Why Visual Performance Matters: Foundations for Occupational Therapy Practice

Transition: "Module 3."

Open here. "Underlying Conditions vs. Functional Limitations." The eye and brain conditions that may sit under what you observe — and the functional problems OT actually treats.

Say why this section matters for their caseload, then advance.

Ask the poll: "Which condition are you least confident recognizing functionally?"

Options:

• Cortical Visual Impairment (CVI)

• Amblyopia / strabismus

• Convergence problems

• Albinism / ONH / coloboma

Take a show of hands or the on-screen tally, then name the pattern you see before advancing.

Frame the slide: "How to use this module."

Walk each point, one sentence each:

• These are possible underlying diagnoses, not OT findings — diagnosis belongs to ophthalmology, optometry, and neurology.

• OT does not diagnose or treat the condition; OT describes and treats the functional limitation it produces.

• The point is vocabulary and mechanism: knowing the condition tells you what ceiling you are working under and which supports are worth trying.

• A short red-flag list still warrants prompt medical eye care, and OT intervention continues in parallel either way.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Contrast the two columns: What it is versus Functional limitations OT treats.

What it is:

• Brain-based, not ocular — the eye exam is often normal

• A visual-processing problem, not low vision

• Often described as a "kaleidoscope" visual experience

Functional limitations OT treats:

• Strong color preference

• Vision improves with movement or positioning

• Visual latency — delayed response

• Breaks down in visual clutter

Ask: "Which column is your student living in right now?"

Contrast the two columns: What it is versus Functional limitations OT treats.

What it is:

• Congenital under-development of the optic nerve

• Prenatal drug or alcohol exposure is commonly cited

• Ranges from mild nerve dysfunction to complete loss

• Frequently presents with autistic-like behaviors — light gazing, stereotypies, social-gaze differences

Functional limitations OT treats:

• Acuity and field loss — print size, contrast, materials placement

• Performance varies by lighting and setting; one acuity number does not predict the day

• Near-work endurance and visual attention

• Autistic-like behaviors are described functionally, never diagnosed by OT

Ask: "Which column is your student living in right now?"

Contrast the two columns: Strabismus versus Amblyopia.

Strabismus:

• Eyes are not aligned with one another; can be congenital or acquired

• Creates a double image the CNS may suppress from one eye ("sensory suppression")

• Can present as a phoria (fusion holds it in check, but effortful) or a tropia (constant, observable deviation)

• Phoria drives visual stress, reduced concentration, slowed reading, and headaches even without a visible turn

Amblyopia:

• Functional "blindness" in central vision from ongoing sensory suppression

• Significantly reduced acuity in the suppressed eye

• Impairs binocular vision — eyes do not work together effectively for daily tasks

• Timing matters medically: the treatment window narrows with age, so an unexamined eye turn is worth naming in your report

Ask: "Which column is your student living in right now?"

Frame the slide: "Naming the direction — vocabulary, not diagnosis."

Walk each point, one sentence each:

• Esotropia — eye turns inward.

• Exotropia — eye turns outward.

• Hypertropia — eye turns upward.

• Hypotropia — eye turns downward.

• OTs may describe an observed eye position; the eye care team confirms and classifies the diagnosis.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Contrast the two columns: Ocular albinism versus Nystagmus.

Ocular albinism:

• Hereditary condition; excess light enters through an unpigmented iris

• Reduced visual acuity and severe photophobia

• Frequently co-occurs with nystagmus and severe astigmatism

Nystagmus:

• Involuntary, rhythmic eye movement — horizontal, vertical, or torsional

• Reduces acuity through poor gaze stability; often experienced as blur

• Rarely isolated — seen with albinism, cataract, optic atrophy, vestibular/cerebellar or brain-injury involvement

• Some individuals find a "null point" head position that improves stability and acuity

Ask: "Which column is your student living in right now?"

Contrast the two columns: Retinopathy of Prematurity & Retinitis Pigmentosa versus Congenital cataracts.

Retinopathy of Prematurity & Retinitis Pigmentosa:

• ROP: abnormal blood vessel growth unique to preterm infants; incidence approaches 100% in the smallest, lowest-birth-weight infants

• RP: inherited, progressive rod-cell loss beginning mid-periphery ("donut" pattern), progressing centrally and peripherally over years

• Both carry a progressive or high-risk course — flag for ongoing ophthalmologic monitoring

Congenital cataracts:

• Present at birth; causes include genetic factors and in-utero exposures (e.g., rubella)

• Most are non-progressive and many do not cause significant impairment

• Bilateral, significant cataracts are typically removed within the first two months of life

• Intra-ocular lens replacement is not used in infancy; corrective lenses or contacts follow surgery

Ask: "Which column is your student living in right now?"

Contrast the two columns: What the diagnosis tells you versus What you write and treat.

What the diagnosis tells you:

• Reduced acuity — detail is limited

• Field loss — part of the world is unavailable

• Photophobia — light load is intolerable

• Unstable fixation or misalignment

• Complexity intolerance (CVI)

What you write and treat:

• Print size, contrast, working distance

• Scanning and placement in the usable field

• Lighting, glare control, seating

• Near-work endurance, tracking, place-keeping

• Array density and response latency

Ask: "Which column is your student living in right now?"

Read the scenario aloud, slowly:

A 2nd-grade student passed a school acuity screening this year. In therapy, he tilts his head to one side while reading, occasionally reports "things look blurry and double," and squints in bright hallway light.

Then put these questions to the room:

• Which underlying conditions could plausibly produce this picture, and which of them would a passed acuity screen fail to detect?

• Write the one sentence of documentation that names the functional limitation you will treat, without naming a diagnosis.

Give 60 seconds of think time before you take answers. Model answers are in the panel beside this script.

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Contrast the two columns: Diagnosed and managed → OT addresses it versus Undiagnosed, unclear, or changing → refer.

Diagnosed and managed → OT addresses it:

• Low acuity: magnification, enlarged print, working distance, seating.

• Contrast loss: bold-line paper, reverse polarity, glare control.

• Field loss: systematic scanning, anchoring, materials in the intact field.

• The OT target is the limitation, never the eye condition.

Undiagnosed, unclear, or changing → refer:

• No comprehensive exam on file, or correction unworn or outgrown.

• A functional loss no one has evaluated, or one that does not match the diagnosis.

• Anything new: eye turn, double vision, field complaint, pain.

• Refer and keep working — the modification goes in today.

Ask: "Which column is your student living in right now?"

Contrast the two columns: Refer promptly versus OT continues in parallel.

Refer promptly:

• New or intermittent eye turn, head tilt, or double vision

• Sudden acuity change, eye pain, or light sensitivity that is new

• No comprehensive eye exam on file, or glasses outgrown or unworn

• Function that does not match the documented diagnosis

OT continues in parallel:

• Print size, contrast, and lighting adjusted today

• Scanning, place-keeping, and copying strategies taught

• Near-work endurance graded and monitored

• Functional observations documented for the eye care report

Ask: "Which column is your student living in right now?"

Land the "so what": Some findings move to the front of the line the day you see them; most do not. Knowing which is which protects the student and your scope.

Explain the mechanism plainly: Pain, sudden change, new diplopia, new head tilt, or an unexplained acuity drop are same-day referrals regardless of caseload.

Then give them the moves — say each one as something they can do Monday:

• Keep the same-day list somewhere you can see it during observations.

• Refer and document on the same day for those findings.

• Continue OT services alongside the referral, never instead of it.

Tell them what success looks like: A new sign in a student you already know — change is more informative than a static finding.

Ask: "Who has a student this describes right now?" Take one answer, then move.

Two-minute case. Read it aloud:

During a Thursday session, a student you have treated for months suddenly holds his head tilted to the right and reports "two of things" when he looks at the board.

Put the question to them: "What is your action today?" Give 60 seconds, no talking.

Model answer (reveal after they commit): Same-day referral: new head tilt plus new diplopia. Notify the family and the school nurse today, document the observation in performance language, do not attempt to characterize the deviation, and keep your session plan for the tasks he can currently do safely.

Close with the rule: New, sudden, or changing signs are urgent regardless of what you have already ruled out.

Reflection prompt: "Write a one-sentence referral note for a student you suspect may have a visual condition that needs eye care. Include only what you observed and why it matters."

Offer the sentence starter: "During [activity], [student] was observed... This matters because it affects..."

Think for one minute, write, then take two shares.

Knowledge check: "Which finding requires the most urgent referral?"

Options:

• A student who reads slowly with large print

• A student who reports sudden double vision after a playground fall

• A student who prefers a specific color highlight

• A student who squints when looking at the board

Correct answer: option 2. Rationale: Sudden double vision after head trauma is an ocular/neurological red flag requiring urgent evaluation. The other findings warrant attention but are not same-day emergencies.