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1
Diagnosis and Management of TBI-Related Vision Problems
Mitchell Scheiman, OD
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Objectives
• To understand the impact of TBI on the visual system
• To review the evaluation of binocular vision, accommodation, and eye movements in the TBI patient
• To review the treatment of TBI-related vision problems
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Introduction
• Patients surviving acquired brain injury generally experience multiple problems:– Cognitive– Psychological– Motor – Sensory
• BV, ACC and EM problems tend to be more complicated
Overview of Traumatic Brain Injury
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Traumatic Brain Injury (TBI)
• Definition:– Injury to the head that is documented in a
medical record with one or more of the following conditions attributed to head injury:
• Observed or self-reported decreased level of consciousness
• Amnesia• Skull fracture• Objective neurological or neuropsychological
abnormality• Diagnosed intracranial lesion
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Epidemiology of TBI
• 175 to 200 per 100,000 population or about two million head injuries each year
• Over 1.5 million Americans suffer nonfatal traumatic brain injuries each year that do not require hospitalization
• Another 300,000 individuals suffer brain injuries severe enough to require hospitalization
• 100,000 resulting in a lasting disability• Prevalence of TBI is estimated to be 2.5
million to 6.5 million individuals
TBI: Iraq and Afghanistan Wars
• Every war produces a characteristic injury that becomes that conflict's "signature wound".
• WWII– radiation-induced cancer from atomic
bombs
• Vietnam war– Post Traumatic Stress Disorder (PTSD)
• Iraq War– TBI
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Classification of TBI
• Mild• Moderate• Severe
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Judging Severity of TBI
Post Traumatic Amnesia Scale (PTA)• The time between injury and recovery
of continuous memory for day-to-day events
• Best measure of quantity of brain tissue destroyed by TBI
• Can be used months or even years after TBI
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Post Traumatic Amnesia (PTA) Scale
PTA Score Severity of Injury
< 10 minutes Very mild
10 to 60 minutes Mild
1 to 24 hours Moderate
1 to 7 days Severe
> 7 days Very severe
TBI: Prevalence of Vision Problems in Civilian Population
• 160 records of patients with TBI (160) reviewed – 90% had BV/ACC/EM disorders
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Ciuffreda KJ, Kapoor N, Rutner D, et al. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry 2007;78:155-61
Results
• TBI– Accommodative insufficiency: 41.1%– Convergence insufficiency: 56.3%– Strabismus:
25.6%– Cranial nerve Palsy: 10.0%
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Recent Prevalence Studies in Military/VA Populations
Goodrich, G et al.- 2007
• 50 patients admitted to Polytrauma Rehab Center (PRC) from December 2004 to November 2006
• Mean age of subjects 28.1 years • All subjects had experienced a TBI• Blast injuries accounted for half of all
injuries
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Goodrich, G et al. Visual function in patients of a polytrauma rehabilitation center: A descriptive study. Journal of Rehabilitation Research & Development 2007; 44: 929–936
Results
Problem All Subjects
(n=46)
Blast
(n=21)
NonBlast
(n=25)
Convergence Insufficiency
30% 24% 36%
Accommodative Dysfunction
22% 24% 20%
Pursuit/Saccade Dysfunction
20% 5% 32%
Visual Field Defects
21% (100 Eyes)
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Brahm, et al. - 2009
• Frequency of visual impairment in combat-injured service members with TBI– Polytrauma Rehab Center (PRC) inpatient (n=68)
– Polytrauma Network Site (PNS) outpatient (n=124)• Mean age : 28years old
– 84% of PRC patients: TBI associated with blast event
– 90% of PNS patients: TBI associated with blast event
Brahm KD, et al. Visual impairment and dysfunction in combat-injured servicemembers with TBI. Optom Vis Sci 2009;86:817-825 16
Brahm et al.
• Convergence insufficiency (CI):42%
• Accommodative Insufficiency: 42%• Pursuit/Saccadic Dysfunction: 33%• Visual Field Defects: 32%• Bilateral poor visual acuity: 4%
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Stelmack - 2009
• Retrospective record review performed for 103 patients with polytrauma
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Joan A. Stelmack, O.D., M.P.H. Visual function in patients followed at a Veterans Affairs Polytrauma Network Site: An electronic medical record review. Optometry 2009;80:419-424
Results
Problem TBI PolytraumaAccommodative disorder 47% 30%Convergence disorder 28% 13%Visual field loss 14% 23%Pursuits/saccade disorders 6% 9%Diplopia 8% 15%
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Prevalence of CI in the TBI Population
• Ranges from 13% to 44%• In 2 of 3 studies of military population, CI
most prevalent vision disorder and in the third study, CI, 2nd most common vision problem
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Common Vision Problems after TBI?
• Binocular Vision– Convergence Insufficiency (CI)
• Accommodative Problems– Accommodative Insufficiency (AI)
• Eye Movement disorders• Visual Field Disorders• Low vision?
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Optometric Role
TBI-Related Vision Disorders
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Significance
• Vision problems common after TBI• Significant negative impact ability to
return to active duty• Effect on:
– Reading– Writing– Driving
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Optometric Role
• Historically ODs not been part of the rehabilitation team in civilian and military hospitals
• Team typically includes:– Physicians – Occupational therapists– Physical therapists – Speech language pathologists
• Eyecare usually provided by an ophthalmologist– Emphasis on acuity and eye disease
• Common for some vision problems associated with TBI to be left undetected or untreated
• Unique opportunity for Military ODs
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Military Optometric Role
• Primary Care Military ODs– Because of high prevalence of TBI-
related vision disorders• Assessment and diagnosis of vision
problems of patients with TBI
– Vision Rehabilitation • Passive treatment
– Lenses, prism, occlusion
• Active treatment – Vision rehabilitation
Vision Rehabilitation Models
Civilian Model• Diagnosis: Primary Care
OD• Passive Tx: Primary Care
OD• Vision Therapy
– Refer to specialist– Performed by “vision
therapist”
Military Model• Diagnosis: Primary Care
OD• Passive Tx: Primary Care
OD• Vision Rehabilitation
– Prescribed by Primary care OD
– Performed by occupational therapist
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Model of Care
Vision Rehabilitation Team
• Eye Care Professionals– Optometrists – Ophthalmologists
• Rehabilitation Professionals– Occupational Therapists (OTs)
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Occupational Therapist (OTs)
• Education– Master's degree or higher is minimum
requirement for entry into the field– All States regulate the practice of occupational
therapy
• American Occupational Therapy Association:– “OTs help people across the lifespan participate
in the things they want and need to do through the therapeutic use of everyday activities (occupations)”
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Proposed Model
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TBI Protocol
• Should include mandatory vision examination by primary care optometrist
• Minimum data base– Visual acuity– Eye health– Accommodation– Binocular vision– Eye movements – Visual field
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Optometrist
• Role of Optometrist – Primary Care Role– Eye Disease
• Medical treatment• Refer to Ophthalmologist
– Advanced medical treatment– Surgical treatment
• Refractive, Binocular, Accommodative, Eye Movement Disorders– Assessment– Diagnosis– Prescribe treatment
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Optometrist
• Intervention plan• Prescribe lenses• Prescribe prism• Prescribe occlusion• Prescribe vision rehabilitation
• Supervise treatment• Periodic follow-up
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Occupational Therapist
– Identification of patients at risk for vision problems
– Screening• Accommodation• Binocular vision• Eye Movements• Visual Processing
– Administration of vision rehabilitation
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Three Component Model of Vision
Visual IntegrityVisual Efficiency
Visual Information Processing
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Visual Integrity
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Visual Efficiency Skills
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Visual Information Processing Disorders
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Summary
• 3 component model
– Important for optometrists and rehabilitation specialists to conceptualize and use same model of vision
Conclusions
• Prevalence of vision disorders after TBI is very high
• Soldiers returning after TBI deserve the very best vision care– Comprehensive evaluation– Appropriate and timely vision rehabilitation
• Lenses
• Prism
• Occlusion
• Vision rehabilitation40
For Model to Work
• Military ODs:– Evaluation– Diagnosis– Treatment
• Passive• Active
– Must know enough about vision rehab to supervise OTs
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