NeuroRehabilitation 42 (2018) 223–233 223

DOI:10.3233/NRE-172263
IOS Press

Occupational therapists’ perspectives

on binocular diplopia in neurorehabilitation:
A national survey
Gillian Burgessa,b,∗ and Vanessa D. Jewellc
a University of California, San Francisco Medical Center, San Francisco, CA, USA
b School of Pharmacy and Health Professions, Creighton University, Omaha, NE, USA
c Assistant Professor and Director of the Post-Professional Doctorate of Occupational Therapy Program,

Creighton University, Omaha, NE, USA

Abstract.
BACKGROUND: Oculomotor dysfunction affects a significant number of adults with neurological conditions and binocular
diplopia is a common symptom which impacts an individual’s ability to participate in meaningful daily activities. Occupational
therapists use partial and complete occlusion to minimize binocular diplopia, however a review of the literature reflected
a lack of standardized protocol for each intervention technique. The purpose of this study was to examine occupational
therapists’ perspectives on the use of partial and complete occlusion and the clinical reasoning process used.
METHODS: An electronic survey was distributed to occupational therapists working in a variety of practice settings.
The survey contained questions relating to demographics, the selected occlusion technique, and clinical reasoning for that
selection.
RESULTS: More than half of the 106 respondents used partial occlusion more frequently than complete occlusion. There was
no correlation between respondent experience and self-report of competence in managing binocular diplopia. Respondents
based their clinical reasoning on available evidence, client factors, and clinical expertise.
CONCLUSION: Respondents offered conflicting perspectives on each occlusion technique. Future studies are required to
examine which occlusion technique benefits clients.

Keywords: Brain injury, clinical reasoning, complete occlusion, low vision, neurorehabilitation, partial occlusion

1. Literature review presentation of visual impairment in these individu-

Acquired brain injury (ABI), which includes
cerebrovascular accidents (CVA) or stroke, and trau-
matic brain injury (TBI), affects over 10 million
people globally every year (Hyder, Wunderlich,
Puvanachandra, Gururaj, & Kobusingye, 2007).
Visual impairment is frequently associated with ABI
and oculomotor dysfunction is the most common
∗ Address for correspondence: Gillian Burgess, 2500 California
Plaza, Omaha, NE 68178, USA. Tel.: +1 478 227 3896; E-mail:
gillianburgess@creighton.edu.
als (Ciuffreda et al., 2008). Oculomotor dysfunction
occurs when the eyes do not work together to fixate
on an object, to move from one object to the next, or to
follow a moving object (Warren, 2011). Oculomotor
dysfunction affects up to 54% of adults with CVA
alone, not including TBI, reflecting its significant
impact on people with ABI (Rowe, 2011). In addition
to ABI, oculomotor dysfunction can occur as a result
of a disease process, examples being Parkinson’s
disease, multiple sclerosis, tumor resection, brain
cancer, myasthenia gravis, and encephalitis (Rosen-
field, 2011). Cockerham and colleagues (2009) noted

1053-8135/18/$35.00 © 2018 – IOS Press and the authors. All rights reserved
224 G. Burgess and V.D. Jewell / Perspectives on binocular diplopia
that a frequently reported symptom of oculomotor
dysfunction is binocular diplopia, or double vision.
Binocular diplopia (BD) is a visual deficit result-
ing from ocular misalignment where the individual
perceives two images; the image stimulates the fovea
of one eye and the non-foveal region of the other
eye (Greenwald, Kapoor, & Singh, 2012; Scheiman,
Scheiman, & Whittaker, 2007). If ocular alignment is
not achieved, the individual perceives a distorted or
duplicate image. Phillips (2007) stated that an indi-
vidual with BD will usually find relief when the input
from one eye is blocked through occlusion, thereby
removing the duplicate image.
A person with BD may experience balance deficits,
visual fatigue, and headaches (Garcia-Munoz,
Carbonell-Bonete, & Cacho-Martinez, 2014). Con-
sequently, BD can lead to decreased participation in
activities of daily living (ADLs) and instrumental
activities of daily living (IADLs) including read-
ing, ambulation, driving, engaging in leisure pursuits,
education, and work, which can have a signifi-
cant effect on an individual’s function (Rowe et al.,
2008). These aspects of daily life are the focus of
occupational therapy, where the client’s ability to
engage in occupation is at the core of the profes-
sion (American Occupational Therapy Association
[AOTA], 2014). Occupational therapists and occu-
pational therapy assistants working in acute care
hospitals, inpatient rehabilitation facilities, skilled
nursing facilities, home health, and other commu-
nity settings may encounter adults with BD. In some
cases, these clinicians may be the first healthcare
professionals with whom clients with BD may inter-
act, especially in more rural communities (Scheiman
et al., 2007). Fortunately, BD can be managed through
occlusion of either eye and Politzer (1996) suggested
that either partial or complete occlusion interventions
can be used to temporarily resolve BD.
1.1. Partial occlusion
Partial occlusion is an intervention technique
where the clinician places lightly opaque tape over a
portion of one lens of a pair of glasses. This occludes
just the portion of the visual field where the indi-
vidual perceives diplopia, leaving the remainder of
the visual field unobstructed (Politzer, 1996; War-
ren, 2005). This intervention allows the individual to
achieve single vision while keeping both eyes open,
which is the primary goal in treating BD (Greenwald
et al., 2012).
Although there is evidence in the literature to
support the use of partial occlusion to manage BD
(Houston & Barrett, 2017; Politzer, 1996; Rucker
& Tomsack, 2005; Warren, 2011), there is a paucity
of research available examining the efficacy of par-
tial occlusion over no intervention in the acute stage
after onset of disease or trauma. Riggs, Andrews,
Roberts, and Gilewski (2007) completed a systematic
review investigating effective interventions for visual
impairment after stroke or brain injury and found lim-
ited evidence supporting effective interventions for
resolving BD. The authors cited one study indicating
that partial occlusion correlated with an improve-
ment on the Functional Independence Measure (Beis,
Andre, Baumgarten, & Challier, 1990, as cited in
Riggs et al., 2007), an outcome measure commonly
used in acute rehabilitation facilities to quantify a
person’s performance in self-care, cognition, and
functional mobility (Keith, Granger, Hamilton, &
Sherwin, 1987). Similarly, partial occlusion has been
found to be an effective intervention for managing
BD without the introduction of additional deficits
that could result from closing one eye (Phillips,
2007; Politzer, 1996; Warren, 2011). These additional
deficits can include loss of peripheral awareness,
stereopsis or depth perception, and balance.
1.2. Complete occlusion
Complete occlusion involves placing an eye patch
over the entire eye to remove the duplicate image.
This intervention technique is more commonly used
as it is often considered the most convenient compen-
satory strategy (Phillips, 2007). However, complete
occlusion introduces additional deficits including
loss of peripheral awareness, stereopsis or depth per-
ception, and balance, the most significant of which
is the lack of peripheral awareness (Fraine, 2012;
Politzer, 1996). Politzer (1996) cited a 25% reduction
in the peripheral visual field when complete occlusion
is utilized. This reduction in visual field can have a
profound effect on the individual’s ability to negotiate
his or her environment and can lead to safety con-
cerns (Greenwald et al., 2012). Phillips (2007) echoed
the concerns of Politzer cited above, agreeing that
complete occlusion eliminates stereopsis and results
in the individual’s inability to achieve ocular fusion.
More recently, Houston and Barrett (2017) included
in this list, the concern for introducing spatial neglect
through the use complete occlusion amongst adults
with brain injuries. Clinicians should be mindful of
potential additional impairments introduced through
 G. Burgess and V.D. Jewell / Perspectives on binocular diplopia
selected interventions (Warren, 2011). Moreover,
Fraine (2012) reported that complete occlusion is not
considered a long-term solution for managing BD,
suggesting that a more effective technique should be
implemented.
1.3. Role of occupational therapy in managing
binocular diplopia
An appropriate occlusion intervention can mini-
mize functional impairment and facilitate engage-
ment in daily occupation. Occupational therapists
play a key role in identifying functional deficits
resulting from oculomotor dysfunction (Rowe et al.,
2008; Warren, 2017). It is these clinicians who have
the skills to address both sensorimotor and psychoso-
cial sequelae of BD. These clinicians utilize these
intervention techniques in their practice to reduce the
detrimental effects that BD can have on engagement
in meaningful activity. An occupational therapist
will typically not treat BD. Instead, an eye care
professional will become involved in the long-term
management of BD if the deficit persists past the
acute stages of disease onset or neurological injury
(Warren, 2011). However, since BD can often be tem-
porarily resolved through the occlusion of one eye,
Warren (2011) observed that it is the occupational
therapist or occupational therapy assistant who, after
consulting with the referring physician, can effec-
tively manage BD until the deficit resolves, or until
the individual can consult with an eye care profes-
sional for more definitive management, which may
include the use of prism lenses.
1.4. Problem statement
Partial and complete occlusion are two compen-
satory strategies that occupational therapists can
utilize in the management of clients with BD,
regardless of the clinician’s practice setting. Current
literature presents both benefits to, and disadvan-
tages of, the two types of occlusion and their impact
on an individual’s functional performance. Neverthe-
less, there are no uniform guidelines for clinicians on
the use of partial or complete occlusion. Furthermore,
as indicated in the study by Riggs and colleagues
(2007), there is insufficient evidence to identify which
of the two intervention techniques is more effective
in managing BD.
Despite having knowledge regarding occlusion,
clinicians cannot agree on the reasoning behind the
choice of intervention, and there is no evidence
225
to indicate which intervention is more beneficial
to the client. This presents a challenge to occupa-
tional therapists who have been urged to integrate
the best available evidence together with their own
clinical expertise and client values in making clini-
cal decisions (Sackett, Rosenberg, Gray, Haynes, &
Richardson, 1996). To generate much-needed evi-
dence, it is useful to establish which intervention
technique occupational therapists are utilizing in their
current areas of practice and to determine the fac-
tors that influence clinical decision-making across
the rehabilitation continuum. This information can
both guide clinicians in practice and set a baseline
for future effectiveness studies, and serve as an aid to
the development of occupational therapy education
curricula.
1.5. Purpose statement and research questions
The purpose of this study was to explore cur-
rent practice regarding the use of partial or complete
occlusion and to investigate the clinical reason-
ing occupational therapists utilize in determining
whether to use partial or complete occlusion. The
research questions addressed in this study relate to
clinical practice and clinical reasoning respectively:
1) Do occupational therapists in acute care hospi-
tals, acute rehabilitation facilities, skilled nursing
facilities, home health, and other community set-
tings tend to use partial occlusion or complete
occlusion in the management of adults with binoc-
ular diplopia?
2) What factors guide occupational therapists in
their clinical reasoning to determine whether to
use partial or complete occlusion in managing
adult clients with binocular diplopia?
2. Methods
2.1. Research design
This was a cross-sectional survey design. This
design satisfied the requirements of an overarching
descriptive study as the data described the current
practice of a population of clinicians (Portney &
Watkins, 2015). In this study, the phenomenon under
investigation was the current practice by occupational
therapists in managing BD. The survey included
both closed- and open-ended questions. Responses
to closed-ended questions are often easier for the
226 G. Burgess and V.D. Jewell / Perspectives on binocular diplopia
researcher to collect and analyze (O’Cathain &
Thomas, 2004); however, more detailed information
can often be collected through open-ended questions
(Portney & Watkins, 2015).
2.2. Participants
2.2.1. Inclusion and exclusion criteria
Full-time and part-time occupational therapists
and occupational therapy assistants were eligible to
participate. Clinicians in any practice setting and with
any number of years of clinical experience met the
inclusion criteria. Clinicians with no experience with
BD were excluded from completing the survey, as
were those who did not work with adult clients.
2.3. Instrument
The researchers completed a thorough review of
the literature exploring current practice relating to BD
and developed an anonymous online survey to capture
clinicians’ perspectives on BD. Web-based surveys
may be advantageous over paper surveys for several
reasons: anonymity of respondents may be main-
tained, convenience for the researcher in recording
responses directly to a database for analysis, a lower
financial burden on the researcher, and a reduced
time commitment for the respondents (Eysenbach &
Wyatt, 2002; Portney & Watkins, 2015).
After the survey was reviewed by an expert panel
skilled in research design (n = 5), a sample of five
occupational therapists piloted the survey to assess
face and content validity. One area modified from the
pilot sample was to include a question investigating
the respondent’s perception of the client’s benefit in
managing BD. This change aligned with the Occu-
pational Therapy Practice Framework, highlighting
client-centered care (AOTA, 2014).
The final version of the survey consisted of 29
questions. Eight questions sought to obtain demo-
graphic data from the respondents. The survey
included 10 rating questions, designed to gather data
regarding the choice of intervention and clinicians’
perceptions on the use of partial or complete occlu-
sion in managing BD. Each Likert-scale question
consisted of the categories strongly agree, somewhat
agree, neither agree nor disagree, somewhat disagree,
and strongly disagree.
Five questions sought data on the type of occlusion
used and the frequency with which clinicians used
each method. Four open-ended questions concerned
the clinicians’ clinical decision making. For the fifth
open-ended question, respondents were invited to
make any additional comments regarding the study.
2.4. Procedure
The university’s Institutional Review Board
approved the study. Respondents provided informed
consent through voluntary submission of their
responses. The researchers used non-probability pur-
posive sampling to increase the likelihood that
potential respondents have some knowledge regard-
ing the interventions (Portney & Watkins, 2015). The
primary researcher recruited respondents through
direct emailing of the survey link, via online dis-
cussion boards for professional occupational therapy
practice communities, and on appropriate social
media platforms. The primary researcher used snow-
ball sampling to further increase the sample size
by inviting recipients of the emailed survey link to
forward the link to clinicians in their professional
networks.
The primary researcher posted an explanation of
the research study with the survey link to the Amer-
ican Occupational Therapy Association’s online
community forums on OTConnections (AOTA,
2017a) and on four occupational therapy-related pub-
lic groups on Facebook. In addition, the primary
researcher sent an email announcement letter, with
a link to the survey, to 160 occupational therapists,
students, and faculty known to her. The primary
researcher was responsible for posting reminders to
increase the sample size, posting two reminders to
each of the online discussion boards. Because of
anonymity of respondents, those recruited via email
did not receive reminders. The survey was available
for a period of 10 weeks before closing.
2.5. Data analysis
2.5.1. Quantitative data
The researchers used descriptive statistics, includ-
ing tables and figures, to describe frequencies and
percentages of the characteristics of the respondents
and the interventions used in practice. Spearman’s
correlational analysis was used to investigate a poten-
tial relationship between years of experience and
clinician self-report of competence in managing
BD.
2.5.2. Narrative data
The primary researcher analyzed the narrative data
using thematic analysis. Vaismoradi and colleagues
 G. Burgess and V.D. Jewell / Perspectives on binocular diplopia 227

(2013) described thematic analysis as a systematic Table 1

method of describing narrative data, and determin- Respondent demographics (N = 106)
ing patterns from respondents concerning a particular Characteristic na %b
topic. In this case, this data was obtained from Practice setting
the open-ended survey questions regarding partial Acute care hospital 52 48.6
Sub-acute rehabilitation 40 37.38
or complete occlusion. Using inductive thematic Skilled nursing facility 5 4.67
analysis, patterns emerged from the data. Thematic Home health 3 2.8
analysis is helpful to describe a phenomenon when Out-patient clinic 23 21.5
existing research on the topic is limited (Vaismoradi Day treatment program 4 3.74
Other 5 4.67
et al., 2013). Peer debriefing was performed when Years in practice
both the primary and second researchers reviewed the 0–2 21 19.63
elements to ensure trustworthiness. Peer debriefing 3–5 24 22.43
6–10 24 22.43
can be an effective method of ensuring credibil-
11–15 9 8.41
ity (Graneheim & Lundman, 2004). The researchers 16–20 16 14.95
maintained an audit trail throughout the process. This 21+ 14 12.15
included noting the initial emails sent and postings Employment status
Full-time, career staff 85 80.19
to discussion groups, posting reminders to discus- Part-time, career staff 12 11.32
sion groups, and closing the survey to begin data Full-time, contract staff (per diem) 3 2.83
analysis. Part-time, contract staff (per diem) 6 5.66
Highest level of OT education
Associate’s 1 0.95
Bachelor’s 29 27.62
3. Results Master’s 59 56.19
Clinical doctorate (OTD) 15 14.29
The respondents practiced in acute care hospitals, Research doctorate (PhD) 1 0.95
Specialties or certifications held
inpatient rehabilitation (sub-acute) facilities, skilled None 61 59.22
nursing facilities, home health, out-patient clinics, Low vision 2 1.94
and other community health settings. Of the 130 Stroke 3 2.91
respondents who opened the survey received via Neuro 16 15.53
Brain injury 11 10.68
email or posted on professional forums, 23 did not Certified driver rehabilitation 2 1.94
meet inclusion criteria and one did not complete Other 18 17.48
the survey, which reduced the sample size to 106 Client populations treated
Stroke 105 99.06
respondents (105 occupational therapists and one
Acquired brain injury 96 90.57
occupational therapy assistant). The researchers were Traumatic brain injury 94 88.68
unable to determine the response rate due to the Neurodegenerative disorders 85 80.16
selected recruitment strategies. About half of the Brain tumors 89 83.96
Neuro vision deficits 79 74.53
respondents worked in acute care hospital settings Other 13 12.26
(48%; n = 52). Forty-two percent of respondents had Clients with diplopia per month
less than five years’ experience (n = 45), while 27% 1–5 93 87.74
of respondents had more than 15 years of experi- 6–10 10 9.43
11–15 2 1.89
ence (n = 29). The majority of respondents held a 16 or more 1 0.94
master’s degree (56%; n = 59). Table 1 represents the Note. a Frequencies obtained from the number of respondents who
respondent demographic characteristics. At most, 10 responded for each question. b Some percentages may exceed 100%
respondents did not complete all the questions, how- as survey respondents were able to select more than one response.
ever the researchers chose to include all questions in
the analysis to reflect respondent opinion.
were most frequently utilized. Table 2 represents
3.1. Clinical practice the frequency of occlusion techniques used. Other
methods included the use of prism lenses, ocu-
Respondents were asked how frequently they uti- lomotor and visual scanning exercises, Brock
lized partial occlusion, complete occlusion, other string, DynavisionTM , and Interactive Metronome® .
occlusion methods, or no occlusion in manag- Respondents who did not use an occlusion method
ing BD. Partial occlusion and complete occlusion allowed clients to close one eye to resolve BD.
228 G. Burgess and V.D. Jewell / Perspectives on binocular diplopia
Table 2
Frequency of occlusion technique
Question Always Most of the time
15- Partial occlusion 15.24% 35.24%
18- Complete occlusion 2.02% 13.13%
21- Other occlusion methods 6.25% 6.25%
22- No occlusion 2.13% 6.38%
Fig. 1. Respondent feedback from Likert-scale questions on clinical practice in the use of occlusion.
3.2. Clinical reasoning
Over half the respondents indicated they held no
additional specialty certification (59%; n = 61). Only
two respondents held low vision specialty certifica-
tions. Spearman tests of correlation between years
of clinical experience and respondent report of com-
petence in managing BD yielded results of rs = 0.23
(p < 0.0005).
Following the demographic questions, respon-
dents were asked to complete Likert-scale questions
by selecting one of the following responses for
each question: strongly agree, somewhat agree, nei-
ther agree nor disagree, somewhat disagree, or
strongly disagree. Ninety-six percent of respondents
(n = 103) agreed that clients with BD have more dif-
ficulty performing ADLs than those without visual
impairment (strongly agree 77%; somewhat agree
19%). Ninety-seven percent of respondents (n = 95)
agreed that clients were better able to participate
in ADLs when BD was managed (strongly agree
85%; somewhat agree 12%). Ninety-three percent of
respondents (n = 99) agreed that occupational ther-
apists and occupational therapy assistants should
be able to manage BD in their practice setting
(strongly agree 63%; somewhat agree 30%). Fewer
than 80% of respondents (n = 85) reported feel-
ing competent in managing these clients (strongly
agree 22%; somewhat agree 57%). Only 38% of
Half the time Some of the time Never n
14.29% 25.71% 9.52% 105
8.08% 48.48% 28.28% 99
10.42% 43.75% 33.33% 96
11.70% 63.83% 15.96% 94
respondents (n = 37) agreed that there was sufficient
evidence in the literature regarding the use of partial
and complete occlusion (strongly agree 6%; some-
what agree 32%). Sixty-two percent of respondents
(n = 67) reported that clinicians should consult with
a neuro-optometrist or ophthalmologist before using
partial or complete occlusion (strongly agree 27%;
somewhat agree 35%). The majority of respondents
(55%; n = 59) indicated that they did not have access
to neuro-optometry or ophthalmology services at
their facilities (question 13).
Ninety-six respondents answered the questions “It
does not make a difference how I occlude, as long
as the diplopia is resolved” (question 24); “I always
use the same occlusion technique for all my clients
with BD” (question 25); and “I vary my occlusion
technique based on the needs of my clients” (question
26). Most respondents disagreed with questions 24
and 25, while most agreed with question 26. Figure 1
represents the respondents’ answers.
Additional survey questions investigated the clin-
ical reasoning respondents used in their selection
of occlusion technique. The four open-ended ques-
tions relating to clinical reasoning were coded by
the primary researcher and elements were allowed
to emerge from the data. The respondents’ answers
covered two main elements: clinical decisions taken
from the client’s perspective and clinical decisions
from the clinician’s perspective.
 G. Burgess and V.D. Jewell / Perspectives on binocular diplopia
3.2.1. Clinical indication for partial occlusion
(question 16)
This question (n = 54) required those respondents
who used partial occlusion more than 50% of the time
to provide a clinical example of when they might
select this method over other methods. Respondents
cited client comfort and tolerance for partial occlu-
sion, symptom alleviation, client safety, remediation
versus compensation, and sensory input and sensory
stimulation as factors in their clinical reasoning.
3.2.2. Indication for not using partial occlusion
(question 17)
Respondents (n = 81) cited education of clinicians,
patients/families, medical teams, and nursing staff as
well as lack of consultation with neuro-optometry as
factors in the decision not to use partial occlusion.
Respondents cited their own lack of knowledge on
the topic in 13 of 81 responses (16%). Limitations in
terms of time, equipment, and client cognition, and
poor client tolerance for partial occlusion were also
identified.
3.2.3. Clinical indication for complete occlusion
(question 19)
This question (n = 16) required respondents who
used complete occlusion more than 50% of the
time to provide a clinical example of when they
might select this method over other methods pre-
sented. Respondents identified client comfort and
tolerance for complete occlusion, and client cogni-
tion. Lack of equipment, limited clinician knowledge,
and established physician protocols regarding meth-
ods of occlusion used were presented as examples by
respondents.
3.2.4. Indications for not using complete
occlusion (question 20)
Respondents (n = 84) identified education of clin-
icians, patients/families, medical teams, and nursing
staff as factors as well as respondent perceptions of
complete occlusion being ineffective, compensatory,
and causing a reduction in sensory input. Respon-
dents cited poor client tolerance and compliance, and
lack of sufficient evidence for the use of complete
occlusion as additional reasons for not using com-
plete occlusion in the management of BD.
3.2.5. Additional comments
For the final question of the survey, respondents
were invited to offer additional comments on the role
229
of occupational therapy in managing BD. Twenty-
nine respondents answered this question. The main
findings that emerged from these responses included
the need for additional education and training on
occlusion techniques, the need for occupational ther-
apists to collaborate with an eye care professional,
and a lack of evidence regarding the use of partial or
complete occlusion.
4. Discussion
Occupational therapists across a wide variety or
practice settings indicated that they treated adult
clients who present with BD. The purpose of this
survey was to identify whether occupational thera-
pists and occupational therapy assistants used partial
or complete occlusion in the management of adult
clients with BD and to investigate what factors guide
these clinicians in their clinical reasoning when using
either of the two occlusion techniques. The over-
all results of this study indicated that respondents
strive to consider not only available evidence, but
also their individual clients’ values and preferences
in providing an intervention, which aligns with the
widely-accepted definition of evidence-based prac-
tice from Sackett and colleagues (1996).
4.1. Clinical practice
The most commonly reported intervention tech-
niques were partial and complete occlusion, which is
consistent with available literature (Houston & Bar-
rett, 2017; Phillips, 2007; Politzer, 1996; Rucker &
Tomsack, 2005; Warren, 2011). Both these occlusion
techniques remove the duplicate image to temporar-
ily resolve BD, thereby providing some relief to
the individual with BD. An expected finding from
this study was that respondents agreed that complete
occlusion is more convenient. Both Phillips (2007)
and Politzer (1996) cited complete occlusion as a
simple and effective intervention. Surprisingly, how-
ever, despite the convenience of complete occlusion,
most respondents indicated they used partial occlu-
sion more than half the time, and used complete
occlusion less than half the time. This finding reflects
the respondents’ awareness of the concerns, including
the loss of depth perception, peripheral awareness,
and balance, cited by experts Fraine (2012), Phillips
(2007), Politzer (1996), and Warren (2011) when
complete occlusion is used. It was difficult to obtain
the true frequency with which respondents used each
230 G. Burgess and V.D. Jewell / Perspectives on binocular diplopia
occlusion technique due to the nature of the Likert
questions containing a wide range of frequency rep-
resentations for each occlusion technique used: for
example, the range between Always at 100% and
Most of the Time at 75% is broad.
4.2. Clinical reasoning
Almost all respondents agreed that BD affects an
individual’s function, that function improves when
BD is addressed, and that occupational therapists
should be able to manage BD in their practice set-
tings. Nevertheless, fewer respondents who reported
agreement with these statements felt competent in
managing BD with these clients. This incongru-
ence speaks to a decreased awareness of the role
of occupational therapy in low vision rehabilita-
tion and supports the need for more education in
low vision rehabilitation to be included in occu-
pational therapy program curricula. Furthermore,
the surprising absence of a correlation between
years of clinician experience and self-report of com-
petence in addressing BD, as evidenced by the
strong negative Spearman’s rank correlation, sug-
gests that newer occupational therapy graduates
are no better equipped with the latest knowledge
in low vision rehabilitation than their more expe-
rienced colleagues. As an expert in low vision
rehabilitation, Warren (2017) stressed the fact that
occupational therapists are ideal healthcare profes-
sionals to address visual impairments because of their
solid foundation in neuro-anatomy, neuroscience, and
chronic disease. Clinician expertise is a crucial com-
ponent of evidence-based practice and clinicians need
to be able to assimilate knowledge with evidence.
In contrast to the findings of Rowe and colleagues
(2008) that occupational therapy plays a key role in
managing BD, there were two respondents who did
not agree that this was within the scope of practice
for occupational therapists and occupational therapy
assistants, and five respondents who neither agreed
nor disagreed. This unexpected finding contradicts
the efforts of the AOTA, led by Warren, in developing
a specialty certification for low vision rehabilitation
to promote competence in this area (AOTA, 2017b).
An incidental finding was that only two respondents
held this specialty certification. Occupational ther-
apists are tasked within the Occupational Therapy
Practice Framework (AOTA, 2014) to consider all
client factors, including visual functions, that may
impact the client’s ability to engage in meaningful
occupation. Moreover, occupational therapists have a
unique understanding of the interaction between the
individual and his/her environment (AOTA, 2014).
Promoting low vision rehabilitation in occupational
therapy curricula would help eliminate misconcep-
tions regarding the role of occupational therapy in
low vision rehabilitation such as those expressed by
the seven respondents above.
Similarly, the respondents’ perception of the lack
of evidence surrounding the use of partial and com-
plete occlusion is a cause for concern as it reflects a
disconnect between clinical practice and the Patient
Protection and Affordable Care Act of 2010 ([ACA];
Pub L. 111-148) in which clinicians are urged to
implement interventions that are based on evidence.
However, since Riggs et al. (2007) were also unable to
find sufficient evidence supporting effective interven-
tions for managing BD, the respondents’ perceptions
are valid. Furthermore, respondents cited sound rea-
soning for their choices of occlusion intervention
technique, reflecting their commitment to following
the guidelines of evidence-based practice as identi-
fied by Sackett and colleagues (1996) to incorporate
clinician experience with the best available evidence.
The limited evidence in the literature supports
the use of partial over complete occlusion (Fraine,
2012; Politzer, 1996; Riggs et al, 2007). Politzer
(1996) cited concerns regarding the use of complete
occlusion, including potential loss of visual field,
peripheral vision deficits, and concerns for safety and
loss of depth awareness. Several of these same con-
cerns were reported by the respondents who cited
client safety; improved participation in ADLs and
IADLs; client tolerance and comfort; and clinician
concerns for introducing additional sensory, percep-
tual and visual-spatial deficits as indications for using
partial occlusion. Those who tended to use complete
occlusion cited a lack of knowledge regarding par-
tial occlusion; improved client tolerance for the patch
rather than taped glasses; limited time and equipment;
and operating under the orders of a physician-
directed standardized protocol that promotes the use
of complete occlusion. This seemingly contradictory
reasoning provided by respondents does, however,
reflect that the respondents consider the clients’ per-
spectives in providing care. This aligns with both
the Occupational Therapy Practice Framework and
the Triple Aim of the ACA, where interventions pro-
vided should be of value to the client (AOTA, 2014;
Berwick, Nolan, & Whittington, 2008).
To further indicate respondents’ consideration for
each individual client, an overwhelming 88% of
respondents reported that they vary the occlusion
 G. Burgess and V.D. Jewell / Perspectives on binocular diplopia
technique based on the client’s needs. While it would
be expected that all occupational therapy clinicians
would modify the intervention for the client, in this
case, many respondents indicated that they operated
under a standardized protocol from a physician which
may limit the intervention options. This finding sup-
ports the need for more evidence regarding the value
of occupational therapy in this clinical arena. It also
highlights the need for collaboration with eye care
professionals.
Many respondents did seek the assistance of an
eye care professional to gain additional education in
the use of occlusion techniques. A consistent finding
was that respondents collaborated with an optometrist
or neuro-ophthalmologist before implementing an
occlusion intervention technique and referred their
clients for follow up. Clinicians should be encour-
aged to foster these inter-professional relationships
to best meet their clients’ needs (Warren, 2011). This
applies particularly to clinicians who practice in post-
acute care settings, where clients with chronic BD
may require consultation from an eye care profes-
sional for definitive treatment, including the use of
prism lenses. In these cases, occupational therapists
should remain involved in the client’s care to con-
tinue to assess the client’s needs in all aspects of
participation (Warren, 2017).
4.3. Limitations and future research
There are several limitations related to data collec-
tion. First, the survey was self-developed and only
content and face validity were established. Second,
the survey targeted clinicians who are members of
professional online communities which may not be
representative of all clinicians who use partial or
complete occlusion. This limitation is inherent in pur-
posive sampling (Portney & Watkins, 2015). Third,
the small sample size lessens the ability for the gen-
eralization of findings to a larger population (Portney
& Watkins, 2015). Fourth, the 5-point Likert-scale
questions gave respondents the option of selecting
a neutral response and did not compel the respon-
dents to select a level of agreement or disagreement
with a particular statement (Dolnicar, Grun, Leisch,
& Rossiter, 2014). Finally, due to the anonymity of the
study, member checking was not completed after ana-
lyzing the open-ended questions. However, to offset
the limitations, the researchers used peer debriefing
as one collaborative method of triangulation, which
can enhance credibility (Anderson, 2010).
231
There was much variety in the responses from
clinicians regarding the use of partial and complete
occlusion. This diversity in clinical practice reflects
a need for standardization to establish uniformity
amongst clinicians to best meet the needs of their
clients. Several options should be considered to direct
future research and guide practice. One, clinicians
should be encouraged to publish case studies for the
different occlusion techniques. While this type of evi-
dence is considered lower level evidence, Niederman,
Clarkson, and Richards (2011) suggested that when
stronger evidence is not available, clinicians can con-
sider interventions based on their experience. This
suggestion reflects the guidelines from Sackett and
colleagues (1996) regarding the three components of
evidence-based practice: evidence, clinician exper-
tise, and client values. Two, clinicians should conduct
future research studies looking at the use of both
partial and complete occlusion in occupation-based
assessments. This would allow clinicians to further
examine the functional implications to the client and
explore which occlusion intervention results in more
positive outcomes for the client. This type of study
will facilitate the development of practice guidelines
for the treatment of BD in adults. Finally, respondents
cited lack of education and training regarding the two
occlusion techniques as barriers to utilizing them in
practice. The results of this study may inform the
development of education curricula to emphasize low
vision rehabilitation both in the occupational therapy
classroom and in fieldwork education experiences.
5. Conclusion
Binocular diplopia affects many individuals with
acquired brain injury or neurological disease and
impacts their ability to engage in meaningful occu-
pation. Occupational therapists are uniquely skilled
at recognizing and addressing barriers to participa-
tion. The researchers developed a custom survey to
collect data on occupational therapy clinicians’ per-
spectives on the use of partial and complete occlusion
in adult clients with BD. Most respondents indicated
that they used partial occlusion over complete occlu-
sion, but reported a lack of competence in managing
BD. Despite this self-reported lack of competence,
respondents tended to base their clinical decisions on
the limited evidence from the literature. Furthermore,
respondents outlined contrasting clinical applications
from their own experiences in the use of both par-
tial and complete occlusion and articulated sound
232 G. Burgess and V.D. Jewell / Perspectives on binocular diplopia
clinical reasoning for selecting an intervention tech-
nique for a particular client. The findings from this
study indicated that respondents are attempting to
integrate the three components of evidence-based
practice suggested by Sackett et al. (1996): “individ-
ual clinical expertise . . . the best available evidence
. . . individual patient preferences” (p. 71). However,
with the resulting conflicting perspectives, it is cru-
cial for future researchers to explore the functional
implications for selecting partial or complete occlu-
sion to drive evidence-based practice and to provide
standardized clinical indications for each occlusion
intervention technique.
Acknowledgments
The authors would like to acknowledge Dr.
Kathleen Flecky, Associate Professor at Creighton
University, for her guidance in the research proposal.
Conflict of interest
The authors have no conflicts of interest to declare.
This research study was completed in partial fulfil-
ment of the Creighton University’s post-professional
occupational therapy doctoral degree.
References
American Occupational Therapy Association. (2014). Occu-
pational therapy practice framework: Domain and process
(3rd ed.). American Journal of Occupational Therapy, 68,
S1-S48.
American Occupational Therapy Association. (2017a). OTCon-
nections. Retrieved from https://otconnections.aota.org/
American Occupational Therapy Association. (2017b). Specialty
certification in low vision. Retrieved from http://www.aota.org/
Education-Careers/Advance-Career/Board-Specialty-Certific
ations/Low-vision.aspx
Anderson, C. (2010). Presenting and evaluating qualitative
research. American Journal of Pharmaceutical Education, 74,
141.
Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple
Aim: Care, health, and cost. Health Affairs, 27, 759-769.
Ciuffreda, K. J., Rutner, D., Kapoor, N., Suchoff, I. B., Craig, S., &
Han, M. E. (2008). Vision therapy for oculomotor dysfunctions
in acquired brain injury: A retrospective analysis. Optometry,
79, 18-22.
Cockerham, G. C., Goodrich, G. L., Weichel, E. D., Orcutt,
J. C., Rizzo, J. F., Bower, K. S., & Schuchard, R. A.
(2009). Eye and visual function in traumatic brain injury.
Journal of Rehabilitation Research and Development, 46,
811-818.
Dolnicar, S., Grun, B., Leisch, F., & Rossiter, J. (2014). Three
good reasons NOT to use five and seven point Likert items.
Proceedings from CAUTHE 2011:21st CAUTHE National
Conference. Adelaide, Australia.
Eysenbach, G., & Wyatt, J. (2002). Using the Internet for surveys
and health research. Journal of Medical Internet Research, 4,
e13.
Fraine, L. (2012). Nonsurgical management of diplopia. American
Orthoptic Journal, 62, 13-18.
Garcia-Munoz, A., Carbonell-Bonete, S., & Cacho-Martinez, P.
(2014). Symptomatology associated with accommodative and
binocular vision anomalies. Journal of Optometry, 7, 178-192.
Graneheim, U. H., & Lundman, B. (2004). Concepts, procedures
and measures to achieve trustworthiness. Nurse Education
Now, 2004, 105-112.
Greenwald, B. D., Kapoor, N., & Singh, A. D. (2012). Visual
impairments in the first year after traumatic brain injury. Brain
Injury, 26, 1338-1359.
Houston, K. E., & Barrett, A. M. (2017). Patching for diplopia
contraindicated in patients with brain injury? Optometry and
Vision Science, 94, 120-124.
Hyder, A. A., Wunderlich, C. A., Puvanachandra, P., Gururaj, G.,
& Kobusingye, O. C. (2007). The impact of traumatic brain
injuries: A global perspective. Neurorehabilitation, 22(5),
341-353.
Keith, R. A., Granger, C. V., Hamilton, B. B., & Sherwin, F.
S. (1987). The functional independence measure. Advanced
Clinical Rehabilitation, 1, 6-18.
Niederman, R. Clarkson, J., & Richards, D. (2011). The Affordable
Care Act and evidence-based care. Journal of the American
Dental Association, 142, 364-367.
O’Cathain, A., & Thomas, K. J. (2004). “Any other questions?”
Open questions on questionnaires – A bane or a bonus to
research? BioMed Central Medical Research Methodology, 4.
Patient Protection and Affordable Care Act, Pub. L. 111–148,
§3502, 124 Stat. 119, 124 (2010). Retrieved from www.
healthcare.gov/law/full/index.html
Phillips, P. H. (2007). Treatment of diplopia. Seminars in Neurol-
ogy, 27, 288-298.
Politzer, T. (1996). Case studies of a new approach using partial
and selective occlusion for the clinical treatment of diplopia.
Neurorehabilitation, 6, 213-217.
Portney, L. G., & Watkins, M. P. (2015). Foundations of clinical
research: Applications to practice (3rd Ed.). Philadelphia, PA:
F. A. Davis Company.
Riggs, R. V., Andrews, K., Roberts, P., & Gilewski, M. (2007).
Visual deficit interventions in adult stroke and brain injury: A
systematic review. American Journal of Physical Medicine and
Rehabilitation, 86, 853-860.
Rosenfeld, S. (2011). Vision and occupational therapy. OT Prac-
tice, 16, 7-11.
Rowe, F. (2011). Prevalence of ocular motor cranial nerve palsy
and associations following stroke. Eye, 2011, 881-887.
Rowe, F., Brand, D., Jackson, C. A., Price, A., Walker, L., Harri-
son, S., . . . & Freeman, C. (2008). Visual impairment following
stroke: Do stroke patients require vision assessment? Age and
Ageing, 38, 188-193.
Rucker, J. C., & Tomsack, R. L. (2005). Binocular diplopia: A
practical approach. The Neurologist, 11, 98-110.
Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., &
Richardson, W. S. (1996). Evidence-based medicine: What it
is and what it isn’t. British Medical Journal, 1996, 71-72.
 G. Burgess and V.D. Jewell / Perspectives on binocular diplopia
Scheiman, M. M., Scheiman, M. T., & Whittaker, S. G. (2007).
Low vision rehabilitation: A practical guide for occupational
therapists. Thorofare, NJ: SLACK Inc.
Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content anal-
ysis and thematic analysis: Implications for conducting a
qualitative descriptive study. Nursing and Health Sciences,
2013, 398-405.
Warren, M. (2005). Evaluation and treatment of visual percep-
tual dysfunction adult brain injury – Part I. [Course manual].
VisABILITIES Rehab Services.
233
Warren, M. (2011). Intervention for adults with vision impair-
ment from acquired brain injury. In M. Warren & E. Barstow
(Eds.), Occupational therapy interventions for adults with low
vision (pp. 403-448). Bethesda, MD: American Occupational
Therapy Association.
Warren, M. (2017). How occupational therapy has shaped the field
of low vision rehabilitation: Our past, present, and future. Pro-
ceedings from AOTA: 2017 Annual Conference and Centennial
Celebration. Philadelphia, PA.
Copyright of NeuroRehabilitation is the property of IOS Press and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.