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Tbi military 1
 

Tbi military 1

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    Tbi military 1 Tbi military 1 Presentation Transcript

    • Diagnosis and Management of TBI-Related Vision Problems Mitchell Scheiman, OD
    • 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
    • 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
    • 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
    • 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
    • Classification of TBI
      • Mild
      • Moderate
      • Severe
    • 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
    • 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
      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%
    • 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
      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)
    • 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
    • Brahm et al.
      • Convergence insufficiency (CI): 42%
      • Accommodative Insufficiency: 42%
      • Pursuit/Saccadic Dysfunction: 33%
      • Visual Field Defects: 32%
      • Bilateral poor visual acuity: 4%
    • Stelmack - 2009
      • Retrospective record review performed for 103 patients with polytrauma
      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 Polytrauma
      • Accommodative disorder 47% 30%
      • Convergence disorder 28% 13%
      • Visual field loss 14% 23%
      • Pursuits/saccade disorders 6% 9%
      • Diplopia 8% 15%
    • 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, 2 nd most common vision problem
    • Common Vision Problems after TBI?
      • Binocular Vision
        • Convergence Insufficiency (CI)
      • Accommodative Problems
        • Accommodative Insufficiency (AI)
      • Eye Movement disorders
      • Visual Field Disorders
      • Low vision?
    • Optometric Role TBI-Related Vision Disorders
    • Significance
      • Vision problems common after TBI
      • Significant negative impact ability to return to active duty
      • Effect on:
        • Reading
        • Writing
        • Driving
    • 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
    • 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
    • Model of Care
    • Vision Rehabilitation Team
      • Eye Care Professionals
        • Optometrists
        • Ophthalmologists
      • Rehabilitation Professionals
        • Occupational Therapists (OTs)
    • 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)”
    • Proposed Model
    • 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
    • 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
    • Optometrist
      • Intervention plan
          • Prescribe lenses
          • Prescribe prism
          • Prescribe occlusion
          • Prescribe vision rehabilitation
      • Supervise treatment
      • Periodic follow-up
    • Occupational Therapist
        • Identification of patients at risk for vision problems
        • Screening
          • Accommodation
          • Binocular vision
          • Eye Movements
          • Visual Processing
        • Administration of vision rehabilitation
    • Three Component Model of Vision Visual Integrity Visual Efficiency Visual Information Processing
    • Visual Integrity
    • Visual Efficiency Skills
    • Visual Information Processing Disorders
    • 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 rehabilitation
    • For Model to Work
      • Military ODs:
        • Evaluation
        • Diagnosis
        • Treatment
          • Passive
          • Active
        • Must know enough about vision rehab to supervise OTs