Vision Assessment Test
NAME:
DATE:
AGE:
1) CRANIAL NERVE ASSESSMENTS
II
ACUITY – Snellen Chart
Distance (record if person is being tested with/without correction)
Reading (record if person is being tested with/without correction)
III
OCULOMOTOR – Pupil Reaction
PEARL (Pupils equal and reactive to light)
IV
TROCHLEAR – Eye Movements/Tracking
ROM
SCANNING
SACCADES (King Devick)
VII
FACIAL – Smile/Grimace
ACUITY
Distance: Right:
Left:
with correction
Reading: Right:
Both:
without correction
Left:
with correction
Both:
without correction
PEARL/GENERAL APPEARANCE:
Pupils:
symmetrical
asymmetrical
Pupil size:
normal
constricted
Eyelid function:
normal
impaired
Eye position:
normal
L/R deviated
Head position:
chin normal
deviated down
head tilt
dilated
head turned
TRACKING/ROM:
Pursuits
Poor
Fair
Good
Jerky
Saccades
Poor
Fair
Good
Effortful
Overshoots Target:
R/L
Both
Undershoots Target: R/L
Both
KING DEVICK TESTING
Baseline Trial
Total Time:
Test Cards:
Post-Concussion
Total Time:
Total Errors:
Test Cards:
CONVERGENCE:
NPC:
Break Point:
inches
TTN
TBI VISION QUESTIONNAIRE:
Score: Questions #1-#15:
Total Score:
Equipment Needed: Refer to Resources page for websites to purchase products
2 Pencils
Pen Light
Acuity Charts (Pocket)
King Devick Test
Smooth
BASIC VISION TREATMENT

Grading Activity by Position
o Progression: Supine > Sitting > Theraball > Standing >
o Foam Block > Bosu Ball

Adding Complexity by Cognitive Loading
o Dual Attention Tasks
Kirshner Arrow Chart
Purpose:
1. To develop the ability to organize aspects of body orientation and direction awareness
2. To develop eye movement control.
Materials: Single Arrow Chart (refer to reference page)
Procedure:
1. This procedure involves making a body movement and a balance shift in four different
directions as indicated by the arrows.
The “UP” movement:
Both hands move from the knees to a position where they are raised above the head. The
hands are held palms up. The balance shifts from the toes to the heels during this movement.
The “DOWN” movement:
Both hands move from above the head to the knees. The hands are held palms down. The
balance shifts from the heels to the toes during this movement.
The “RIGHT” movement:
Both hands start on the left, with the palms facing the right, and they move to the right in a
“pushing” motion –across the body. The balance shifts from the left foot to the right foot.
The “LEFT” movement:
Both hands start on the right, with the palms facing the left, and they move to the left in a
“pushing” motion –across the body. The balance shifts from the right foot to the left foot.
Increasing the complexity:
1. Saying and doing at the same time to the direction indicated by the single large arrow
held/indicated by the therapist/trainer.
2. Saying and doing at the same time to the SAME direction indicated on the arrow chart.
Care needs to be taken to make sure that you keep your place.
3. Saying and doing at the same time to the OPPOSITE direction indicated on the letter
chart. Care needs to be taken to make sure that you keep your place.
4. Saying the direction indicated on the arrow chart and doing in the OPPOSITE direction
at the same time to what is indicated on the arrow chart. Care needs to be taken to
make sure that you keep your place.
5. Saying the OPPOSITE direction indicated on the arrow chart and doing in the SAME
direction as indicated on the arrow chart – at the same time. Care needs to be taken to
make sure that you keep your place.
6. Mix it up – as directed by your therapist/trainer.
ASPECTS TO EMPHASISE:
The ability to keep your place.
The ability to make saying and doing directional responses.
The ability to shift gears – and smoothly and easily alter the required response.
Breathing: Slow breathing in between responses and breathe out as the response in called.
The ability to SELF MONITOR your responses and be aware of responses that mismatch.
RETURN TO THE BEGINNING WITH EACH MISTAKE , Measure your progress.
Marsden Ball
Purpose:
 To develop smooth and accurate eye movements in all directions without having to
move your head or body.
 To develop Central/Peripheral Co-operation.
Materials: Marsden Ball (refer to reference page)
Procedure:
1. Suspend the ball from the ceiling so that the ball may be adjusted to various heights.
Lie on your back so that the ball is about 25cm from your nose.
Gently swing the ball so that you can easily track it with your eyes.
Do not move your head.
Pick letters from the ball – calling them out loud.
Be aware of objects around the room.
2. When the above can be done easily.
Therapist/trainer calls out spelling words.
Look for the letters that spell the work on the ball as it swings – without moving your head.
Be aware of objects around the room.
3. Repeat the above sitting down.
4. Repeat the above while standing up – you will need to adjust the height of the ball.
Notes to therapist/trainer: Make sure the subject:



Can feel their eyes moving.
Is aware of other objects in the room around them – check by moving them.
Make sure their head is still at all times – and they move their eyes only.
Remember – Vision Therapy only works if you do the exercises. Happy Training
Marsden Ball
Body Integration 2
Purpose:
To develop smooth and accurate eye movements so that vision guides the body.
To develop Central/Peripheral Co-operation.
Materials: Marsden Ball; Wooden Dowel or Hockey Stick; Paper Tube; Hoop. Can put different
colored strips of duct tape on the wooden dowel or hockey stick to increase complexity.
Procedure:
1. Suspend the ball from the ceiling so that the ball may be adjusted to various heights. ‘
a) Keep your head still when you watch the ball.
b) Hold the dowel/tube in both hands and “bunt” the ball so that is swings away from you – in a
controlled manner.
c) Watch the ball swing away and gently bunt it every time that it swings into reach so that it
once again swings away from you.
2. When the above can be done easily - proceed with one of the following activities:
a) Say your alphabet; one letter each time you bunt the ball.
b) Find a letter on the ball and say it aloud just as you bunt the ball.
c) Do your spelling words while doing this activity – finding specific letters before you bunt the
ball.
3. Repeat the above but try and bunt the ball to the left, right of straight ahead as called by the
therapist/trainer.
4. Instead of bunting the ball with the dowel – hold out a hoop – and try and keep the ball
swinging inside the hoop without it touching the sides.

Notes to therapist/trainer

Make sure the subject:
o
o
o
o
o
Is watching the ball
Can you feel their eyes move
Is leading with their eyes rather than leading with their eyes with their hands
Keeping their head still
Can identify what other things they can see in the room while performing
exercise
Resources
Jennifer Thomas, OTR/L
jenthomasot@yahoo.com or Jennifer.thomas4@va.gov
(801) 979 8824 Cell
Penlight
http://www.amazon.com/Primacare-DL-9223-Disposable-DiagnosticPenlight/dp/B003F13FMQ/ref=sr_1_4?s=hpc&ie=UTF8&qid=1404754447&sr=1-4&keywords=pen+light
Snellen Chart
http://www.amazon.com/s/ref=nb_sb_noss_1?url=search-alias%3Daps&fieldkeywords=snellen%20chart&sprefix=snellen+char%2Caps
Alphabet Pencils
https://www.bernell.com/product/LBPENCIL/799
King-Devick Test for Saccades
http://kingdevicktest.com/for-concussions/purchase/
Marsden Ball ($27)
http://www.bernell.com/category/411
Kirshner Arrow Chart
http://www.totaleyecare.co.nz/uploads/pdfs/KirshnerArrows.pdf
Metronome App: Download on I-phone or Android Device. Also available to purchase a metronome
at any local music store.
Reference Books
50 Tips to Improve your Sports Performance
Dr. Lynn F Hellerstein
http://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Dstripbooks&fieldkeywords=50%20Tips%20to%20Improve%20your%20Sports%20Performance
Neuro Vision Rehabilitation Guide
Dr. Amy Chang
http://www.amazon.com/Neuro-Vision-Rehabilitation-Guide-Chang/dp/1304331679
Testing Definitions
Pursuits
Testing Pursuits: Purpose to determine an athlete’s ability to track smoothly and check full range of
motion.
Equipment needed: Pencil/Alphabet Pencil
Recording/Scoring:
Poor = Difficulty following target with any accuracy, very jerky or jumpy, nystagmoid movements,
incomplete ROM (Range of Motion)
Fair = Generally able to follow the target, but goes off one to two times, with slight jerkiness.
Good = Eye movements are smooth with no jerkiness
Saccades
Testing Saccades: To determine an athlete’s ability to make rapid, accurate eye movements
Equipment: Alphabet Pencils
Record:/Scoring:
Poor: Inability to control eyes with verbal command, consistent over or undershooting, inability to
isolate eyes from head movement
Fair = Athlete able to maintain eyes on target with verbal command 50% of time, with slight under or
overshooting, and able to isolate eye from head movements with verbal reminders.
Good = Athlete able to follow verbal commands 90% of time, with no under or overshooting and
complete eye from head isolation.