Objective:

To increase the patient's awareness of his/her field deficit and to improve their ability to compensate by constantly scanning into the area of loss.

Activities:

1. Penlight Field Awareness Procedure (See activity sheet)
2. Peripheral Visualization Procedure (See activity sheet)
3. Flashlight Tag - Materials needed: 2 flashlights, colored acetate to make one light a different color.
• The therapist and patient face a blank wall in a darkened room from a distance of 8-12 feet. Both flashlights are shined onto the wall and the patient is made aware of which light is theirs. The therapist moves their light quickly to one side and stops. The patient is asked to quickly locate the light and place their light on the other light. This is repeated in different directions giving prompting when the patient cannot locate the light. The therapist can then play "Follow the Leader" by moving their light slowly and asking the patient to keep their light on top of the therapist's light.
4. Headlight Pointing - Equipment needed: Hat or helmet with laser pointer or flashlight attached to top.
• With light mounted on top of patient's head, the therapist calls out different objects in the room. The patient then looks directly at the object making sure the light illuminates the correct target.

  Once the patient shows some skill with the basic technique, the light can be turned slightly in the direction of the field loss. This requires the patient to make a saccadic eye movement into their missing field to check for accuracy of the light on the target.

5. Eye Throwing - Goal: To improve the patient's ability to scan for objects in their weaker field. Equipment needed: None
• Have patient sit comfortably and view a selected fixation target at a comfortable distance directly in front of the patient. Select a second fixation target approximately 30 to 40 degrees into the patient's field of loss.

  For a left hemionopsia/neglect, the patient will look to their right and develop the feeling of throwing their eyes as far to the left as possible. They should pass the second fixation object as they move their eyes to the left, then quickly make a refixation on that object. Hold it for approximately 5 seconds. Next, they look back at the center object of fixation and repeat the activity attempting to throw their eyes slightly further to the left each time the activity is performed.

  For a right hemionopsia/neglect, the patient will begin by looking to their left and throwing their eyes as far to the right as possible past the pre-determined object of fixation and then making a quick refixation to the target for approximately 5 seconds.

  A normal saccadic eye movement is often difficult for these patients since the second target is often located in the patient's blind field. Making the large eye-throwing maneuver allows the target to be located within the patient's dominant field making the location of the target much simpler.

6. Head Touch Fixations - Equipment needed: None
• Therapist should stand or sit behind the patient and randomly touch them on the side of their head asking them to quickly look in the same direction that they are touched. A second observer may be necessary in front of the patient to monitor the patient's success with moving their eyes in the appropriate direction. The patient should hold their fixation in the specified direction as long as the therapist is touching the temple area and should look straight ahead when neither side is touched.

  Patient's with hemionopsia/neglect will typically perform much better on their dominant side, but may have great difficulty maintaining fixation in the direction of their missing field. The therapist should alternate sides, but should give greater attention to the patient's weaker field.

7. Hallway Splitting - Equipment needed: Yard stick or measuring device.
• The patient should be asked to walk down a long corridor or hallway keeping the area on their left and right exactly equal. If the patient tends to walk closer to one side than the other, they should be stopped and the therapist should measure the distance to the wall from their right and from their left. The therapist should then make the necessary adjustment to the patient so that they are, once again, in the center. This type of feedback allows the patient to make necessary compensations for their disrupted spatial perception. Once the patient is fairly accurate at splitting the hallway, the therapist may add a strip of scotch tape down the center of the patient's spectacles covering the entire pupil. This forces the patient to utilize their peripheral vision when performing this activity.
8. Home Activities
• Obstacle Course - Have the patient's family member create an obstacle course utilizing pillows or other household items that the patient must navigate through with special attention to objects on their neglected side.
• Solitaire - Cards should be spread out in a wide field of view in front of the patient, making it necessary for the patient to continually saccades into their neglected field.
• Formfield Cards - Formfield Cards are available through the Optometric Extension Program (1-949-250-8070) Patient is asked to view the dot and circle in the very center of the card and read aloud the first four letters surrounding the central fixation dot. If the patient is able to successfully see all four letters, they are then asked to call out the next four letters that form a square around the central fixation dot. The patient should continue to look directly at the center of the card and utilize their peripheral vision in order to view the letters on the card.

For patients with hemionopsia, they may need to slightly turn their head or move the card into their better field in order to improve their ability to see off to their weaker side.

For patients with a visual field neglect, it may be helpful to color the weaker side of the card with a bright yellow or pink highlighter.

If the patient is unable to see the letters on their weaker side without moving their eyes, ask them to just concentrate on the letters in the pink or yellow field. As patients get better at this, they may find that they are able to see all four letters at the same time.

9. Computerized Activities - (Utilizing the Computer Orthoptics Program)
   • Arrow or Letter Saccades - (directions may be found in the Computer Orthoptics Manual)
   • Visual Scan - (directions may be found in the Computer Orthoptics Manual)