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VISUAL FIELD DEFICITS

in Cerebrovascular Accidents
Lydia Brugere, OTS - Slippery Rock University
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VISION AND VISUAL FIELDS

----X
Light waves enter the eye and are
refracted by cornea and lens. These
are then focused either on the
cones or rods. Chemical reaction
occurs in the rods and cones to
generate a membrane potential. If
the membrane potential is strong
enough, an action potential forms
along cranial nerve II (the optic
nerve) which sends signals to the
optic chiasm.

Based on where the optic nerves

are impacted in a stroke or other
brain injury, it can result in different
kinds of visual field deficits. This is
due to the midline crossing of optic
nerves at the optic chiasm
(Gutman, 2017; Luchynsky, 2021)
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VISUAL FIELD DEFICITS

- - - - X
Visual field deficits can affect all areas of the visual fields, whether it be the one side of
both eyes (contralateral homonymous hemianopia), central vision (bitemporal
hemianopia), the vision of one eye (ipsilateral monocular blindness), or any of the other
visual field deficits shown here.
(Gutman, 2017; Luchynsky, 2021)
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Impacts of Visual Field Deficits

- - - - X

Visual field deficits can impact all areas of a person’s life, including, but not limited to:

1. Length of hospital stay

2. Likelihood of discharge home

3. Activities of daily living performance

4. Reading

5. Driving

6. Safety awareness

7. Work performance

(Blackport et al., 2022)

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OCCUPATIONAL AND PHYSICAL THERAPY’S ROLE

- - - - X
Screening: Doing a brief visual screen with all patients on stroke protocol
- Visual field screens in all four quadrants of vision
- Cancellation tests (digital or paper)
- Albert’s test - patients cross out all the lines they see on a stationary piece
of paper
- Behavioral and functional assessment (such as environmental navigation
and ADL performance
- Referral: Refer to neurological ophthalmologists
- (It is no longer recommended to simply refer patients to their personal eye
doctor)
- Intervention: Occupational therapists can provide several interventions
associated with visual field outcomes
- Visual scanning
- Lighthouse method
- Head turning
- Anchoring
- Audiovisual integration
(Blackport et al., 2022)
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INTERVENTIONS
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The following interventions are a few of those recommended by stroke organizations
and current evidence:

- Visual scanning
- Lighthouse method
- Head turning
- Anchoring
- Audiovisual integration
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Visual scanning
- - - - X
This intervention focuses on the individual’s ability to scan and process their
environment. A restorative approach, visual scanning retrains the patient to scan the
affected hemifield.
Visual scanning exercises can be done using items in the natural environment (e.g.,
scanning a drawer for specific items), using paper scanning exercises (e.g., cancellation
worksheets, “find all the c’s”), or using computerized programing (e.g., the Bioness
Integrated Therapy System [BITS]). The therapist should select a task that encourages
the patient to scan as broad of an area as possible.
(Blackport et al., 2022; Gutman, 2017; Hanna & Rowe, 2017; Luchynsky, 2021)

Lighthouse method
This method uses visual imagery to encourage
patients to scan their environment. The patient
envisions themselves as a lighthouse to
remember to turn their head, move their eyes,
and scan left and right. Using this method,
patients are reminded that, like a lighthouse,
they are capable of pointing out obstacles and
a safe path by adequately scanning their
environment.
(Blackport et al., 2022; Niemeier et al., 2001)
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Head turning
Rotation of the head towards the affected
hemifield is a compensatory and restorative
approach that has similar impact as the
lighthouse technique and has implications with
driver rehab. Encouraging head turning
promotes safety and compensates for the visual
field loss. Turning the head and fixating on
obstacles is a recommended strategy to promote
safe navigation. Stroke patients also undergo
changes in postural control, so retraining them in head turning can address these
postural deficits.
(Houston et al., 2022; Lima et al., 2019)

Anchoring
This method is an adaptive approach, focusing on training
the individual to turn their head and scan until they see the
“anchor,” which can be a high contrast line, highlighter, etc.
This strategy builds spatial awareness and works to retrain
the brain to take in information from the affected hemifield.
(Gutman, 2017; Luchynsky, 2021)

Audiovisual integration
This method uses audio and visual feedback to train individuals, and it has been found
to be more effective than visual feedback alone. During audiovisual training, an audio
will be played in the direction of the hemifield loss during scanning activities to remind
patients to look toward the affected side. This integrated approach can also be used by
giving a verbal cue to look left or right during scanning tasks.
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(Hanna & Rowe, 2017; Xu et al., 2021)

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References

Blackport, D., Singh, J., Pauli, G., Harnett, A., Saikaley, M., Iruthayarajah, J., Donais, J., &

Teasell, R. (2022). Chapter 13: Neglect and visuospatial disorders. In Evidence-based

review of stroke rehabilitation (pp. 1-132). Heart and Stroke Foundation.

Gutman, S. A. (2017). Quick reference neuroscience for rehabilitation professionals: the

essential neurologic principles underlying rehabilitation practice. Slack Incorporated.

Hanna, K. L. & Rowe, F. J. (2017). Clinical versus evidence-based rehabilitation options for

post-stroke visual impairment. Neuro-Ophthalmology, 41(6), 297–305.

https://doi.org/10.1080/01658107.2017.1337159

Houston, K. E., Peli, E., Luo, G., Bowers, A. R., & Woods, R. L. (2022). Effects of perceptual-

motor training on collision judgments with peripheral prism expanded vision. Optometry

and Vision Science: Official Publication of the American Academy of Optometry, 99(12),

875–884. https://doi.org/10.1097/OPX.0000000000001957

Lima, C. A., Alouche, S. R., Schiavinato Baldan, S. M., de Freitas, P. B. & Sbeghen Ferreira

Freitas, S. M. (2019). Influence of target uncertainty on reaching movements while

standing in stroke. Human Movement Science, 64, 283-295.

https://doi.org/10.1016/j.humov.2019.02.014

Luchynsky, M. (2021, October 18). Vision [PowerPoint Slides]. Desire2Learn.

https://sru.desire2learn.com/content/enforced1/2989889-13445.202109/OCTH

%20615%202021%20Vision%20PPT%20student%20version.pdf?

_&d2lSessionVal=l3ZXNYQnrMayVEvEbAFxd22Cx

Niemeier, J. P., Cifu, D. X., & Kishore, R. (2001). The lighthouse strategy: Improving the

functional status of patients with unilateral neglect after stroke and brain injury using a
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visual imagery intervention. Topics in Stroke Rehabilitation, 8(2), 10–18.

https://doi.org/10.1310/7UKK-HJ0F-GDWF-HHM8

Xu, J., Emmermann, B., & Bowers, A. (2021). Auditory reminder cues to promote proactive

scanning on approach to intersections in drivers with homonymous hemianopia. JAMA

Ophthalmology, 140(1), 75-78. https://doi.org/10.1001/jamaophthalmol.2021.5007