1. A Gun Shot to the Head: Oculo-Visual & Perceptual Anomalies
D. Maino, D. Schlange, R. Donati, C. Bakouris, M. Nikoniuk • Illinois College of Optometry
Table 1: Examination/Follow-up Findings
ABSTRACT BACKGROUND conducted a vision information process assessment that
Date
01/21/09
Refractive Error
OD -.50-.25X090
Best Visual Acuity
20/20-
Strabismus
8 PD LH dist
Function
External Eye Health
lagophthalmus
Internal Eye Health
ON Temp Pallor
Visual Field
L hemianopic
OS Pl 20/20- 6 PD XT Dry eye VF defect
BACKGROUND: Traumatic brain injury (TBI) results from Each year 1.4 million people in the U.S. suffer a traumatic demonstrated several areas of visual perceptual/vision in- 8 PD LH near
mild, moderate or severe trauma to the head. The use of brain injury with 50,000 dying and 235,000 being hos- formation processing dysfunction (Table 3). 18 PD XT
01/28/09 No change No RDS forms
firearms, motor vehicles and falls causing the most deaths LIR OR ? Diplopia W4D
pitalized. More than a million are evaluated in but then The Visagraph was performed at the beginning of treat- Acc insufficiency
from TBI with firearms being the leading cause of death
released from an emergency room. For children 14 years ment on 04/2009 and again during the recent follow-up
02/11/09 OD Pl-.50X090 20/20 4BI/3BU No Change No Change No Change
among persons aged 20 to 74 years. The CDC estimates that Follow-up Evaluation Rx OS -.50 sph 20/20- 4BI/3BD
of age and younger, traumatic brain injury accounts for assessment (Table 4.) Significant improvement was noted 04/21/09
5.3 million Americans (2% of the US population) have Follow-up Evaluation Diplopia still present, not as frequently noted, added 6BUOD and 6BI OS using Fresnel prism lenses
suffered a TBI. More than 1.4 million people a year sustain almost 2700 deaths, 37,000 hospital admissions, and during this year as a result of multidisciplinary treatment
03/02/10 OD Pl 20/15 6BI/5BU 10XP 10 LHT dist Intermittent Diplopia No Change No Change No Change AO LE VF AO RE VF
a TBI with 50,000 of these individuals dying and 235,000 435,000 emergency room visits. For children birth to 4yrs including prism glasses, office/home vision therapy and Comprehensive Evaluation OS -.25 SPH 20/20 6BI/5BD 15XP 4LHT near +.75 MEM (Dry eye improving)
Diplopia significantly less
being hospitalized. and adults older than 75 falls are the most frequently en- other components of his TBI rehabilitation program (OT, Patient did not want to continue any therapy except for the wearing of the glasses. The prescription given with the prism eliminated the diplopia most of the time.
CASE REPORT: A 25 y/o H M (AO) with a history of a gunshot counter cause of TBI, while children birth to 4yrs and teens PT, Speech/Language, psychological counseling, family Table 2: Optometric Vision Therapy
to the right side of the head presented with left side spastic- 15-19 yrs are most at risk for having traumatic brain injury. support, etc.) (See Table 4) 04/28/09 Started in-office optometric vision therapy (OVT) program (Vision Builder activities)
ity, hemianopsia, diplopia, problems tracking a moving Violence remains the second leading cause of fatalities in 05-26-09 to 09/14/09 Continued OVT (Vision Builder, Rotating Pegboard, Wayne Saccadic Fixator, Brockstring, Vectograms) 8 VT sessions
The TOVA (Test of Variables of Attention) was completed 09/14/09 Patient discontinued OVT
object and reading difficulty. AO had completed a post TBI the US with violence related deaths exceeding auto ac- Practicing hand eye and pursuits with a rotator TBI Patient using the Wayne Saccadic Fixator
rehabilitation program (OT, PT, Speech/Lang), but still has PT on 03/2010 because of concern with AO’s attentional is-
Table 3: Vision Information Processing Assessment findings below expected performance
cidents as a major cause of TBI related fatality. Gun inci- 02/04/09
2X a week. His current medications include Phenytoin, Sertra- sues and difficulty staying on task. The results for atten-
dents account for 40% of TBI associated deaths.
line, Kepra and Baclofen. AO had no known allergies. He had tion, impulsivity, response time, variability of response DEM Reversals Frequency Fine Motor Visual-Motor Integration Test of Visual Perceptual Skills
OM Dysfunction Recognition subtest Wold Sentence Copy Test DT VMI Visual Discrimination
a small amount of myopia and astigmatism. An exotropia CASE SUMMARY time, d’ deterioration score and ADHD score (subject’s Visual Sequential-Memory
Visual Form Constancy
with left hyper was noted at far/near. Other functional vision AO was originally seen in the Illinois Eye Institute Disabili- comparison with an ADHD age-matched norms) are sum- Visual Figure-Ground
and vision information processing problems were noted as ties Service on 01-21-09. He was a former Chicago gang Visual Closure
marized in Table 5.
well. The fundus was remarkable for temporal ON pallor. His member who was shot in the head 1.5 years earlier suffer- Table 4: The Visagraph was first completed 4/2009 and one year later on 3/2010. Table 5: The TOVA (Test of Variables of Attention) was completed on
final diagnosis was exotropia, hypertropia, diplopia, suppres- Treatment recommendations included a prescription with Significant improvement was achieved during this year as a result of his TBI 03/2010 because of concern with AO’s attentional issues and difficulty
ing a traumatic brain injury. He had completed all of his and vision rehabilitation program. staying on task. The results for attention, impulsivity, response time, TBI patient post rehab TBI patient using Paddle Ball computer therapy
sion, oculomotor dysfunction, accommodative instability, dry vertical and horizontal prism, artificial tears, and optometric variability of response time, d’ deterioration score are summarized
acute rehabilitative therapy programs, but was still partici- Visagraph Results: PreVT & 1-Year In-progress VT
CONCLUSIONS
below. His ADHD score (subject’s comparison with ADHD age-matched
eye, optic nerve pallor, left hemianopsia, visual attention dis- vision therapy. Vision therapy sessions included the use of In-Progress Change norms) was not normal at -5.59 (normal = ≤ -1.80) is suggestive of ADHA.
pating in physical therapy. AO noted a left side weakness; Visagraph Parameters Pre-VT 4/09
3/10 (+ = improved) TOVA - Inattention and Impulsivity
order and multiple vision information processing anomalies. various hand-eye/oculomotor therapy, Vision Builder com- Although AO had multiple symptoms, he was not ready to accept the new
eye irritation, tearing, itching OS, and occasional double Fixations / 100 words 250 182 68+ TOVA - Inattention and Impulsivity
A multifocal prescription was given with both ground in and puter software, Brock String, Major Amblyoscope, and ac- 1st half (12 min) of test person he had become versus the macho gang member he was. His ability
Regressions /100 words 59 33 26+ 120
Fresnel prisms. Artificial tears and Omega-3s with appropri- vision both horizontally and vertically. His medications in- 2ndhalf (12 min) of test
1st half (12 min) of test
to accept help and to take an active part in his vision rehabilitation program
commodative techniques. The patient discontinued vision Span (words) / fixation 0.40 0.55 0.15+
100
120
2nd half (12 min) of test
Standard Score
ate hydration were suggested for the dry eye. In/out of office cluded Phenytoin, Sertraline, Kepra, and Baclofen. A com- 80
100 was limited by this. There were also other issues that included transporta-
therapy after a few sessions to concentrate on his physical Patient's Attention control
Standard Score
Reading rate (words/min) 98 135 37+ 60
80 deteriorates during the last tion and fiscal concerns. He was informed that we would be available to
optometric vision therapy program was started. prehensive medical history was not possible since he ap- Patient's Attention control
15 min. of 24 during the last
therapy program. Relative Efficiency (grade) 0.32 (1.1) 0.63 (2.5) 0.31 (1.4)+
40
60 deteriorates min. test. continue his care when he was able to participate fully and that he should
CONCLUSIONS: AO showed many of the oculo-visual anoma- peared to be reluctant to share this information with us. 20
40 15 min. of 24 min. test.
Impulsivity is normal
return to us at least once a year for a comprehensive evaluation. Even with
Cross correlation 0.61 0.89 0.28 +
lies associated with Post Trauma Vision Syndrome. We have AO returned for a comprehensive evaluation on 3-2-10 that 0
20
Impulsivity is normal
Several of the medical sources that he gave us were not Anomalies 1/1/23 2/4/10 1/3/13 + 0 Inattention Impusivity this limited involvement in therapy, positive and significant changes were
decreased his dry eye symptoms, eliminated his diplopia and showed a decreased incidence of strabismus, but other- Inattention Impusivity made that helped to improve his quality of life.
valid and, therefore no further information could be ob- Multiple regressions 2 1 1+
significantly improved his oculomotor abilities. Because of wise only moderate changes from the initial evaluation. TOVA - Response Time & Variability
tained. (See examination findings in table 1) (Vision thera- Saccadic start differences 43 29 14+
this, his reading and quality of life has already improved. Un- He did not wish to start vision therapy again and only Fixation Duration S.D. 118ms 97ms 21+
TOVA - Response Time & Variability
py information in Table 2) 1st half (12 min) of test
fortunately after several visits he decided not to continue wanted glasses. He was informed to return to us when Improvement in ALL parameters
120
2ndhalf (12 min) of test
1st half (12 min) of test
CONTACT
therapy primarily because of transportation issues and possi- AO returned to the Peds/BV/Disability Service for a strabis- 120
100
he was ready to fully participate in an active therapy pro- 2nd half (12 min) of test
Standard Score
100
80
ble non-acceptance of his limitations. All individuals with TBI mus evaluation and visual field. It was noted that he dem- Response Time and the
gram. We will conduct a follow-up vision information
Standard Score
80 VariabilityTime and the
60
Response of Response
should be assessed and treated by an optometrist who may onstrated an intermittent left hypertropia and exotropia, 60
40
Time deteriorate rapidly
Variability of Response
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
processing assessment at that time as well. Time deterioratemin. of
during last 12-15 rapidly
dmaino@ico.edu
be able to provide additional rehabilitative services beyond a dry eye and a left hemianopic visual field loss. We also
40
20 this 24 min. test. Normal
during last 12-15 min. of
20
is standard score ≥ 80.
this 24 min. test. Normal www.ico.edu
those routinely offered by the medical community.
0
Response Variability
is standard score ≥ 80.
0
Response Variability

2. References
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A PDF of this poster is available at http://www.slideshare.net/DMAINO
Many of the OVD references available at http://www.covd.org/Home/OVDJournal/OVD401/tabid/263/Default.aspx
Contact: Dominick M. Maino, OD, MEd, FAAO, FCOVD-A; dmaino@ico.edu; http://www.ico.edu, http://www.MainosMemos.blogspot.com