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Tbi military 1

  1. 1. Diagnosis and Management of TBI-Related Vision Problems Mitchell Scheiman, OD
  2. 2. Objectives <ul><li>To understand the impact of TBI on the visual system </li></ul><ul><li>To review the evaluation of binocular vision, accommodation, and eye movements in the TBI patient </li></ul><ul><li>To review the treatment of TBI-related vision problems </li></ul>
  3. 3. Introduction <ul><li>Patients surviving acquired brain injury generally experience multiple problems: </li></ul><ul><ul><li>Cognitive </li></ul></ul><ul><ul><li>Psychological </li></ul></ul><ul><ul><li>Motor </li></ul></ul><ul><ul><li>Sensory </li></ul></ul><ul><li>BV, ACC and EM problems tend to be more complicated </li></ul>
  4. 4. Overview of Traumatic Brain Injury
  5. 5. Traumatic Brain Injury (TBI) <ul><li>Definition: </li></ul><ul><ul><li>Injury to the head that is documented in a medical record with one or more of the following conditions attributed to head injury: </li></ul></ul><ul><ul><ul><li>Observed or self-reported decreased level of consciousness </li></ul></ul></ul><ul><ul><ul><li>Amnesia </li></ul></ul></ul><ul><ul><ul><li>Skull fracture </li></ul></ul></ul><ul><ul><ul><li>Objective neurological or neuropsychological abnormality </li></ul></ul></ul><ul><ul><ul><li>Diagnosed intracranial lesion </li></ul></ul></ul>
  6. 6. Epidemiology of TBI <ul><li>175 to 200 per 100,000 population or about two million head injuries each year </li></ul><ul><li>Over 1.5 million Americans suffer nonfatal traumatic brain injuries each year that do not require hospitalization </li></ul><ul><li>Another 300,000 individuals suffer brain injuries severe enough to require hospitalization </li></ul><ul><li>100,000 resulting in a lasting disability </li></ul><ul><li>Prevalence of TBI is estimated to be 2.5 million to 6.5 million individuals </li></ul>
  7. 7. TBI: Iraq and Afghanistan Wars <ul><li>Every war produces a characteristic injury that becomes that conflict's &quot;signature wound&quot;. </li></ul><ul><li>WWII </li></ul><ul><ul><li>radiation-induced cancer from atomic bombs </li></ul></ul><ul><li>Vietnam war </li></ul><ul><ul><li>Post Traumatic Stress Disorder (PTSD) </li></ul></ul><ul><li>Iraq War </li></ul><ul><ul><li>TBI </li></ul></ul>
  8. 8. Classification of TBI <ul><li>Mild </li></ul><ul><li>Moderate </li></ul><ul><li>Severe </li></ul>
  9. 9. Judging Severity of TBI <ul><li>Post Traumatic Amnesia Scale (PTA) </li></ul><ul><li>The time between injury and recovery of continuous memory for day-to-day events </li></ul><ul><li>Best measure of quantity of brain tissue destroyed by TBI </li></ul><ul><li>Can be used months or even years after TBI </li></ul>
  10. 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. 11. TBI: Prevalence of Vision Problems in Civilian Population <ul><li>160 records of patients with TBI (160) reviewed </li></ul><ul><ul><li>90% had BV/ACC/EM disorders </li></ul></ul>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. 12. Results <ul><li>TBI </li></ul><ul><ul><li>Accommodative insufficiency: 41.1% </li></ul></ul><ul><ul><li>Convergence insufficiency: 56.3% </li></ul></ul><ul><ul><li>Strabismus: 25.6% </li></ul></ul><ul><ul><li>Cranial nerve Palsy: 10.0% </li></ul></ul>
  13. 13. Recent Prevalence Studies in Military/VA Populations
  14. 14. Goodrich, G et al.- 2007 <ul><li>50 patients admitted to Polytrauma Rehab Center (PRC) from December 2004 to November 2006 </li></ul><ul><li>Mean age of subjects 28.1 years </li></ul><ul><li>All subjects had experienced a TBI </li></ul><ul><li>Blast injuries accounted for half of all injuries </li></ul>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. 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. 16. Brahm, et al. - 2009 <ul><li>Frequency of visual impairment in combat-injured service members with TBI </li></ul><ul><ul><li>Polytrauma Rehab Center (PRC) inpatient (n=68) </li></ul></ul><ul><ul><li>Polytrauma Network Site (PNS) outpatient (n=124) </li></ul></ul><ul><li>Mean age : 28years old </li></ul><ul><ul><li>84% of PRC patients: TBI associated with blast event </li></ul></ul><ul><ul><li>90% of PNS patients: TBI associated with blast event </li></ul></ul>Brahm KD, et al. Visual impairment and dysfunction in combat-injured servicemembers with TBI. Optom Vis Sci 2009;86:817-825
  17. 17. Brahm et al. <ul><li>Convergence insufficiency (CI): 42% </li></ul><ul><li>Accommodative Insufficiency: 42% </li></ul><ul><li>Pursuit/Saccadic Dysfunction: 33% </li></ul><ul><li>Visual Field Defects: 32% </li></ul><ul><li>Bilateral poor visual acuity: 4% </li></ul>
  18. 18. Stelmack - 2009 <ul><li>Retrospective record review performed for 103 patients with polytrauma </li></ul>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. 19. Results <ul><li>Problem TBI Polytrauma </li></ul><ul><li>Accommodative disorder 47% 30% </li></ul><ul><li>Convergence disorder 28% 13% </li></ul><ul><li>Visual field loss 14% 23% </li></ul><ul><li>Pursuits/saccade disorders 6% 9% </li></ul><ul><li>Diplopia 8% 15% </li></ul>
  20. 20. Prevalence of CI in the TBI Population <ul><li>Ranges from 13% to 44% </li></ul><ul><li>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 </li></ul>
  21. 21. Common Vision Problems after TBI? <ul><li>Binocular Vision </li></ul><ul><ul><li>Convergence Insufficiency (CI) </li></ul></ul><ul><li>Accommodative Problems </li></ul><ul><ul><li>Accommodative Insufficiency (AI) </li></ul></ul><ul><li>Eye Movement disorders </li></ul><ul><li>Visual Field Disorders </li></ul><ul><li>Low vision? </li></ul>
  22. 22. Optometric Role TBI-Related Vision Disorders
  23. 23. Significance <ul><li>Vision problems common after TBI </li></ul><ul><li>Significant negative impact ability to return to active duty </li></ul><ul><li>Effect on: </li></ul><ul><ul><li>Reading </li></ul></ul><ul><ul><li>Writing </li></ul></ul><ul><ul><li>Driving </li></ul></ul>
  24. 24. Optometric Role <ul><li>Historically ODs not been part of the rehabilitation team in civilian and military hospitals </li></ul><ul><li>Team typically includes: </li></ul><ul><ul><li>Physicians </li></ul></ul><ul><ul><li>Occupational therapists </li></ul></ul><ul><ul><li>Physical therapists </li></ul></ul><ul><ul><li>Speech language pathologists </li></ul></ul><ul><li>Eyecare usually provided by an ophthalmologist </li></ul><ul><ul><li>Emphasis on acuity and eye disease </li></ul></ul><ul><li>Common for some vision problems associated with TBI to be left undetected or untreated </li></ul><ul><li>Unique opportunity for Military ODs </li></ul>
  25. 25. Military Optometric Role <ul><li>Primary Care Military ODs </li></ul><ul><ul><li>Because of high prevalence of TBI-related vision disorders </li></ul></ul><ul><ul><ul><li>Assessment and diagnosis of vision problems of patients with TBI </li></ul></ul></ul><ul><ul><li>Vision Rehabilitation </li></ul></ul><ul><ul><ul><li>Passive treatment </li></ul></ul></ul><ul><ul><ul><ul><li>Lenses, prism, occlusion </li></ul></ul></ul></ul><ul><ul><ul><li>Active treatment </li></ul></ul></ul><ul><ul><ul><ul><li>Vision rehabilitation </li></ul></ul></ul></ul>
  26. 26. Vision Rehabilitation Models <ul><li>Civilian Model </li></ul><ul><li>Diagnosis: Primary Care OD </li></ul><ul><li>Passive Tx: Primary Care OD </li></ul><ul><li>Vision Therapy </li></ul><ul><ul><li>Refer to specialist </li></ul></ul><ul><ul><li>Performed by “vision therapist” </li></ul></ul><ul><li>Military Model </li></ul><ul><li>Diagnosis: Primary Care OD </li></ul><ul><li>Passive Tx: Primary Care OD </li></ul><ul><li>Vision Rehabilitation </li></ul><ul><ul><li>Prescribed by Primary care OD </li></ul></ul><ul><ul><li>Performed by occupational therapist </li></ul></ul>
  27. 27. Model of Care
  28. 28. Vision Rehabilitation Team <ul><li>Eye Care Professionals </li></ul><ul><ul><li>Optometrists </li></ul></ul><ul><ul><li>Ophthalmologists </li></ul></ul><ul><li>Rehabilitation Professionals </li></ul><ul><ul><li>Occupational Therapists (OTs) </li></ul></ul>
  29. 29. Occupational Therapist (OTs) <ul><li>Education </li></ul><ul><ul><li>Master's degree or higher is minimum requirement for entry into the field </li></ul></ul><ul><ul><li>All States regulate the practice of occupational therapy </li></ul></ul><ul><li>American Occupational Therapy Association: </li></ul><ul><ul><li>“ OTs help people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities (occupations)” </li></ul></ul>
  30. 30. Proposed Model
  31. 31. TBI Protocol <ul><li>Should include mandatory vision examination by primary care optometrist </li></ul><ul><li>Minimum data base </li></ul><ul><ul><li>Visual acuity </li></ul></ul><ul><ul><li>Eye health </li></ul></ul><ul><ul><li>Accommodation </li></ul></ul><ul><ul><li>Binocular vision </li></ul></ul><ul><ul><li>Eye movements </li></ul></ul><ul><ul><li>Visual field </li></ul></ul>
  32. 32. Optometrist <ul><li>Role of Optometrist – Primary Care Role </li></ul><ul><ul><li>Eye Disease </li></ul></ul><ul><ul><ul><li>Medical treatment </li></ul></ul></ul><ul><ul><ul><li>Refer to Ophthalmologist </li></ul></ul></ul><ul><ul><ul><ul><li>Advanced medical treatment </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Surgical treatment </li></ul></ul></ul></ul><ul><li>Refractive, Binocular, Accommodative, Eye Movement Disorders </li></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Prescribe treatment </li></ul></ul>
  33. 33. Optometrist <ul><li>Intervention plan </li></ul><ul><ul><ul><li>Prescribe lenses </li></ul></ul></ul><ul><ul><ul><li>Prescribe prism </li></ul></ul></ul><ul><ul><ul><li>Prescribe occlusion </li></ul></ul></ul><ul><ul><ul><li>Prescribe vision rehabilitation </li></ul></ul></ul><ul><li>Supervise treatment </li></ul><ul><li>Periodic follow-up </li></ul>
  34. 34. Occupational Therapist <ul><ul><li>Identification of patients at risk for vision problems </li></ul></ul><ul><ul><li>Screening </li></ul></ul><ul><ul><ul><li>Accommodation </li></ul></ul></ul><ul><ul><ul><li>Binocular vision </li></ul></ul></ul><ul><ul><ul><li>Eye Movements </li></ul></ul></ul><ul><ul><ul><li>Visual Processing </li></ul></ul></ul><ul><ul><li>Administration of vision rehabilitation </li></ul></ul>
  35. 35. Three Component Model of Vision Visual Integrity Visual Efficiency Visual Information Processing
  36. 36. Visual Integrity
  37. 37. Visual Efficiency Skills
  38. 38. Visual Information Processing Disorders
  39. 39. Summary <ul><li>3 component model </li></ul><ul><ul><li>Important for optometrists and rehabilitation specialists to conceptualize and use same model of vision </li></ul></ul>
  40. 40. Conclusions <ul><li>Prevalence of vision disorders after TBI is very high </li></ul><ul><li>Soldiers returning after TBI deserve the very best vision care </li></ul><ul><ul><li>Comprehensive evaluation </li></ul></ul><ul><ul><li>Appropriate and timely vision rehabilitation </li></ul></ul><ul><ul><ul><li>Lenses </li></ul></ul></ul><ul><ul><ul><li>Prism </li></ul></ul></ul><ul><ul><ul><li>Occlusion </li></ul></ul></ul><ul><ul><ul><li>Vision rehabilitation </li></ul></ul></ul>
  41. 41. For Model to Work <ul><li>Military ODs: </li></ul><ul><ul><li>Evaluation </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Passive </li></ul></ul></ul><ul><ul><ul><li>Active </li></ul></ul></ul><ul><ul><li>Must know enough about vision rehab to supervise OTs </li></ul></ul>