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ACQUIRED BRAIN INJURY:
MANAGEMENT OF
SYMPTOMS
POST-CEREBRAL VASCULA
ACCIDENT
Maggie Jan O.D. , Emetisse Yazdanmehr
Blind R...
Prevalence
 Every year, at least 1.7 million TBIs occur either
as an isolated injury or along with other injuries.1
 TBI...
Statistics
TBI by Age +
 Children under 4yo and Individuals age 15 to 24 have the
highest risk of TBI. The risk also incr...
Causes
 The leading causes of TBI are:
 Falls (35.2%);
 Motor vehicle-traffic crashes (17.3%);
 Struck by/against even...
Brain Injury Definitions
 TBI (Traumatic Brain Injury) vs ABI (Acquired
Brain Injury)Traumatic Brain Injury
• typically t...
Examples of Acquired Vision
Loss
 Stroke
 Optic Neuropathy
 Papilledema
 Optic Neuritis
 Brain Hemorrhage
 Brain Com...
Loss of Function
Visual
Disorder:
anatomical
change
Visual
impairment:
functional loss
resulting from
disorder
Visual
Disa...
Visual Acuity VS. Functional
Vision
 Visual Acuity:
 VA, VF, Stereo, Binocular system, Contrast, Light
sensitivity, Colo...
Treatment via Rehabilitation
 Treatment for brain injury patients often
overlaps with low vision rehabilitation & vision
...
Case: Patient FT
 53 year-old male
 CC: left sided field loss in both eyes since
incidence of head/neck trauma 8 years a...
Case: Patient Goals
 To improve visual performance with
objects to the pt’s left
 To be able to navigate through crowded...
Case: Ocular/Medical Hx
 Incoming Ocular Diagnosis: field loss in both
eyes secondary to cerebrovascular accident in
2004...
Case: Entrance Test
Findings
 DVA (cc) using the ETDRS chart
 OD: 20/50
 OS: 20/64 OU: 20/40
 Pupils: P3/3 ERRL3+/3+ (...
Case: Refraction
 Habitual SVD VA:
 OD: -0.25 -0.50 x108 20/50
ETDRS
 OS: -0.50 -0.75 x090 20/64
ETDRS
 Subjective Ref...
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 c...
Case: Etiology
 Damage to the optic pathways in the brain on
the opposite side of the field loss (occipital
cortex or opt...
Case: Diagnosis
 Carotid Artery Dissection secondary to
head/neck trauma
 CAD is a separation of the layers of the arter...
Case: Symptoms Of HH
 Loss of vision left half of the visual field, both
eyes
 Symptoms: patients tend to bump into wall...
Case: Treatment &
Management
 Peli Prism:
 20 PD Base Left Over OS
 Placed 6 mm superior/inferior to the center
of the ...
Case: Treatment &
Management
 Prisms bend light toward the apex (opposite to the
prism base)
 Prisms with their base tow...
Case: Treatment &
Management
 Patient Education: Recommended to only look
through prisms to spot objects superiorly and
i...
Case Study: Rehabilitation
 To address the patient’s loss of ADL’s, patient
recommended to enter inpatient program for
co...
Community and Government-
Based Services
 Government Resources
 State – Department of Rehabilitation, Orientation
Center...
Conclusions/Summary
 Treat the person as a whole
 What can TBI Exam+Rehabilitation do for
patients?
 Maximize use of th...
Thank You!
 Poster Presentation compiled at the VA Long
Beach Healthcare System
 Low Vision & Traumatic Brain Injury Res...
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"Acquired Brain Injury: Management of Symptoms Post-Cerebral Vascular Accident" [Poster, South Eastern Congress Of Optometry International SECO –March 2014]

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Maggie Jan, O.D. F.A.A.O, Emetisse Yazdanmehr, O.D.

Published in: Health & Medicine
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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. 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. 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. 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. 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. 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. 6. Examples of Acquired Vision Loss  Stroke  Optic Neuropathy  Papilledema  Optic Neuritis  Brain Hemorrhage  Brain Compressive Lesion/Tumor  Alcohol Toxicity
  7. 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. 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. 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. 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. 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. 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. 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. 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. 15. Case: Fundus Examination  ONH: 1+ Pallor OU  Macula: WNL OU  C/D:  OD: 0.15R  OS: 0.20R  Periphery: WNL OU
  16. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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