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  • 1. Diagnosis and Management of TBI-Related Vision Problems Mitchell Scheiman, OD
  • 2. 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
  • 3. Introduction
    • Patients surviving acquired brain injury generally experience multiple problems:
      • Cognitive
      • Psychological
      • Motor
      • Sensory
    • BV, ACC and EM problems tend to be more complicated
  • 4. Overview of Traumatic Brain Injury
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. Classification of TBI
    • Mild
    • Moderate
    • Severe
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. Results
    • TBI
      • Accommodative insufficiency: 41.1%
      • Convergence insufficiency: 56.3%
      • Strabismus: 25.6%
      • Cranial nerve Palsy: 10.0%
  • 13. Recent Prevalence Studies in Military/VA Populations
  • 14. 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
  • 15. 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)
  • 16. 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
  • 17. Brahm et al.
    • Convergence insufficiency (CI): 42%
    • Accommodative Insufficiency: 42%
    • Pursuit/Saccadic Dysfunction: 33%
    • Visual Field Defects: 32%
    • Bilateral poor visual acuity: 4%
  • 18. 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
  • 19. 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%
  • 20. 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
  • 21. Common Vision Problems after TBI?
    • Binocular Vision
      • Convergence Insufficiency (CI)
    • Accommodative Problems
      • Accommodative Insufficiency (AI)
    • Eye Movement disorders
    • Visual Field Disorders
    • Low vision?
  • 22. Optometric Role TBI-Related Vision Disorders
  • 23. Significance
    • Vision problems common after TBI
    • Significant negative impact ability to return to active duty
    • Effect on:
      • Reading
      • Writing
      • Driving
  • 24. 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
  • 25. 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
  • 26. 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
  • 27. Model of Care
  • 28. Vision Rehabilitation Team
    • Eye Care Professionals
      • Optometrists
      • Ophthalmologists
    • Rehabilitation Professionals
      • Occupational Therapists (OTs)
  • 29. 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)”
  • 30. Proposed Model
  • 31. 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
  • 32. 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
  • 33. Optometrist
    • Intervention plan
        • Prescribe lenses
        • Prescribe prism
        • Prescribe occlusion
        • Prescribe vision rehabilitation
    • Supervise treatment
    • Periodic follow-up
  • 34. Occupational Therapist
      • Identification of patients at risk for vision problems
      • Screening
        • Accommodation
        • Binocular vision
        • Eye Movements
        • Visual Processing
      • Administration of vision rehabilitation
  • 35. Three Component Model of Vision Visual Integrity Visual Efficiency Visual Information Processing
  • 36. Visual Integrity
  • 37. Visual Efficiency Skills
  • 38. Visual Information Processing Disorders
  • 39. Summary
    • 3 component model
      • Important for optometrists and rehabilitation specialists to conceptualize and use same model of vision
  • 40. 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
  • 41. For Model to Work
    • Military ODs:
      • Evaluation
      • Diagnosis
      • Treatment
        • Passive
        • Active
      • Must know enough about vision rehab to supervise OTs