Ask%20Well,%20Listen%20Well,%20Be%20Observant,%20Go%20Looking%20For

1
Ask Well,Listen Well,Be Observant,Go Looking
For

• Kara Gagnon, OD, FAAO
• Director of Low Vision Optometry
• Eastern Blind Rehabilitation Center
• VA Connecticut Healthcare System
• 950 Campbell Avenue
• West Haven CT 06516

2
The Soldiers Story

• 51 year old male
• Registered Nurse/Army Medic
• 14 months spent in Iraq
• Team diffused mines and explosives
• Endured 18 IED Explosions
• Twice Unconscious
• Symptoms after Exposure to initial blasts
• Headaches
• Photosensitivity
• Double vision
• Blurred Vision
• Tinnitus
• These symptoms were initially transient, after
  repeated blasts duration increased

3
The Soldiers Story

• March 2007 severe blast exposure, soldier
  unconscious for less than 30 minutes. Taken off
  duty for 2-3 days.
• Symptoms
• Headaches
• Photosensitivity
• Double vision
• Blurred Vision
• Memory Problems
• Sleep Disturbances
• Tinnitus
• All blasts exposed to after this head injury
  causing unconsciousness, recovery time from
  these symptoms was significantly prolonged.

4
The Soldiers Story

• August 2007 he was exposed to severe blast,
  rendered unconscious,
• for unknown period of time. Taken off
  duty for 10 days.
• Chronic Symptoms
• Headaches
• Extreme Photosensitivity had to wear dark
  sunglasses indoors
• Poor light and dark adaptation
• Double vision
• Blurred Vision
• Problems with reading- would have burning
  sensation of his eyes and fatigue after 10
  minutes or so, feeling that the right eye was
  not processing information
• Bumping into things on his right side, Things
  kept popping up on my right side.
• Significant balance issues
• Dizziness
• Tinnitus
• Impaired hearing in both ears, right ear can
  only hear noises can not process words
• Difficulties with organization of speech
• Problems with fine motor skills on left side
• Memory Problems
• Sleep Disturbances
• I tried, but I could not come back, I was in
  denial, I was waiting for things to get
  better

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Wifes Observations

• Her Husband was an avid reader upon return,
  would not read at all
• Extremely light sensitive
• Easily loses balance, used to take long walks
  with dogs, now takes very short walks
• Falling down stairs, bumping into things
• Poor memory
• Losing his temper
• Sleep disturbances
• His driving was unsafe, did not see things on his
  right side

6
Clinicians Observations

• Extremely Light Sensitive
• Fixated above my head when conversing with me,
  occasionally would fixate my eyes in primary gaze
• Demonstrated Poor balance
• Intermittently trailing the right side of the
  wall.
• Turned head to right to listen to me
• Searching for words, difficulty with speech
• Had significant difficulty relaying
  historyunless I asked very specific directed
  questions.
• Fatigued after a very short period
• Became nauseous easily during ocular motility
  testing

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Mechanics of Traumatic Brain Injury

• Open Head Trauma
• Direct Invasion through the skull (focal
  injury)
• Closed Head Trauma- most common
• Blow to the head that does not cause a direct
  pathway
• (global or diffuse injury)
• Accelerated- moving object hits the head or
  head hits
• a stationary object causing a focal
  wound or trauma
• Decelerated- body is restrained, causing soft
  tissues
• of the brain to move within the
  skull
• Percussion- Shock wave from IED causing
  diffuse axonal
• injury similar to the decelerated
  injury

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Diffuse Axonal InjuryDecelerated Injury

• Stretching and Sheering of axons
• Processing Speed- axons ability to
  neuro-transmit across synapse

Above image from www.uihealthcare.com/topics/medi
caldepartment...
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Sequence of Response to TBI

• Primary Response
• Occurs at the moment of injury or insult
• Lacerations, contusions, fractures, diffuse
  axonal tearing, hematomas
• Secondary Response
• Occurs hours to weeks post injury
• Auto-regulatory physiological mechanisms
  disrupted
• Neurotoxins are released
• Cascade of biochemical reactions
• Further brain damage
• Post Concussion Syndrome
• Post Trauma Vision Syndrome (PTVS)

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Visual Pathway Closed Head Trauma
Above image from www.mhhe.com/socscience/intro/ca
fe/prof/image.htm
Above image from camelot.mssm.edu/ygyu/research.
html
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Hierarchical Visual Processing Brain Mapping
Above image from psychology.wikia.com/wiki/Compar
ative_anatomy...
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Areas of the brain affected

• Frontal lobe
• Process visual information needed for motor
  planning
• Integrating voluntary movement of skeletal muscle
  and voluntary eye movements
• Abstract thinking, foresight and judgment
• Temporal lobe
• Combines sensory information associated with
  recognition and identification of objects
• Receives auditory stimuli and produces language

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Areas of the brain affected cont.

• Parietal lobe
• Involved with integrating information about
  object identification and object localization
  
• Occipital lobe
• Primary visual association area

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Lateralization of Brain Function

• Right Brain
• Simultaneous, Spatial Big Picture
• Visual
• Forest
• Left Brain
• Sequential, Temporal Detail
• Language
• Trees

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Primary Ocular Sequella

• Internal Orbital Injury Fractured Orbital Wall
• Floor fractures cause hypotropia hypertropia
  diplopia
• Medial fractures cause orbital emphysema- blood
  or air from nasal sinuses, secondary orbital
  cellulitis
• External Injury
• Extraocular muscle movement- comitancy
• Hypoesthesia
• Enopthalmos
• Proptosis
• Corneal Abrasions
• Corneal lesions
• Lid Injuries

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Secondary Visual Sequella

• Post Trauma Vision Syndrome (PTVS)
• Oculomotor Imbalance Strabismus
• Oculomotor Dysfunction Ocular Fixation and
  Ocular Motor Difficulties, pursuits and saccades
• Accommodative Abnormalities amplitude and
  facility
• Convergence Insufficiency
• Visual Field Loss and Inattention
• Vestibular and Disequilibrium- inability to match
  visual information with kinesthetic
  proprioceptive and vestibular experiences
• Lagopthalmous
• Pupillary Defects Anisocoria

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Post Trauma Vision Syndrome Symptoms

• Double vision
• Problems with depth perception
• Blurred near vision
• Perceived movement of print
• Asthenopia
• Loss of place when reading
• Reduced reading speed
• Inability to read despite the ability to write
• Avoidance of near tasks
• Headaches
• Photosensitivity
• Dry Eye Symptoms -decreased blink rate

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Post Trauma Vision Syndrome Symptoms, continued

• Visual Memory Deficits
• Visual perceptual processing deficits inability
  to perceive spatial relationships between and
  among objects
• Difficulty locating/fixating on an object and
  pursuing the object visually as it moves
• Objects appear to move when they are not actually
  moving
• Bumping into objects/exhibits abnormal posture
• Poor concentration and attention
• Inability to perceive the entire picture or to
  integrate its parts
• Inability to distinguish colors
• Inability to visually guide their arms, legs,
  hands and feet
• Inability to recognize objects with their vision
  alone

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Visual disturbances
Ocular motor dysfunction Most common
Vergence (56.3)1 Convergence insufficiency
Accommodation (41.1)1 Accommodative insufficiency
Version (51.3)1 Saccadic deficiency
Cranial nerve palsy (6.9)1 Cranial nerve III palsy
Strabismus (25.6)1 Strabismus at near
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Visual disturbances cont.

• Visual field defects 38.756
• Most common
• Scattered defects (58.06)
• Photosensitivity
• Associated with elevated dark adaptation
  threshold7

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Visual disturbances cont.

• Vestibular and balance problems
• Results from mismatch of visual information
• Associated with
• Fixation disparity
• Accommodative
• Vergence problems
• Blurred vision
• Ocular motor dysfunction
• Ocular disease
• Most common
• Corneal abrasion, blepharitis, chalazion/hordeolum
  , dry eye, traumatic cataract, vitreal prolapse
  and optic atrophy8

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Visual Perceptual Processing Deficits

• Disturbances in Body Image
• Disturbances in Spatial Relationships
• Right-left discrimination problems
• Laterality - directionality
• Visual Agnosia/difficulties in object recognition
• Visual Form Constancy
• Visual Figure Ground
• Visual Discrimination
• Visual Memory Losses
• Visual Sequential Memory
• Visual Motor Skills
• Apraxia difficulty in manipulation of objects

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Examination of a TBI Patient

• Detailed case history and ocular inventory
• Description of incident
• Any loss of consciousness
• Localization of injury or Diffuse Axonal Injury
  (DAI)
• Detailed ocular inventory including
• Missing part of visual field
• Bumping into objects or walls
• Asthenopia
• Light sensitivity
• Decreased night vision
• Dry eye symptoms
• Headaches
• Dizziness
• Reading symptoms

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Examination cont.

• Visual acuity
• Distance and near
• Utilize different charts
• Snellen, ETDRS, Feinbloom, broken wheel, and Lea
  symbols
• May need to isolate lines and/or letters
• Contrast sensitivity
• Pelli Robson chart

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Contrast Sensitivity

• Subjectively Illumination History
• Objectively Vistek/ Pelli Robinson Charts

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Lighting Evaluation
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Examination cont.

• Visual field screening
• Confrontation visual fields
• FDT perimetry screening
• If defects noted on screening, then Humphrey or
  Goldmann visual field testing should be performed

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Examination cont.

• Cover test
• Distance and near
• Steady or unsteady fixation
• Color vision
• Stereopsis
• Ocular motility
• EOMs
• Pursuits and saccades

Above image from www.michaelgaigg.com/.../
Above image from www.good-lite.com/Details.cfm?Pr
odID313
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Examination cont.

• Refraction with binocular balance
• Phoria testing
• Von Graefe (in-phoropter)
• Modified Thorington (out-of-phoropter)
• Maddox Rod in 9 diagnostic action fields
• Parks 3 step (if vertical deviation in primary
  gaze)
• Vergence testing
• Risley prism (in-phoropter)
• Prism bar (out-of-phoropter)

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Examination cont.

• Accommodation
• Amplitudes
• Minus lens (in-phoropter)
• Push up or pull away (out-of-phoropter)
• Facility/Flexibility
• NRA and PRA
• Flippers
• Monocular and binocular
• Posture/Accuracy
• MEM
• Fused or Unfused Cross-Cylinder

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Ocular Motility Accommodation Assessments

• Versions
• Saccadic Fixations
• Ocular Pursuits
• Near Point of Convergence
• Convergence facility
• near/far change

• Accommodative Amplitude
• binocular monocular
• Accommodative facility
• near/far change

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Examination cont.

• Ocular health evaluation
• Pupils
• Slit lamp exam
• Dilated fundus exam

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Additional Testing

• Vestibular ocular reflex (VOR)
• Dynamic visual acuity
• Head thrusts
• Balance testing
• Romberg
• Tandem walking
• Auditory
• Basic hearing test
• Caloric testing (COWS)

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Additional Testing cont.

• Visually evoked potential (VEP)
• An objective test used to assess the function of
  the visual system beyond the retina
• Measures the response of the visual cortex to
  continuous stimulation and the conduction of
  signal from the optic nerve to the occipital
  cortex

Above image from www.virtualmedicalcentre.com/hea
lthinvestigat...
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Treatment Strategy

• Input of Visual Information
• Ocular health problems
• Optical and Refractive problems
• lenses, prism, tints, coatings,
• selective occlusion
• Neuro-optometric Vision Therapy

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Optical Treatment Modalities

• Prescription of appropriate lenses for distance
  and near
• Anti-reflective coatings, tints to reduce glare
  and photosensitivity
• Correcting Prism
• Convergence Insufficiency
• Vertical Deviations
• Fixation Disparities

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Simplified vision therapy for most common visual
disturbances of TBI

• Deficits of saccades
• Patient makes large, oblique saccades into four
  corners of room x 10
• Increase difficulty by decreasing distance
  between targets
• Vergence dysfunction
• Increase vergence demand slowly and gradually
  until diplopia reported, then decrease demand
  until single vision reported
• Accommodation dysfunction
• Target is brought from arms length slowly and
  smoothly toward the patient until it blurs, then
  the target is slowly and smoothly moved back to
  arms length x 10
• Patient looks at target 10ft away for 3 seconds,
  then looks at target 16in away for 3 seconds x 10
  
• Patient views target thru (-) lens for 10
  seconds, then () lens for 10 seconds x 10

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Treatment cont.

• Vestibulo-Ocular reflex (VOR) therapy
• Responsible for stabilizing visual world while
  head is in motion
• Dynamic fusion facility
• Multiple Brock String with balance
• Wayne Fixator with balance
• Use prisms, lenses, and filters to change input
  during therapy
• Patient uses thumb at arms length as target and
  slowly moves head left and right while fixating
  thumb
• Can increase speed of head movement as therapy
  progresses
• Tints
• 15 absorption blue

41
Near Evaluation Continued

• Closed-Circuit Television (CCTV)
• CCTV Spectacles
• Habitual Working Distance/Appropriate add
• Occlusion of Non-dominant Eye
• Preferred Tint to maximize contrast

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Intermediate Evaluation

• Telemicroscope
• Magnifying Mirror

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Optometric Management of Visual Field Loss

• Scanning/Awareness
• Sectoral Yoked Prism
• Fresnel prism
• Tight fit Noxious Stimulus
• Full Yoked Prism in reading RX

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Goldmann visual field results
OD
OS
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Clinical PearlsShare with Interdisciplinary Team

• Eye signs may be subtle
• Eye signs may be intermittent
• Symptoms may be masked
• Symptoms may be interpreted differently based on
  discipline
• Patients may not attribute complaints to an eye
  problem

48
References

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   Occurrence of oculomotor dysfunctions in acquired
   brain injury A retrospective analysis. Optometry
   200778155-161.
2. Hoge CW, McGurk D, Thomas JL, et al. Mild
   traumatic brain injury in U.S. soldiers returning
   from Iraq. The New England Journal of Medicine
   2008358(5)453-463.
3. Cohen AH and Rein LD. The effect of head trauma
   on the visual system The doctor of optometry as
   a member of the rehabilitation team. Journal of
   the American Optometric Association
   199263530-536.
4. Ciuffreda KJ, Rutner D, Kapoor N, et al. Vision
   therapy for oculomotor dysfunctions in acquired
   brain injury A retrospective analysis. Optometry
   20087918-22.
5. Kapoor N and Ciuffreda KJ. Vision disturbances
   following traumatic brain injury. Current
   Treatment Options in Neurology 20024271-280.
6. Suchoff IB, Kapoor N, Cuiffreda KJ, et al. The
   frequency of occurrence, types, and
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   Optometry 2008 79259-265.
7. Du T, Cuiffreda KJ, Kapoor N. Elevated dark
   adaptation thresholds in traumatic brain injury.
   Brain injury 200519(13)1125-1138.
8. Rutner D, Kapoor N, Cuiffreda KJ, et al.
   Occurrence of ocular disease in traumatic brain
   injury in a selected sample A retrospective
   analysis. Brain Injury 200620(10)1079-1086.
9. Newcombe VFJ, Williams GB, Nortje J, et al.
   Analysis of acute traumatic axonal injury using
   diffusion tensore imaging. British Journal of
   Neurosurgery 200721(4)340-348.