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ACQUIRED BRAIN INJURY:
MANAGEMENT OF
SYMPTOMS
POST-CEREBRAL VASCULA
ACCIDENT
Maggie Jan O.D. , Emetisse Yazdanmehr
Blind Rehabilitation Center
Department of Veterans Affairs – Long Beach Healthcare
System
Southern California College of Optometry at Ketchum
Prevalence
 Every year, at least 1.7 million TBIs occur either
as an isolated injury or along with other injuries.1
 TBI is a contributing factor to a third (30.5%) of
all injury-related deaths in the United States.1
 Direct medical costs and indirect costs such as
lost productivity of TBI totaled an estimated
$76.5 billion in the United States in 2000.2,3
1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations,
and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
2. Finkelstein E, Corso P, Miller T and associates. The Incidence and Economic Burden of Injuries in the United States. New York (NY):
Oxford University Press; 2006.
3. Coronado, McGuire, Faul, Sugerman, Pearson. The Epidemiology and Prevention of TBI (in press) 2012.
Statistics
TBI by Age +
 Children under 4yo and Individuals age 15 to 24 have the
highest risk of TBI. The risk also increases after age 60.1
 Almost half a million (473,947) emergency department visits
for TBI are made annually by children aged 0 to 14 years.
 Adults aged 75 years and older have the highest rates of TBI-
related hospitalization and death.
TBI by Gender++
 TBI affects males at twice the rate of females. Higher
mortality rates among males indicate that males are more
likely than females to suffer severe injuries.1
 The two age groups at highest risk for TBI are 0 to 4 year
olds and 15 to 19 year olds.
(+) Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations,
and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
(++)
Causes
 The leading causes of TBI are:
 Falls (35.2%);
 Motor vehicle-traffic crashes (17.3%);
 Struck by/against events (16.5%);
 Assaults (10%); and
 Unknown/Other (21%). 1
 Blasts are a leading cause of TBI for active
duty military personnel in war zones.2
1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and
Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
2. Defense and Veterans Brain Injury Center (DVBIC). Washington (DC): U.S. Department of Defense; 2005.
Brain Injury Definitions
 TBI (Traumatic Brain Injury) vs ABI (Acquired
Brain Injury)Traumatic Brain Injury
• typically the result of
an external blow to the
head like a fall or
accident
Acquired Brain Injury
• results from damage to
the brain caused by
strokes, tumors,
anoxia, hypoxia,
toxins, degenerative
diseases, near-
drowning and/or other
conditions not
necessarily caused by
an external force.
Examples of Acquired Vision
Loss
 Stroke
 Optic Neuropathy
 Papilledema
 Optic Neuritis
 Brain Hemorrhage
 Brain Compressive Lesion/Tumor
 Alcohol Toxicity
Loss of Function
Visual
Disorder:
anatomical
change
Visual
impairment:
functional loss
resulting from
disorder
Visual
Disability:
inability to
perform a task
due to
impairment
Visual
Handicap:
when disability
impacts patient’s
quality of life
Disorder Visual
Impairment
Visual Disability Visual
Handicap
Optic
Neuritis
Decreased
VA
(ex: 20/100)
55 yo accountant
can’t read
documents at
work
Loss of work
Stroke Decreased
VA
(ex: 20/60)
70yo, retired,
reports no
problems at home
(does not read or
drive)
(-) handicap
Open
Cranial
Wound:
Brain
Injury
Decreased
VF (ex: <15
degrees)
35yo, mobility
issues, can’t
travel
independently,
likes to cook can’t
see what she’s
Can’t enjoy
jogging
anymore.
Can’t drive to
grocery store,
can’t cook.
Visual Acuity VS. Functional
Vision
 Visual Acuity:
 VA, VF, Stereo, Binocular system, Contrast, Light
sensitivity, Color
 Functional Vision:
 Person’s ability to use their vision to effectively
accomplish a task
Treatment via Rehabilitation
 Treatment for brain injury patients often
overlaps with low vision rehabilitation & vision
therapy
Definition of Blindness
 Based on Visual Acuity OR Visual Field of the
better seeing eye
 VA: Distance BCVA 20/200 or worse
 VF: 20 degrees or less
 (California Leg Code 21965, Social Security
Case: Patient FT
 53 year-old male
 CC: left sided field loss in both eyes since
incidence of head/neck trauma 8 years ago
 HPI: Pt complains of bumping into objects and
people on his left side and having trouble
navigating through crowded spaces, afraid of
public places. Reports of difficulty at work
 Patient Orientation: depressed
Case: Patient Goals
 To improve visual performance with
objects to the pt’s left
 To be able to navigate through crowded
spaces without fear of bumping into the
crowd
Case: Ocular/Medical Hx
 Incoming Ocular Diagnosis: field loss in both
eyes secondary to cerebrovascular accident in
2004 which caused dissection of the carotid
artery
 Last Eye Exam: 7 years ago
 Ocular Meds: None
 FOHX: Unremarkable for Glaucoma and ARMD
 PMHx: Coronary Artery Disease, Essential
HTN
Case: Entrance Test
Findings
 DVA (cc) using the ETDRS chart
 OD: 20/50
 OS: 20/64 OU: 20/40
 Pupils: P3/3 ERRL3+/3+ (-) APD
 CT (cc) : ortho’/ortho
 Confrontation Fields: gross restriction of left
side OU
 SLE: WNL OU
 IOP: WNL OU
Case: Refraction
 Habitual SVD VA:
 OD: -0.25 -0.50 x108 20/50
ETDRS
 OS: -0.50 -0.75 x090 20/64
ETDRS
 Subjective Refraction:
 OD: -0.25 -0.50 x025 20/25
ETDRS
 OS: -0.25 -1.00 x095 20/25 ETDRS
 OU 20/20
Case: Fundus Examination
 ONH: 1+ Pallor OU
 Macula: WNL OU
 C/D:
 OD: 0.15R
 OS: 0.20R
 Periphery: WNL OU
Case: Visual Field Testing
 Octopus 30-2 Standard
 OD: Total Left Field Defect with slight 5-10
degrees to right sided creep across the vertical
midline
 OD: Total Left Field Defect with slight 5-10
degrees to right sided creep across the vertical
midline
 Diagnosis: Left Homonymous Hemianopsia
Case: Etiology
 Damage to the optic pathways in the brain on
the opposite side of the field loss (occipital
cortex or optic tract) due to stroke, tumors or
trauma
Case: Diagnosis
 Carotid Artery Dissection secondary to
head/neck trauma
 CAD is a separation of the layers of the artery
wall supplying oxygen-bearing blood to the
head and brain
 Can be spontaneous in patients with
connective tissue disorder or in this case
traumatic
Case: Symptoms Of HH
 Loss of vision left half of the visual field, both
eyes
 Symptoms: patients tend to bump into walls,
trip over objects or walk into people on the
side where the visual field is missing
Case: Treatment &
Management
 Peli Prism:
 20 PD Base Left Over OS
 Placed 6 mm superior/inferior to the center
of the pupil (on back surface of lens)
Pros:
• Can Expand the visual field by
over 20 degrees
• Visual confusion is limited to
the periphery only
• Relatively inexpensive
Cons:
• Patient may be confused by
image shifts
• Glare can bother some
wearers
Case: Treatment &
Management
 Prisms bend light toward the apex (opposite to the
prism base)
 Prisms with their base toward the blind visual field
of pt, will bend the light and provide an image away
from the blind field and into the pt’s visible field
 In the case of FT who has a left homonymous
hemianopsia, Peli prisms with base to the left side
over left eye will provide an image in the patient’s
right visual field where he has vision
Case: Treatment &
Management
 Patient Education: Recommended to only look
through prisms to spot objects superiorly and
inferiorly to pt’s left. Pt was advised not to
continuously view through the prisms, instructed to
practice while sitting only and to gradually walk
around looking through them once pt feels more
comfortable with visual information
 Pt reported improvement with the prisms although he
still bumped into objects
 Tangent Screen Visual Fields Performed with prisms on:
 Increased 25 degrees field measured at 1 meter
Case Study: Rehabilitation
 To address the patient’s loss of ADL’s, patient
recommended to enter inpatient program for
computer training, living skills training, orientation
and mobility.
 At the VA Blind Rehabilitation Center, in-patient
program patient receives cane training and reports
improved independence and mobility
 Patient to undergo vision therapy with computer-
based therapy: to encourage visual skills and some
recovery in the injured region of the brain.
Community and Government-
Based Services
 Government Resources
 State – Department of Rehabilitation, Orientation
Center for Blind (CA), Commission for the Blind
(TX)
 Eligibility: Has a visual impairment that make sit
significantly difficult to get or keep a job
 Federal – VA Polytrauma Rehabilitation Center
(PRC)
 Private
 Casa Colina – TBI inpatient Center
 Non-Profit
Conclusions/Summary
 Treat the person as a whole
 What can TBI Exam+Rehabilitation do for
patients?
 Maximize use of their remaining vision
 Maintain independence
 Build confidence
 Enhance quality of life
 What are the tools?
 Aids
 Training
 Education/Counseling
Thank You!
 Poster Presentation compiled at the VA Long
Beach Healthcare System
 Low Vision & Traumatic Brain Injury Residency
Program Southern California College of
Optometry @ Marshall B. Ketchum University
 Special Thanks: Blind Rehabilitation Center Staff

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"Acquired Brain Injury: Management of Symptoms Post-Cerebral Vascular Accident" [Poster, South Eastern Congress Of Optometry International SECO –March 2014]

  • 1. ACQUIRED BRAIN INJURY: MANAGEMENT OF SYMPTOMS POST-CEREBRAL VASCULA ACCIDENT Maggie Jan O.D. , Emetisse Yazdanmehr Blind Rehabilitation Center Department of Veterans Affairs – Long Beach Healthcare System Southern California College of Optometry at Ketchum
  • 2. Prevalence  Every year, at least 1.7 million TBIs occur either as an isolated injury or along with other injuries.1  TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the United States.1  Direct medical costs and indirect costs such as lost productivity of TBI totaled an estimated $76.5 billion in the United States in 2000.2,3 1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. 2. Finkelstein E, Corso P, Miller T and associates. The Incidence and Economic Burden of Injuries in the United States. New York (NY): Oxford University Press; 2006. 3. Coronado, McGuire, Faul, Sugerman, Pearson. The Epidemiology and Prevention of TBI (in press) 2012.
  • 3. Statistics TBI by Age +  Children under 4yo and Individuals age 15 to 24 have the highest risk of TBI. The risk also increases after age 60.1  Almost half a million (473,947) emergency department visits for TBI are made annually by children aged 0 to 14 years.  Adults aged 75 years and older have the highest rates of TBI- related hospitalization and death. TBI by Gender++  TBI affects males at twice the rate of females. Higher mortality rates among males indicate that males are more likely than females to suffer severe injuries.1  The two age groups at highest risk for TBI are 0 to 4 year olds and 15 to 19 year olds. (+) Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. (++)
  • 4. Causes  The leading causes of TBI are:  Falls (35.2%);  Motor vehicle-traffic crashes (17.3%);  Struck by/against events (16.5%);  Assaults (10%); and  Unknown/Other (21%). 1  Blasts are a leading cause of TBI for active duty military personnel in war zones.2 1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. 2. Defense and Veterans Brain Injury Center (DVBIC). Washington (DC): U.S. Department of Defense; 2005.
  • 5. Brain Injury Definitions  TBI (Traumatic Brain Injury) vs ABI (Acquired Brain Injury)Traumatic Brain Injury • typically the result of an external blow to the head like a fall or accident Acquired Brain Injury • results from damage to the brain caused by strokes, tumors, anoxia, hypoxia, toxins, degenerative diseases, near- drowning and/or other conditions not necessarily caused by an external force.
  • 6. Examples of Acquired Vision Loss  Stroke  Optic Neuropathy  Papilledema  Optic Neuritis  Brain Hemorrhage  Brain Compressive Lesion/Tumor  Alcohol Toxicity
  • 7. Loss of Function Visual Disorder: anatomical change Visual impairment: functional loss resulting from disorder Visual Disability: inability to perform a task due to impairment Visual Handicap: when disability impacts patient’s quality of life Disorder Visual Impairment Visual Disability Visual Handicap Optic Neuritis Decreased VA (ex: 20/100) 55 yo accountant can’t read documents at work Loss of work Stroke Decreased VA (ex: 20/60) 70yo, retired, reports no problems at home (does not read or drive) (-) handicap Open Cranial Wound: Brain Injury Decreased VF (ex: <15 degrees) 35yo, mobility issues, can’t travel independently, likes to cook can’t see what she’s Can’t enjoy jogging anymore. Can’t drive to grocery store, can’t cook.
  • 8. Visual Acuity VS. Functional Vision  Visual Acuity:  VA, VF, Stereo, Binocular system, Contrast, Light sensitivity, Color  Functional Vision:  Person’s ability to use their vision to effectively accomplish a task
  • 9. Treatment via Rehabilitation  Treatment for brain injury patients often overlaps with low vision rehabilitation & vision therapy Definition of Blindness  Based on Visual Acuity OR Visual Field of the better seeing eye  VA: Distance BCVA 20/200 or worse  VF: 20 degrees or less  (California Leg Code 21965, Social Security
  • 10. Case: Patient FT  53 year-old male  CC: left sided field loss in both eyes since incidence of head/neck trauma 8 years ago  HPI: Pt complains of bumping into objects and people on his left side and having trouble navigating through crowded spaces, afraid of public places. Reports of difficulty at work  Patient Orientation: depressed
  • 11. Case: Patient Goals  To improve visual performance with objects to the pt’s left  To be able to navigate through crowded spaces without fear of bumping into the crowd
  • 12. Case: Ocular/Medical Hx  Incoming Ocular Diagnosis: field loss in both eyes secondary to cerebrovascular accident in 2004 which caused dissection of the carotid artery  Last Eye Exam: 7 years ago  Ocular Meds: None  FOHX: Unremarkable for Glaucoma and ARMD  PMHx: Coronary Artery Disease, Essential HTN
  • 13. Case: Entrance Test Findings  DVA (cc) using the ETDRS chart  OD: 20/50  OS: 20/64 OU: 20/40  Pupils: P3/3 ERRL3+/3+ (-) APD  CT (cc) : ortho’/ortho  Confrontation Fields: gross restriction of left side OU  SLE: WNL OU  IOP: WNL OU
  • 14. Case: Refraction  Habitual SVD VA:  OD: -0.25 -0.50 x108 20/50 ETDRS  OS: -0.50 -0.75 x090 20/64 ETDRS  Subjective Refraction:  OD: -0.25 -0.50 x025 20/25 ETDRS  OS: -0.25 -1.00 x095 20/25 ETDRS  OU 20/20
  • 15. Case: Fundus Examination  ONH: 1+ Pallor OU  Macula: WNL OU  C/D:  OD: 0.15R  OS: 0.20R  Periphery: WNL OU
  • 16. Case: Visual Field Testing  Octopus 30-2 Standard  OD: Total Left Field Defect with slight 5-10 degrees to right sided creep across the vertical midline  OD: Total Left Field Defect with slight 5-10 degrees to right sided creep across the vertical midline  Diagnosis: Left Homonymous Hemianopsia
  • 17. Case: Etiology  Damage to the optic pathways in the brain on the opposite side of the field loss (occipital cortex or optic tract) due to stroke, tumors or trauma
  • 18. Case: Diagnosis  Carotid Artery Dissection secondary to head/neck trauma  CAD is a separation of the layers of the artery wall supplying oxygen-bearing blood to the head and brain  Can be spontaneous in patients with connective tissue disorder or in this case traumatic
  • 19. Case: Symptoms Of HH  Loss of vision left half of the visual field, both eyes  Symptoms: patients tend to bump into walls, trip over objects or walk into people on the side where the visual field is missing
  • 20. Case: Treatment & Management  Peli Prism:  20 PD Base Left Over OS  Placed 6 mm superior/inferior to the center of the pupil (on back surface of lens) Pros: • Can Expand the visual field by over 20 degrees • Visual confusion is limited to the periphery only • Relatively inexpensive Cons: • Patient may be confused by image shifts • Glare can bother some wearers
  • 21. Case: Treatment & Management  Prisms bend light toward the apex (opposite to the prism base)  Prisms with their base toward the blind visual field of pt, will bend the light and provide an image away from the blind field and into the pt’s visible field  In the case of FT who has a left homonymous hemianopsia, Peli prisms with base to the left side over left eye will provide an image in the patient’s right visual field where he has vision
  • 22. Case: Treatment & Management  Patient Education: Recommended to only look through prisms to spot objects superiorly and inferiorly to pt’s left. Pt was advised not to continuously view through the prisms, instructed to practice while sitting only and to gradually walk around looking through them once pt feels more comfortable with visual information  Pt reported improvement with the prisms although he still bumped into objects  Tangent Screen Visual Fields Performed with prisms on:  Increased 25 degrees field measured at 1 meter
  • 23. Case Study: Rehabilitation  To address the patient’s loss of ADL’s, patient recommended to enter inpatient program for computer training, living skills training, orientation and mobility.  At the VA Blind Rehabilitation Center, in-patient program patient receives cane training and reports improved independence and mobility  Patient to undergo vision therapy with computer- based therapy: to encourage visual skills and some recovery in the injured region of the brain.
  • 24. Community and Government- Based Services  Government Resources  State – Department of Rehabilitation, Orientation Center for Blind (CA), Commission for the Blind (TX)  Eligibility: Has a visual impairment that make sit significantly difficult to get or keep a job  Federal – VA Polytrauma Rehabilitation Center (PRC)  Private  Casa Colina – TBI inpatient Center  Non-Profit
  • 25. Conclusions/Summary  Treat the person as a whole  What can TBI Exam+Rehabilitation do for patients?  Maximize use of their remaining vision  Maintain independence  Build confidence  Enhance quality of life  What are the tools?  Aids  Training  Education/Counseling
  • 26. Thank You!  Poster Presentation compiled at the VA Long Beach Healthcare System  Low Vision & Traumatic Brain Injury Residency Program Southern California College of Optometry @ Marshall B. Ketchum University  Special Thanks: Blind Rehabilitation Center Staff