheelchair or when ambulating consistently bumps into furniture or objects on the left side in familiar environments becomes disoriented when moving in environment; unable to locate needed landmarks fails to acknowledge or notice persons positioned on the left side fails to pick up or notice an object on the left side during a visual search for the object places only the right foot on the wheelchair footplate or the right ear piece of eyeglasses on the ear and does not correct error shaves or applies cosmetics only on the right side of the face or combs only the right side of his/her hair and does not correct error only eats food located on the right side of a plate and cannot locate uneaten food misreads time on a clock and does not attempt to correct error omits or misreads words and does not attempt to correct error complains of clumsiness but is uncertain as to the reason for the clumsiness places both legs through one hole in underwear or pants misplaces clothing or toiletry items when dressing and does not attempt to locate them unable to correct performance with only auditory or visual cuing; also requires physical cuing and often needs repeated cuing demonstrates poor carryover of strategies taught to compensate for the visual field deficit

bivaba Clinical Observations Indicating Visual Impairment page 5 OCULOMOTOR DYSFUNCTION complains of double vision, or blurring vision or a shadow when viewing objects which may vary with the focal length or direction of gaze and may be constant or intermittent assumes a consistent and deliberate head position when viewing objects and resists changing this head position is reluctant to participate in activities presented at a specific focal distance or attempts to change the distance at which the task is placed (for example, changes focal distance of reading materials) complains of blurring of vision when changing focus from a near object to a distant object and/or is very slow in transitioning between focal distances shuts an eye or turns head to view an object complains of eye pain with movement of the eyes squints when viewing objects shows excessive blinking when viewing objects which is not related to eye irritation eye(s) appear to turn in or out when viewing objects The following observations may indicate convergence insufficiency in addition to other oculomotor deficiencies complains of inability to keep objects in focus especially at a near distance complains of eye fatigue or eye pain (not related to eye irritation) after a period of sustained focus on a task especially at a near distance complains that print begins to swirl or move on a page after a period of sustained focus complains of difficulty concentrating on tasks requiring sustained focus at a near distance complains of a headache after a period of sustained viewing especially at a near distance complains of fatigue after a period of sustained viewing especially at a near distance ADDITIONAL OBSERVATIONS

Brain Injury Visual Assessment Battery for Adults page 1 BASIC VISUAL FUNCTION ASSESSMENT Client: Examiner: Date: Diagnosis: Glasses: yes no Bifocal: yes no Additional (note sensitivity and adaptation to light, ability to see colors, presence of phantom vision) APPEARANCE (observe pupil size and symmetry as client fixates distant target) PUPILLARY FUNCTION 2 3 4 5 6 7 8 9mm Right eye Pupil Gauge normal constricted dilated Left eye normal constricted dilated RESPONSIVENESS TO LIGHT STIMULATION Shine penlight into eye for 2 seconds as client fixates distant target; observe response of both pupils. Normal response is in italics. Light Stimulation to Right Eye: Light Stimulation to Left Eye: Right eye Left eye Right eye Left eye constricts quickly constricts quickly constricts quickly constricts quickly remains constricted remains constricted remains constricted remains constricted constricts sluggishly constricts sluggishly constricts sluggishly constricts sluggishly begins to dilate begins to dilate begins to dilate begins to dilate does not constrict does not constrict does not constrict does not constrict

bivaba Basic Visual Function Assessment page 2 PUPILLARY RESPONSE TO ACCOMMODATION Observe pupil response as client shifts fixation between distant and near target. pupil(s) constrict with accommodation pupil(s) do not constrict with accommodation EYE DOMINANCE Instruct the client to view the flower design through the card with the 8mm hole; observe which eye the client uses to view the design through the hole. right eye used to view the flower design left eye used to view the flower design ACUITY INTERMEDIATE DISTANCE Instruct the client to identify numbers on the Intermediate Distance Chart at a distance of 1 meter. Right eye (OD): Left eye (OS): Eyes together (OU): Snellen 20/ Snellen 20/ Snellen 20/ Metric 1/ Metric 1/ Metric 1/ READING ACUITY Instruct the client to read the sentences on the Warren text card at a distance of 40cm/16 inches. Eyes together: Snellen 20/ Diopters needed: Errors made when reading: omits letters/words on R L side difficulty reading larger text; easier on smaller text views text out of corner of eye print swirls; is distorted

bivaba Basic Visual Function Assessment page page 33 CONTRAST SENSITIVITY FUNCTION Instruct the client to read the first number of each row on the Lea Numbers Screener at a distance of 40 cm using both eyes together. Check the box on the last line the client can accurately identify the first number.! The client does not see any of the numbers. Contrast sensitivity function is extremely limited and enhancement of contrast is needed for the client to function. The client may require assistance to ambulate safely in environments. Ability to resume driving is highly questionable and should be carefully evaluated.! The client recognizes numbers only at the 25% level. Enhancement of contrast is needed for the client to function safely and independently. The client may require assistance to ambulate safely in environments. Driving performance should be carefully evaluated especially with regards to night driving and driving in cloudy conditions.! The client recognizes numbers to the 10% level. The client likely will have difficulty detecting subtle changes in the support surface, reading materials printed in low contrast formats, seeing black and white photographs, facial features, water, and other low contrast materials. Magnification and increased illumination may assist the client to recognize low contrast features. Driving performance should be carefully evaluated especially with regards to night driving and driving in cloudy conditions.! The client recognizes numbers to the 5-2.5% level. The client likely will have difficulty seeing facial expressions and recognizing friends across the street. He or she may have difficulty detecting curbs and other low contrast drop offs. Increased illumination may assist the client to recognize low contrast features and modification of the environment to increase the contrast of important environmental features is recommended. VISUAL FIELD AMERICAN ACADEMY OF OPHTHALMOLOGY RED DOT TEST Present the red dot targets simultaneously in the areas desig - nated by the letters A,B,C,D,E. Ask the client if 1 or 2 dots are seen. Mark the form with a + if the target is seen, a - if the target is not seen and a D if the target is seen but appears diminished in color. Client fixates examiners eye during the test. A C C A A C C A B D E D B B D E D B R L R L Testing Right Eye Testing Left Eye

bivaba Basic Visual Function Assessment page 4 KINETIC TWO PERSON CONFRONTATION TEST Instruct the client to indicate when the penlight is seen as it is moved from behind the client by the rear examiner. Mark the form with a x where the target was first seen. The client fixates a target held by the front examiner during the test. Shaded areas indicate the boundaries of the normal visual field. HORIZONTAL VISUAL FIELD VERTICAL VISUAL FIELD

Brain Injury Visual Assessment Battery for Adults page 1 OCULOMOTOR FUNCTION ASSESSMENT Client: Examiner: Date: Diagnosis: VISUAL HISTORY Date of last eye exam: Good vision prior to injury? yes no Describe: Eyeglasses: yes no Correction: distance near bifocal Are eyeglasses worn all of the time? How long have eyeglasses been worn? yes only for reading only for distance/driving since childhood as an adult since injury History of: congenital strabismus corrective eye surgery [age: ] eye patching eye exercises eye trauma in conjunction with brain injury prior to brain injury [date: ] surgical intervention [type of surgery: ] Subjective complaints of diplopia: disappears when one eye is closed remains with closing of one eye lateral near constant primary gaze left gaze vertical far intermittent right gaze all gaze directions Area of fusion: distance from face: ability to maintain: Neck range of motion: within normal limits: restricted: right left up down Functional complaints: blurring of print when reading unable to keep objects in focus balance difficulty past pointing/reaching eye fatigue/eye pain/headache with sustained focusing difficulty maintaining concentration with sustained focus nausea/blurring vision with head movement blurring of vision when changing focal distance

bivaba Oculomotor Function Assessment page 2 GENERAL APPEARANCE Instruct the client to focus on a distant target; observe pupil size and symmetry, function of eyelid, nystagmus, presence of a deviated head position; record deviations on the eye diagram and on the form. Pupils: symmetrical asymmetrical Pupil size: R normal constricted dilated L normal constricted dilated Eyelid function: R normal impaired L normal impaired Eye position R normal deviated L normal deviated Head position: chin down head turned head tilt CORNEAL REFLECTION Instruct the client to focus on a distant target, hold penlight centered in front of the client s face; observe the corneal reflection in each eye and record the position of the reflection on the eye diagram and on the form. Reflection: equal both eyes deviated in left eye (out in up down) deviated in right eye (out in up down) EYE MOVEMENTS SMOOTH PURSUIT Instruct the client to focus on the penlight; move the penlight slowly in an arc 20 inches from the face through the 9 cardinal directions of gaze. Record deficiencies/deviations in eye movement on the eye diagrams. diagonal upper right up diagonal upper left client s right primary gaze client s left diagonal lower right down diagonal lower left

bivaba Oculomotor Function Assessment page 3 CONVERGENCE Instruct the client to focus on the penlight (held vertically). Beginning at 20 inches, slowly move the penlight towards the bridge of the client s nose. Observe convergent eye movements. Record the distance from the nose at which the client breaks fixation in 1 or both eyes. Record deficiencies/deviations in eye movement on the eye diagram. Also note pupillary response, effort, and ability to sustain convergence. Near point for convergence: (in inches) DIPLOPIA TESTING COVER/UNCOVER TEST Instruct the client to focus on a distant target held at eye level behind the examiner. Quickly cover the eye which appears to have intact oculomotor function with the occluder. Observe the uncovered eye to see if it moves to take up fixation on the target. If eye movement occurs, record the direction of the eye movement on the eye diagram. Testing left eye PRIMARY GAZE Testing right eye ALTERNATE COVER TEST Instruct the client to focus on a distant target held at eye level behind the examiner. Quickly switch the occluder back and forth between the eyes leaving the occluder over the eye for 2 seconds before switching. Observe whether the eye under cover moves to take up fixation once the cover has been removed. If eye movement occurs, record the direction of the eye movement on the eye diagram. Testing left eye PRIMARY GAZE Testing right eye

Brain Injury Visual Assessment Battery for Adults page 1 VISUAL ATTENTION ASSESSMENT Client: Examiner: Date: Diagnosis: Additional SEARCH STRATEGIES for NEAR SPACE STRUCTURED VISUAL ARRAY Instruct the client to mark the form as designated for each subtest and to place his or her marker down when finished. Begin timing when client initiates search ; stop timing when client is completely finished including checking work for accuracy. Record the number of correct responses. Calculate percentages using Appendix E. Most commonly used effective search strategies are in italics. Examples of effective search strategies are given on page 5. SINGLE LETTER SEARCH-SIMPLE Number of accurate responses: (40 targets) Percent correct: Time: Error type: omissions: left right center lines skipped: misidentifications: Search strategy used: symmetrical horizontal left to right abbreviated asymmetrical; right to left symmetrical horizontal rectilinear right side random, no predictable symmetrical vertical left to right left side symmetrical vertical rectilinear verbal cue given: benefits no benefit checks work for accuracy physical cue given: benefits no benefit SINGLE LETTER SEARCH-CROWDED Number of accurate responses: (40 targets) Percent correct: Time: Error type: omissions: left right center lines skipped: misidentifications: Search strategy used: symmetrical horizontal left to right abbreviated asymmetrical; right to left symmetrical horizontal rectilinear right side random, no predictable symmetrical vertical left to right left side symmetrical vertical rectilinear verbal cue given: benefits no benefit checks work for accuracy physical cue given: benefits no benefit

bivaba Visual Attention Assessment page 2 WORD SEARCH Number of accurate responses: (30 targets) Percent correct: Time: Error type: omissions: left right center lines skipped: misidentifications: Search strategy used: symmetrical horizontal left to right abbreviated asymmetrical; right to left symmetrical horizontal rectilinear right side random, no predictable symmetrical vertical left to right left side symmetrical vertical rectilinear verbal cue given: benefits no benefit checks work for accuracy physical cue given: benefits no benefit STRUCTURED COMPLEX CIRCLES SEARCH Number of accurate responses: (30 targets) Percent correct: Time: Error type: omissions: left right center lines skipped: misidentifications: Search strategy used: symmetrical horizontal left to right abbreviated asymmetrical; right to left symmetrical horizontal rectilinear right side random, no predictable symmetrical vertical left to right left side symmetrical vertical rectilinear verbal cue given: benefits no benefit checks work for accuracy physical cue given: benefits no benefit RANDOM PLAIN CIRCLES-SIMPLE UNSTRUCTURED VISUAL ARRAY Number of accurate responses: (20 targets) Percent correct: Time: Error type: omissions: left right center double numbers: misnumbers: Search strategy used: symmetrical horizontal left to right abbreviated asymmetrical; right to left symmetrical horizontal rectilinear right side random, no predictable symmetrical vertical left to right left side symmetrical vertical rectilinear verbal cue given: benefits no benefit checks work for accuracy physical cue given: benefits no benefit

bivaba Visual Attention Assessment page 3 RANDOM PLAIN CIRCLES-CROWDED Number of accurate responses: (40 targets) Percent correct: Time: Error type: omissions: left right center double numbers: misnumbers: Search strategy used: symmetrical horizontal left to right abbreviated asymmetrical; right to left symmetrical horizontal rectilinear right side random, no predictable symmetrical vertical left to right left side symmetrical vertical rectilinear verbal cue given: benefits no benefit checks work for accuracy physical cue given: benefits no benefit RANDOM COMPLEX CIRCLES SEARCH Number of accurate responses: (40 targets) Percent correct: Time: Error type: omissions: left right center lines skipped: misidentifications: Search strategy used: symmetrical horizontal left to right abbreviated asymmetrical; right to left symmetrical horizontal rectilinear right side random, no predictable symmetrical vertical left to right left side symmetrical vertical rectilinear verbal cue given: benefits no benefit checks work for accuracy physical cue given: benefits no benefit ATTENTION TO DETAIL TELEPHONE NUMBER COPY Instruct the client to copy down the numbers. Count the number of errors. Inform the client of the number of errors and instruct him or her to locate and correct them. Begin timing when the client starts reading the numbers. Stop timing when the client puts down his or her marker, prior to correcting the errors noted by the examiner but after self correction. Print size accommodates acuities to 20/100. Initial Performance: Number of accurate responses: (10) Percent correct: Time: Error type: omissions: misidentifications: After Corrections: Number of accurate responses: Percent correct: Time:

bivaba Visual Attention Assessment page 4 DESIGN COPY Place one sheet of paper and the design card at the client s midline and instruct the client to copy the design as accurately as possible. The client is given one sheet of paper per design. Begin timing when the client picks up the pencil and stop timing when he or she places the pencil on the table. Effective performance attributes are in italics. House Time: all details in drawing are present drawing contains additional details 1-2 details are missing from drawing drawing is elongated or diminished on one side > 2 details are missing from drawing half drawing rechecks drawing for accuracy Flower Time: all details in drawing are present drawing contains additional details 1-2 details are missing from drawing drawing is elongated or diminished on one side > 2 details are missing from drawing half drawing rechecks drawing for accuracy Clock Time: all details in drawing are present drawing contains additional details 1-2 details are missing from drawing drawing is elongated or diminished on one side > 2 details are missing from drawing half drawing rechecks drawing for accuracy Comments SEARCH STRATEGIES for EXTRAPERSONAL SPACE SCANBOARD Instruct the client to point out the 10 numbers on the board as he or she sees them. Record the scan path taken by the client by numbering the order of the client s response on the diagram below. Scan path: 6 3 5 7 1 0 2 8 4 9 Comments

bivaba Visual Attention Assessment page 5 SCANCOURSE Attach 10 targets to each side of a long hallway. Bring the client to one end of the hallway. Instruct the client to read out the numbers/letters on the cards as he or she walks down the hallway. The client should continue to ambulate while reading out the cards; he or she is not to stop to read the cards. Two test trials are completed. Reverse the direction of the course on the second trial. Trial 1: Number of accurate responses: right: (10) left: (10) Percent correct: right: left: Observation of client performance: client misses cards only on one side of the hallway client randomly misses cards on both sides of hallway client stops to locate and read cards; unable to search and ambulate simultaneously client misses cards placed in unexpected locations Trial 2 Number of accurate responses: right: (10) left: (10) Percent correct: right: left: Observation of client performance: client misses cards only on one side of the hallway client randomly misses cards on both sides of hallway client stops to locate and read cards; unable to search and ambulate simultaneously client misses cards placed in unexpected locations Reference: Effective Search Patterns Horizontal left to right Horizontal rectilinear Vertical rectilinear Vertical left to right

Brain Injury Visual Assessment Battery for Adults page 1 TELEPHONE NUMBER COPY Client: Examiner: Date: Diagnosis: 988-2368 356-7876 288-9876 515-6687 338-9769 486-6384 884-2633 533-8767 495-5843 623-7391