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Visioary ophthalmology tbi presentation 9.7.14


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Presentation by Dr. Jennifer Kungle

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Visioary ophthalmology tbi presentation 9.7.14

  1. 1. Dr. Jennifer J. Kungle The Center for Vision Development Annapolis, Maryland
  2. 2. Outline 1. What is Neuro-Optometric Rehabilitation? 2. Interdisciplinary Approach to Treatment 3. Visual Field Loss Vs. Visual Spatial Inattention 4. Treatment with lenses/prisms/patching 5. The Vestibular Connection 6. Visual Perceptual Deficits 7. Visual Evoked Potential’s
  3. 3. What is Neuro-Optometric Rehabilitation? A service which provides, coordinates and manages all of the visual needs of patients with neurological insult Neuro in NOR  External Insults  Closed or penetrating trauma  Internal Insults  Stroke (CVA), brain surgery
  4. 4. Neuro-Optometric Rehabilitation Optometric in NOR  Eye Health  Visual Field  Refractive Needs  Prism  Occlusion  Low Vision  Visual Rehabilitative Therapy
  5. 5. Neuro-Optometric Rehabilitation Rehabilitation in NOR  Multidiscipline Team  Occupational Therapist, Physical Therapist, Vestibular Therapist, Speech Therapist, Cranio-Sacral Therapist, Physiatrist, Psychologist, Case Worker, Neurologist, Cardiologist, Internist, Audiologist, Ophthalmologist, Attorneys, Educators, Insurance Case Worker, Mobility Specialist  Communication with the entire team – ADVOCACY – to help the patient rehabilitate
  6. 6. Right/Left Brain Generalizations Right Brain Damage 1. Left Hemiplegia, hemianopia 2. Neglect of left side of self and/or space 3. Lack of recognizing objects, people, colors (Agnosia's) 4. Spatial inaccuracies in judgments of speed of motion 5. “Lost in Space”
  7. 7. Left Brain Damage 1. Right hemiplegia, hemianopia 2. Neglect of right side of space (rare) 3. Language difficulties, Aphasias
  8. 8. Neuro-Optometric Rehabilitation Timeline of Care: 1. Acute Assessment in Hospital ER 2. Assessment in Rehab Facility  Begin in-patient therapies  May receive a vision evaluation/initial treatment 3. Outpatient care or homecare
  9. 9. Visual Field Deficits  Extremely common following acquired brain injury  Varies from small scotomas to a complete homonymous hemifield  Causes changes in perception of 3/D space  Disrupts binocular vision; may cause double vision  15% of patients with homonymous hemianopia experience diplopia  Shifts center of gravity causing balance and mobility issues  Right field loss near the fovea significantly impacts reading as previewing next word in periphery is hindered
  10. 10. Visual Field Deficits  Visual field deficits occur in approximately 40% of patients with a TBI; 67% of patients with a cerebral vascular accident (CVA)  Most deficits with CVA’s are homonymous (30%); scattered (13%); nonhomonymous (13%); or restricted visual field (8%)  With TBI population, scattered deficits (22%), homonymous (9%), restricted field (6%) and nonhomonymous (1%)
  11. 11. Perimetric testing  The normal visual field extends 60 degrees nasally and 90 degrees temporally  Standard visual field testing is performed on a 30 or 24 degree field; however for these types of patients a 60 degree field test is ideal to fully assess their visual function  Perimetric testing is not always possible due to physical, cognitive, behavioral or attentive states
  12. 12. Humphreys Visual Field Analyzer
  13. 13. FDT Visual Field Analyzer
  14. 14. Tangent Screen
  15. 15. Treatment  Homonymous hemianopia will show some sign of spontaneous resolution in 50-60% of patients within the first 6 months  Little has been shown to improve beyond this time frame spontaneously; however improvements can be made with specific rehabilitative techniques
  16. 16. Treatment – Quadrant field loss Superior Field Loss  Patients need warning about overhead lighting and cabinets, and should be reminded to scan new environments they enter Inferior Field Loss  Interfere with reading and mobility and should be treated similar to a patient with a hemianopic deficit
  17. 17. Treatments Double Vision  Treatment to restore binocular vision can be employed with optometric vision therapy  Assessment should be made as to whether the loss of binocularity is helpful in overcoming a visual field deficit by expanding the visual field. If so, cling patches or occlusion foils can be utilized to address the double vision in primary gaze.  Binasal Occluders  Prism
  18. 18. Treatments Perceptual Speed – critical for safety  Tachistoscope training (Flash games)  Computer programs Scanning  Practice large saccades into the blind field, followed by smooth pursuit in opposite direction  Limit head movement (limit vestibular input)  Must also be practiced while moving
  19. 19. Treatments Borderzone Stimulation  Most field recovery happens at the blind edge of the sighted field in homonymous hemianopia Peripheral Prism Application  Gottleib prism mounted on peripheral edge of lens  Shifts blind field towards midline once you look into the prism
  20. 20. Gottleib Prism
  21. 21. Treatments Prism for Balance  Yoked prism can be used to realign a patient’s center of gravity and improve overall balance
  22. 22. Visual-Spatial Inattention  Cognitive deficit that refers to a relative lack of awareness to objects, people or visual stimuli presented in the visual space contralateral to the location of the cerebral lesion  Also referred to as visual-spatial neglect, unilateral spatial inattention (USI), visual hemi-inattention or visual imperception  Between 65-80% of patients with a stroke have been reported to experience visual-spatial neglect
  23. 23. Visual-Spatial Inattention  Frequently associated with hemianopia, hemiparesis and other perceptual and sensorimotor deficits  Typically left visual-spatial neglect occurs following a right hemispheric injury; this form is more common and longer lasting than right side visual-spatial neglect  It will vary from person to person in severity
  24. 24. Visual-Spatial Inattention  Patients with left visual-spatial neglect will veer to the left when walking or bump their left shoulder on door frames  They will frequently lose their spatial orientation and become confused even in familiar environments.  While eating they will leave food on the left side of their plates; they will forget to comb or shave the left side of their face; may be startled by presence of their left arm
  25. 25. Visual-Spatial Inattention The Parietal Lobe is the most common location for the lesion causing visual-spatial neglect. Other studies have found lesions in the frontal lobe, parietofrontal white matter tracks, subcortical regions (basal ganglia, pulvinar) and the dopaminergic pathways. The patient is unaware of the spatial loss and denies that a problem exists
  26. 26. Testing for Visual-Spatial Inattention 1. Extinction Test – via Confrontational Fields 2. Line Bisection Task 3. Letter Cancellation 4. Hart Chart 5. Picture Scanning 6. Picture Drawing
  27. 27. Testing for Visual-Spatial Inattention
  28. 28. Hart Chart
  29. 29. Draw a clock Test
  30. 30. Interventions for Visual-Spatial Inattention Compensatory  Draw a red highlighted line down the vertical margin of each page; can use a red velcro strip, ruler or reading guide  Turn the page 90 degrees to avoid reading across the body midline  Trace underneath sentences with a pen to keep track of what has been read  Brightly colored T-square to help with tracking and returning to the left margin
  31. 31. Interventions for Visual-Spatial Inattention Rehabilitative Activities  Tracking exercises, visual search techniques  Margolis eye throwing technique  Involves proprioception and kinesthetic cueing to ensure complete scanning of the environment  Body Image Awareness  Silhouette  Body Lifts  Prism Adaptation  2 week trial minimum  Alters perception of space
  32. 32. Post Traumatic Vision Syndrome 1. Convergence Insufficiency 2. Exotropia/High Exophoria 3. Accommodative Deficiencies 4. Photophobia 5. Low Blink Rate 6. Visual Spatial Distortions 7. Oculomotor Deficits (saccades, pursuits) 8. Difficulties with attention and concentration
  33. 33.  The physical lines of print appear to create an irritating set of mirages in up to 50% of all readers whose brains are hyper-reactive to most sensory inputs.  These illusions take a number of forms, but most frequently make the print seem to move on the page with a flowing, rippled look or a swirling of the text in the periphery of one’s vision.
  34. 34. Lens Treatments 1. Avoid multifocals ***** 2. Always consider two pairs of glasses 3. May also require additional computer Rx 4. Tints, polarization, anti-glare coatings 5. May require additional wrap around sunglasses
  35. 35. Prism Treatments 1. Compensatory Prisms  Fresnel Press-On Prisms (temporary)
  36. 36. Fresnel Prisms
  37. 37. Prism Treatments 1. Compensatory Prism - monocular  Base Out for Esotropes  Base In for Exotropes  Vertical Prism for Hyper/Hypotropias  Oblique axis 2. Therapeutic Prisms  Yoked-Prism  Shift spatial world to improve midline shifts, balance and mobility, enhance stereopsis, eliminate visual-spatial inattention
  38. 38. Occlusion Treatments Elastic Patches  avoid solid pirate patch, opt for a translucent/frosted clear patch whenever possible  great for patients who don’t wear glasses  still allows for peripheral awareness
  39. 39. Occlusion Treatments  Cling Patches (Bangerter Occlusion Foils) can vary from opaque (light perception) to varying degrees of translucency  Provide varying acuities, i.e. 20/50, 20/200, light perception
  40. 40. Occlusion Treatments  Partial or spot patches can be used as immediate treatment for double vision.  Partial patches will allow the patient to maintain peripheral awareness and facilitates their overall coordination and balance.  Occlusion Therapy without an assessment is NOT recommended.
  41. 41. Superior Occlusion
  42. 42. Inferior Occlusion
  43. 43. Spot Occlusion
  44. 44. Streff Wedge
  45. 45. Binasal Occluders  Encourages divergence  Eliminates cross fixation with esotropes
  46. 46. Bitemporal Occlusion  Promotes convergence  Helpful for some exotropes or high exophore’s
  47. 47. Where to find these products? Bernell Vision Corporation  Wholesale prices to vision specialists Optometric Education Foundation
  48. 48. Visual-Vestibular Processing There is an intimate relationship between vision, vestibular and motor processing  Stand on one foot: balance is achieved due to input from vision, vestibular and proprioception  Stand on one foot with eyes closed: you start to lose your balance because visual information is lost to provide motion stabilization
  49. 49. Visual-Vestibular Processing  Dynamic Visual Acuity  Use Snellen Chart; lateral head movements 2 cycles per second  2 line drop in acuity – Abnormal Vestibular Function  Do lenses improve or reduce acuity?  Watch for progressive lenses/bifocals
  50. 50. Vestibular-Ocular Reflex  Reflexive eye movement in the opposite direction to head movement in order to stabilize retinal image and prevent BLUR  One of the fastest reflexes in the body  Stimulation of semicircular canals send impulse along CN VIII; contralateral CN VI nuclei; lateral rectus/opposite medial rectus (CN III) eye muscles
  51. 51. VOR Gain  Change in the eye angle divided by change in head angle during head movement  Ideally VOR Gain = 1  It will vary if bifocals/progressive lenses are worn  Low plus lenses will magnify and increase VOR gain, thus decreasing dizziness; can eliminate need for sunglasses  Eye tracking exercises will increase VOR Gain
  52. 52. Dizziness – Optometric Management  Need to stress peripheral awareness and switch from central (focal) to peripheral (ambient) quickly to minimize dizziness  Assess blink patterns, to aid refixation which will decrease dizziness  Encourage multiple fixations during walking/turning, ‘visual anchors’
  53. 53. Visual Information Processing  Active process of locating, extracting and interpreting visual information from the environment  These deficits can be academically, socially and vocationally disabling Symptoms:  Difficulties with attention and concentration  Memory deficiencies  Decreased processing speed  Poor spatial orientation
  54. 54. Visual Memory “The true art of memory is attention.” Samuel Johnson  Memory deficits are one of the most persistent effects of TBI.  Reported to occur in approximately 70-80% of victims.  Impact day to day functioning.  Prevent patients from returning to work.  Prohibit independent living.
  55. 55. “Pooh looked at his two paws. He knew that one of them was the right and he knew that when you had decided which one of them was the right then the other was the left; but he could never remember where to begin.” A.A. Milne
  56. 56. Visual Spatial Deficits  Figure-ground discrimination  Visual closure  Form perception  Right/left discrimination  Visualization  Visual thinking  Visual logic/reasoning
  57. 57. Copyright © Diopsys, Inc. 2012. All Rights Reserved. Patent Pending. How MUCH How FAST
  58. 58. Clinical Indications for VEP  Visual Disturbances  Amblyopia  Subjective Disturbances  Double Vision  Binocular Vision Disorder  Visual Field Defect  Color Vision Deficiencies  Night Blindness  Disorders of the Optic Nerve & Visual Pathway  Papilledema  Optic Atrophy  Glaucomatous Optic Atrophy  Drusen of the Optic Disc  Optic Neuritis  Injury to Eye or Brain  TBI  Concussion
  59. 59. Additional Information  Neuro-Optometric Rehabilitation Association  College of Optometrists in Vision Development  
  60. 60. Thank you!