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

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 Soldier’s 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 Soldier’s 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 Soldier’s 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”

5. Wife’s 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. Clinician’s 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 history…unless I asked very specific directed questions. • Fatigued after a very short period • Became nauseous easily during ocular motility testing

7. 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

8. 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/medicaldepartment...

9. 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)

10. Visual Pathway Closed Head Trauma Above image from: www.mhhe.com/socscience/intro/cafe/prof/image.htm Above image from: camelot.mssm.edu/~ygyu/research.html

11. Hierarchical Visual Processing Brain Mapping Above image from: psychology.wikia.com/wiki/Comparative_anatomy...

12. 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

13. Areas of the brain affected cont. • Parietal lobe • Involved with integrating information about “object identification” and “object localization” • Occipital lobe • Primary visual association area

14. Lateralization of Brain Function • Right Brain • Simultaneous, Spatial –Big Picture • Visual “Forest” • Left Brain • Sequential, Temporal –Detail • Language “Trees”

15. 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

16. 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

17. 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

18. 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 it’s parts • Inability to distinguish colors • Inability to visually guide their arms, legs, hands and feet • Inability to recognize objects with their vision alone

19. Visual disturbances

20. Visual disturbances cont. • Visual field defects 38.75%6 • Most common: • Scattered defects (58.06%) • Photosensitivity • Associated with elevated dark adaptation threshold7

21. 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

22. 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

23. 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

24. 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

26. Contrast Sensitivity • Subjectively: Illumination History • Objectively: Vistek/ Pelli Robinson Charts

27. Lighting Evaluation

28. 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

29. 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?ProdID=313

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

31. 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

33. Versions Saccadic Fixations Ocular Pursuits Near Point of Convergence Convergence facility near/far change Accommodative Amplitude binocular & monocular Accommodative facility near/far change Ocular Motility & Accommodation Assessments

34. Examination cont. • Ocular health evaluation: • Pupils • Slit lamp exam • Dilated fundus exam

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

36. 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/healthinvestigat...

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

38. 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

39. 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 arm’s length slowly and smoothly toward the patient until it blurs, then the target is slowly and smoothly moved back to arm’s 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

40. 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 arm’s 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

42. Intermediate Evaluation • Telemicroscope • Magnifying Mirror

43. Optometric Management of Visual Field Loss • Scanning/Awareness • Sectoral Yoked Prism • Fresnel prism • Tight fit: Noxious Stimulus • Full Yoked Prism in reading RX

44. Goldmann visual field results OD OS

47. 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 • Ciuffreda KJ, Kapoor N, Rutner D, et al. Occurrence of oculomotor dysfunctions in acquired brain injury: A retrospective analysis. Optometry 2007;78:155-161. • 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 2008;358(5):453-463. • 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 1992;63:530-536. • Ciuffreda KJ, Rutner D, Kapoor N, et al. Vision therapy for oculomotor dysfunctions in acquired brain injury: A retrospective analysis. Optometry 2008;79:18-22. • Kapoor N and Ciuffreda KJ. Vision disturbances following traumatic brain injury. Current Treatment Options in Neurology 2002;4:271-280. • Suchoff IB, Kapoor N, Cuiffreda KJ, et al. The frequency of occurrence, types, and characteristics of visual field defects in acquired brain injury: A retrospective analysis. Optometry 2008; 79:259-265. • Du T, Cuiffreda KJ, Kapoor N. Elevated dark adaptation thresholds in traumatic brain injury. Brain injury 2005;19(13):1125-1138. • 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 2006;20(10):1079-1086. • Newcombe VFJ, Williams GB, Nortje J, et al. Analysis of acute traumatic axonal injury using diffusion tensore imaging. British Journal of Neurosurgery 2007;21(4):340-348.