AER CONFERENCE 2012 Visual Anomalies from Brain Injury and Rehabilitation Strategies

1. Paul Koons, M.S., C.O.M.S., C.L.V.T., C.B.I.S. Email: Paul.koons@va.gov AER CONFERENCE 2012Visual Anomalies from Brain Injury and Rehabilitation Strategies

2. Background/Experience • Pa. College of Optometry /Salus Univ 1999 • Graduate studies • Orientation & Mobility , Low Vision Therapy Experience: • NYC Lighthouse International • State Blind Rehab agencies (Pa, CO, Va) • Presently Veteran’s Affairs – Polytrauma center blindness and vision loss specialist (Palo Alto & currently Richmond)

3. Goals of Presentation • Define Polytrauma with emphasis on vision loss • Discuss Mechanism of Injury causing Brain Injury • Types of visual deficits / anomalies • Rehabilitation Timelines • Multi-Discipline therapies addressing deficits • Part of Team: MD, OD, PT, KT, OT, SLP, RT, Psych, RN, LPN, MSW • Case studies • Resources • Audience goal - think about your networks for addressing brain injury and visual deficits

4. Disclaimer statement • This presenter has no financial interest in any of the makes, models of rehab equipment, devices, sunwear or assessment tools

5. Brain Injury: • TBI – an acquired brain injury caused by an external physical force, resulting in partial functional disability or psychosocial impairment, or both, adversely affecting educational performance. • TBI – Traumatic Brain Injury (MVA, Fall, GSW, IED blast) • ABI – Acquired Brain Injury (Stroke, Brain Tumor, Anoxia, Hypoxia, Seizures, Blood clots)

6. TBI Severity and Prognosis

7. Severity of Brain Injury • Mild TBI / Concussion – Loss of Consciousness less than 30 minutes (or NO loss)- Post Traumatic Amnesia for less than 24 hours. Post Concussion Symptoms • Moderate TBI – Coma more than 20-30 minutes, but LESS than 24 hours. Some long term problems in one or more areas • Severe TBI – Coma longer than 24 hours, often lasting days or weeks, Longer term impairments

8. Estimates of TBI Severity • Mild TBI / Concussion – up to 80% of all cases. • Moderate TBI 10% - 30% • Severe TBI 5% - 25% • According to Brain Injury Assoc of America

9. Traumatic Brain Injury in America • Not “just” a VA problem • Polytrauma highlighted because of high incidence of occurrence in Iraq / Afghanistan (OEF/OIF) • Relevance to community services (Brain injury Association of America) • 1.4 – 1.7 million Americans sustain TBI Annually • One every 21 seconds • 700,000 Americans experience stroke annually • One every 45 seconds

10. Annual incidence of TBI per Age group • 0-4 years old (1121 per 100,000 cases) • 15-19 years old (814 per 100,000 cases) • 5-9 years old (659 per 100,000 cases) • 75 years and older (659 per 100,000 cases) • Often times any brain injury during initial years not realized until later years • According to Brain Injury Assoc of America

11. Highest incidence of death due to TBI • 75 years and older (51 per 100,000) • 20-24 years old (28 per 100,000) • 15-19 years old (24 per 100,000) -According to Brain Injury Assoc of America

12. Multiple TBI Risk Factors • After 1 TBI, the risk for a 2nd is 3x greater • After 2 TBIs, the risk is 8x greater Brain Injury Association of America

13. Brain Injury Recovery timeline • General 2 Year “Window” for Recovery • Try to “Estimate” degree of recovery in initial 6 months since Injury • Severity of Brain Injury a factor, also Anoxic/Hypoxic Brain Injury may kill off more brain cells unable to regenerate • Bottom Line – Recovery has been seen several years later, but initial 2 year timeline is a “benchmark”

14. Ophthalmologic and Optometric Interventions • Ocular Health Exam • Prescription of appropriate corrective lenses • Use of occlusion – complete or partial • Prisms – yoked, Fresnel • Medical and surgical intervention when warranted • Optometric plan of care for ocular motor, accommodative dysfunctions

15. Polytrauma • Polytrauma is currently defined as multiple injuries of which one (or a combination) is life threatening. • Co-Morbidities associated with TBI • Vision, Hearing, Physical, Cognitive, Behavioral, PTSD, Sleep, etc

16. Mechanism of Injury • Motor Vehicle Accident • Sports Concussions • Falls • Physical Altercations • Stroke, Brain Tumor (multiple TIA’s) • Gun Shot Wound (could be self-inflicted) • Anoxia / Hypoxia • Cranial Depression to relieve brain swelling prior to Cranioplasty procedure

17. Bullet Wound: Entering Left Frontal-Temporal area, Passing through parietal, midline into Right Occipital area Possibly resulting in: Contre coupe: Motor Vehicle Accident, trauma etc. Possible watershed effect: damage to frontal lobe, Occipital lobe, extensive bleeding, extensive swelling etc Haemorrhage: Parietal/Temporal: Specific site indicative of stroke, Frontal: typical blunt object trauma Occipital: Tumour

18. Improvised ExplosiveDevices (IEDs)

19. IED Blast “Global” damage to brain and body Described as “PRESSURE” Wave “Torsional” effect or twisting of brain within skull IED's also cause damage due to projectile bomb fragments, debris and individual being ‘thrown’ Penetrating vs. non-penetrating injuries

20. Polytrauma Veterans Affairs 5 Main Polytrauma VA Hospitals in U.S.A. • Tampa, Florida • Minneapolis, MN • Palo Alto, CA • Richmond, Va • San Antonio, Tx

21. Richmond VAMC Population (Mechanism of Injury) since 2007

22. Richmond TBI rehabPopulation (Injury Location)*since Sept. 2007

23. Some Emerging Characteristics of Polytrauma Patients • They are a unique population with unique, long term issues • They may not be good self-advocates • Many are young and have full lives ahead • They are “tech-savvy” • They may not want services • Most have family involvement and maintain military culture

24. Most commonly reported visual symptoms related to TBI • Headaches • Diplopia /double vision • Vertigo / Vestibular issues • Asthenopia • Weakness or fatigue of the eyes, usually accompanied by headache and dimming of vision (may affect training in am / p.m.) • Accommodation - Inability to focus • Movement of print when reading • Difficulty with visual tracking and fixations • Photophobia / Photosensitivity (night glare)

25. Site of Lesion

26. Visual Pathway - numbers indicate how lesion affect visual field(s)Red/Blue = image seen Gray = blind area

27. Left Vs Right Brain Functions uses logicdetail orientedfacts rulewords and languagepresent and pastmath and sciencecan comprehendknowingacknowledgesorder/pattern perceptionknows object namereality basedforms strategiespracticalsafe uses feeling"big picture" orientedimagination rulessymbols and imagespresent and futurephilosophy & religioncan "get it" (i.e. meaning)believes music Facial recognitionspatial perceptionknows object functionfantasy basedpresents possibilitiesrisk taking Left Brain Functions Right Brain Functions

28. Visual Anomalies of Brain Injury Binocular dysfunction • Convergence • Accommodation • Saccadic/Pursuit • Ocular motor • Fixation Visual Field Loss often seen: • Quadranopia • Hemianopia • macular sparing? • General Peripheral loss

29. Methods to create success and independence through rehabilitation • 1. “Fix / Improve Vision” – vision therapy or surgery • 2. Use devices/lenses to improve vision (Magnifiers, Telescopes, Rx, Readers, Prisms, white cane) • 3. Compensatory Strategies (eccentric fixation, scanning to blind visual field, place reading stand in better visual field)

30. Role of Vision Specialist Consultative for Mild TBI patients: • performs diagnostic screening as needed and requests referral to the appropriate Eye specialist • provides recommendations for use of optical and non-optical devices to the other therapies; • monitors client’s level of visual functioning and provides intermittent screening • provides intermittent follow-up services

31. Role of Vision Specialist Interventional Therapist/ moderate to severe TBIs • Provides daily intervention as per recommendation of the evaluating eye specialist and based on an established plan of care – duration, • Frequency of treatment and functional goals are pre-established prior to commencement of treatment • Progression and discharge from this service will be based on outcome and/or discharge from facility • Provide follow-up plan (use of readers, visual search, compensatory strategies)

32. Intervention Strategies Implemented by Vision Specialists • Follow-up education and training in use of prescribed corrective lenses • Training and education on the use of occluders and prism glasses to promote independence and safety during completion of ADL functions • Education on use of appropriate glare remediation

33. Intervention Strategies • Graded static and dynamic training to improve use of an organized and systematic scanning strategy • Training in the use of non-optical aids • Orientation and mobility training

34. Intervention Strategies • Manipulation of the environment a. reduction of background pattern b. use of adequate illumination c. increase in background contrast d. anchoring and boundary marking strategies

35. Intervention Strategies • Environmental modification to improve awareness of missing visual space • I.e.: bed placement to improve awareness/scanning to auditory stimuli – hallway • I.e.: Place reading stand and material into/out of remaining visual field

36. Screening and Assessment Process Vision Program F/U SLP/OT/PT Intervention

37. Glossary • Accommodation • Version • Saccade • Pursuit • Convergence • Divergence • Visual Fields • Photosensitivity changizi.wordpress.com

38. Research articles on Binocular Dysfunctions in TBI population (military & civilian) • Stelmack et al., 2009 (all levels of TBI in Hines VA hospital) • 47% accommodative disorders • 28% convergence insufficiency • Brahm et al., 2009 (all levels of TBI in Palo Alto VA hospital) • 39.6% of accommodative insufficiency • 42.6% of convergence insufficiency • Goodrich et al, 2007 (all levels of TBI in Palo Alto VA hospital) • 21.7% had accommodative dysfunction • 30.4% had convergence insufficiency • Ciuffreda et al., 2007 (Civilian, TBI rehabilitation) • 41 % had accommodative dysfunction • 42.5% had convergence insufficiency • Lew et al., 2007 (mild TBI) • 21% accommodative insufficiency • 46% convergence insufficiency *all patients diagnosed in Optometric clinics within 3 months post trauma

39. RIC Eye/TBI Clinic n=100 (2007-2009)Most Common Vision Disorders following TBI • Photosensitivity 34% • Convergence Insufficiency 31% • Saccadic Dysfunction 24% • Dry Eye 23% • Accommodative issues 18% • Tropia (Eye Turn) 13% • Visual Field defects 10% *research design was conservative as these are primary dx but many of these overlap such as photosensitivity and accommodation

40. Accommodation • Definition: ability to focus near and distant targets • Measure Accommodation monocularly(diopter) • Our eyes ‘bending’ power

41. Rehab strategies for Accommodation insufficiency

42. Ms. V Visual Dysfunctions • 28 yr old with left Sylvian fissure AVM embolization left cerebral hemisphere ischemia • Accommodation insufficiency • Reduced near point of convergence • Saccadic dysfunction • Dry eye • Floaters OS per patient • Photosensitivity

43. Reading with +/- power flipperscan be performed monoc. / binoc.

44. Hart Chart Activities (Saccades and Accommodation therapy)

45. Version / Eye movement • Definition: smooth eye movements in the same direction • Saccade - efficient eye movement from one fixation point to another • Pursuit - two eyes ability to follow a target • Fixation-eyes’ ability to stop on an object and bring it into focus (fixate and focus)

46. Large and Small Saccades

47. Large Visual Saccades

48. Reading with small visual saccades

49. Rehab strategies for SaccadesDevelopmental Eye Movement (DEM)Test A + B = C (time measured)

50. Saccadic Reading Exercises