Occupational therapists should try to establish a baseline for vision upon admission whenever possible in acute care and acute rehab. OTs can use this battery of visual screens to quickly establish such as baseline to compare to at discharge. If a suspected condition warrants additional assessment, OTs can use a more sensitive and thorough tool – in a perfect world, that is.

However, taking out assessment materials, conducting them, and scoring them can be very time-consuming and is just not feasible in settings such as acute care. In acute rehab, there may be more time to conduct more in depth visual assessments, however OTs often have other factors to address as well – ADLs, IADLs, DME, caregiver assistance, healthcare management, and other deficits such as cognition, physical ability, and psychosocial symptoms. All of these visual assessments were created pre-COVID-19, and many of the materials contained in these assessments may not pass the infection control test — non-porous, quickly drying, or made to be single-use.

The visual screen that I use with almost every client has the benefits of:

  • Quick to administer
  • Relatively accurate and reliable
  • Minimal use of materials needed
  • Easily understood by OTs and allied health professionals
  • Free (yay!)
  • Low chance of exacerbating symptoms such as vertigo or nausea

What You’ll Need

  • Pens or bright highlighters (optional)
  • Chair (optimal) or bed
  • An alert client

The client should be seated and be able to maintain their support in their chair (not slide out). If they are at risk, you may opt to use a torso belt wrapped around a wheelchair/chair temporarily and/or block the client’s lower extremities. They can be done in a semi-fowler’s or supine position, but the OT will need to reach over and walk around to both sides of the bed potentially and it may not be as accurate as you will not be (1) close to the client and (2) directly in front of the client.

Instruct the client that the purpose to test how their eyes are performing. Poor or low vision is a highly correlated with falls and injury.

Interview

Beginning with the interview, you can ask your client about prior level of function if they had near- or far-sightedness. It generally corresponds with the types of visual adaptations (glasses, contacts) that the client has as long as they have been to the optometrist relatively recently. Older adults are likely to wear bi- or tri-focals. Some may even have prisms for visual field deficits (VFDs). Ask about diplopia, dark spots, blind spots, or any other abnormalities in vision.

Visual Acuity

If you have a wall clock, ask the client to tell you what the time is. These clocks are often a fair distance away. Ask the client to read something closer, such as a food menu. Clients should have their visual adaptations on. You’ll often encounter clients who have either broken, lost, or misplaced them since admission. Be proactive and ask family members to bring replacements in if they are expected to have a longer length of stay such as in ARU. If the client is relatively high functioning to be able to mobilize easily and you have a Snellen chart, you can use this instead to get a more accurate report of their visual acuity.

Smooth Pursuits

You can use a finger, a pen, penlight, or similar object held about 18-24 inches away. Move it in a smooth horizontal then vertical “H” pattern, watching for any nystagmus (eye bouncing).

Convergence

Convergence is simply a smooth pursuit motion that approaches the client’s nose (between the eyes). Ask the client if they have and currently experience diplopia. If diplopia is reported, it should go away with closing of 1 eye.

Saccades

With 2 index fingers, 2 pens, or 2 highlighters held 18-24 inches away, ask the client to focus on the tips of the objects between left and right. Hold objects further apart for more dramatic effect during observation. Eyes should both dart and fixate on each object.

Visual Fields/Peripheral Vision

Confrontation Test

Position yourself at eye level with the client. Ask the client to cover one eye at a time with one hand (or close it if unable to e.g., hemiparesis). Do the same with your respective eye. With your other hand, bring and index finger from the client’s peripheral (starting from unable to be seen), and come towards both of your centers. Try to come at a “spherical” motion instead of straight horizontal (our vision is round, not flat). Come from upper left, lower left, upper right, and lower right quadrants for each eye. There should be 8 total motions. Ask the client to say when they see your finger, e.g., “now”. Write down or remember which eye and quadrant is deficient.

Inattention/Neglect

  1. Clock drawing
  2. Letter cancellation

A laser pointer can help screen for inattention and neglect – shine the laser in front of the client on the wall at random locations and ask the client to point to it. Go off to the sides and see if the client notices.

See our post on inattention and neglect testing.

Other Considerations

  • Contrast
  • Color-blindness
  • PERRLA (pupils equal, round and reactive to light and accommodation)
  • Glare sensitivity
  • Pre-existing visual conditions, e.g. diabetic retinopathy

Situations and D/C Planning

Sometimes, your client may not understand your directions for these screens. Client with neurological deficits tend to have difficulty with some directions such as with confrontation testing. Try your best. You can demonstrate what you mean. If a client just does not understand, document “unable to complete 2′ understanding of directions”, or something like that.

At re-assessment and/or discharge, you can quickly compare the difference to baseline at evaluation. Consider referring your client to a specialist if you suspect a serious condition or if you think they may benefit from an evaluation with them. Your client may be a good candidate for compensatory aides such as prism glasses.

As clients depend heavily on vision in their everyday function and to avoid falls, you can use these vision screens at evaluation to establish a baseline for progress and documentation.