AOA TBI Evaluation and Management 2021 Simonson
brain_injury_vision_symptom_survey
Course Learning Objectives:
- Understand the impact of TBI on patients’ neurological and visual performance.
- Diagnose visual deficits related to TBI utilizing optometric testing including: oculomotor, eye alignment, accommodation, pupil function, contrast sensitivity, depth perception, and peripheral vision assessments.
- Develop management strategies for TBI-related vision disorders including the use of lenses, filters, prism, partial occlusion, and vision therapy rehabilitation.
- Know when to refer a TBI patient to other physicians and rehabilitation therapists.
- Educate patients on optometrist’s role in the prevention of further injury.
- Provide recommendations for appropriate accommodations to improve work and academic performance.
TBI Visual Evaluation and Management Outline:
- TBI is an acute brain injury resulting from mechanical energy to the head from external physical forces.
- TBI incidence in the US: 1.7 - 4 million (CDC, Journal of Neurology)
- falls (35%)
- motor vehicle-related injuries (17%)
- strikes or blows to the head from or against an object (17%), such as in sports injuries
References: www.cdc.gov/TraumaticBrainInjury
- Neurology of the visual pathway
- diffuse axonal injury (DAI) has emerged as one of the most common and important pathological features of traumatic brain injury (TBI)
- diffuse axonal injury does not show up on scans.
- Effects of TBI on the visual system
- Areas of potential injury (pathways and lobes)
- Types of TBI
- Visual field defects and spatial inattention
- Post-traumatic vision syndrome
- Common symptoms
- Headache (30 – 90%)
- Dizziness
- Light sensitivity
- Blurred vision
- Visual motion sensitivity
- Sound (especially background noise) sensitivity
- Insomnia
- Mood alteration
- Memory issues
- These intracellular responses are NOT directly correlated to severity of TBI
- Some people with mTBI can have more microtubule damage and post inflammatory damage than people who recovered from more severe TBI
- Diagnosis of TBI-related visual deficits (~90% of people with TBI have vision problem)
- Common symptoms
- TBI incidence in the US: 1.7 - 4 million (CDC, Journal of Neurology)
Expected Recovery Timeline
- Balance Recovery <7 days
- Symptom Scores 5-14 days
- Cognitive Recovery 7-21 days
- Oculomotor Recovery 21-28 days
Examination
Key questions to ask post-injury (Goodrich et al, 2013)
- What changes have you experienced in your vision?
- Are you light sensitive, in- or outdoors?
- Do you experience double vision?
- Have you noticed a change in your peripheral vision?
- Do you have blurred vision at distance or near?
- Has there been a change in reading?
- Do you lose place while reading?
- How long can you read before you need to take and break or stop?
- Do you experience Headaches?
- Do you have trouble remembering what you’ve read?
Emergent Visual Conditions
- Flashes of light
- Floaters in field of view
- Restricted field of vision
- "Curtains" billowing into field of view
Urgent Visual Conditions
- Inability to completely close eyes
- Difficulty moving or turning eyes
- Pain with movement of the eyes
- Pain in or around eyes
- Wandering eye
- Double vision
Vision Rehabilitation Conditions
- Blurred vision for distance viewing / Blurred vision for near viewing
- Slow shift of focus from near to far to near
- Difficulty copying or taking notes
- Pulling or tugging sensation around eyes / Discomfort while reading/ Eyes get tired while reading / Headaches while reading
- Unable to sustain near work or reading for periods of time / General fatigue while work/reading
- Covering, closing one eye
- Loss of place while reading / Easily distracted when reading / Difficulty remembering what has been read
- Decreased attention span / Reduced concentration ability
Post-concussion Vision Evaluation:
Pediatric post-concussion Check-list (CDC) Concussion Checklist Kids
Visual acuity, refractive status, oculomotility, accommodation, binocularity
Northeastern State University College of Optometry’s Oculomotor Test
VOMS: Vestibular/Ocular-Motor Screening VOMSExam
Ocular health
Visual field, visual neglect, egocentric localization (midline shift) BESSmanual
Visual Perceptual testing: Visual Figure-ground, Visual Closure, Visual Reaction Time, Visual Memory
Acute Concussion Evaluation Form
TBI Prevention, Education, and Outreach
Patient population: Athletes, Parents of children, Recreational activity participants
Prevention:
- Awareness, Risk assessment
- King-Devick Test
- Pre-season training protocols
- Vision screenings
- Sports training
- Optometric Treatment and Vision Rehabilitation
- General health considerations: Nutrition, Exercise, vitamin info sheet for best brain healing and function
- Multidisciplinary, team approach: Patients may be seeing multiple practitioners, When to refer
Spectacle Prescription
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- Small refractive errors often make a large difference
- Tinted lenses (Blue, grey; light and dark tints)
- Treating diplopia with lenses: low plus, prism, occlusion
- Field loss: Prism to increase field awareness
- Yoked prism
Environmental Accommodations
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ACE_care_plan_returning_to_work-a
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- Lighting
- Screens
- Reduction in screen time and near work often necessary
- Changing color spectrum and brightness
- Classroom and work accommodations: Classroom Accommodations Letter detailed
- Rehabilitation
- Vision therapy designed for patient’s diagnosis and goals
- Are there any activities that you wish you could do?
- What are your visual needs to return to school, your sport or work?
- What are your recovery goals?
Visual-vestibular therapy often required
Specialized therapy for visual inattention and other visual processing deficits
General Reading References:
- http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/Vision.htm
- Review of Optometry, “Save a Life, Neuro-Optometry Primer: The Brain” by Mario Gutierrez, OD, FAAO. https://www.reviewofoptometry.com/CMSDocuments/2009/9/Neuro-Optom-Supp_RO-09.02.09.pdf
- http://cpdailyliving.com/cortical-visual-impairment-cvi-cerebral-palsy-underdiagnosed-undertreated/
- http://www.perkinselearning.org/videos/webcast/cortical-visual-impairment-and-evaluation-functional-vision
- http://www.visiontherapysuccess.com/headtrauma.php
- Vision Therapy for Post-Concussion Vision Disorders. Gallaway, M, et al. Optometry & Vision Science: Jan 2017 – Vol 94 – Issue 1 – p. 68-73 .
- A Review of the Current Practice in Diagnosis and Management of Visual Complaints Associated with Concussion and Post concussion Syndrome. Heinmiller, L and Gunton, K. Curr Opin Ophthalmol 2016; 27(5): 407-412.
- Current and Emerging Rehabilitation for Concussion: A Review of the Evidence. Broglio, S, et al. Clin Sports Med 2015 April; 34 (2): 213-231.
- Concurrent Vision Dysfunctions in Convergence Insufficiency with Traumatic Brain Injury. Alvarez, T, et al. Optom Vis Sci. 2012 December: 89 (12)
- http://www.headcasecompany.com/concussion_info/stats_on_concussions_sports
Testing
- OCULOMOTOR
- Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A brief vestibular and ocular motor screening (VOMS) assessment to evaluate preliminary concussion: Preliminary findings. Am J Sports Med; in press.Form Sources: https://www.bamc.org/media/1393/voms-exam.pdfhttps://www.physiotherapyalberta.ca/files/vomstool.pdfVOMS Instruction Sethttps://www.youtube.com/watch?v=PJLv5zdmEns
- Anzalone AJ, Blueitt D, Case T, McGuffin T, Pollard K, Garrison JC, Jones MT, Pavur R, Turner S, Oliver JM. A positive Vestibular/Ocular Motor Screening (VOMS) is associated with increased recovery time after sports-related concussion in youth and adolescent athletes. AJSM 2017;45(2)474-479
- Yorke AM, Smith L, Babcock M, Alsalaheen B. Validity and reliability of the Vestibular/Ocular Motor Screening and associations with common concussion screening tools. Sports Health. 2017;9(2): 174-180.
- The King-Devick Test: https://kingdevicktest.com/
- NSUCO-Oculomotor-Test Instruction SetNorms for Oculomotor Skills: Pursuits and Saccades: https://www.oepf.org/sites/default/files/journals/jbo-volume-3-issue-6/3-6%20Maples.pdf
- PERIPHERAL VISION
- Tests for Neglect/Unilateral Spatial Inattention: https://www.strokengine.ca
- amsler-grid
- PERCEPTION: VISUAL/VESTIBULAR
- BINOCULAR (Sensory Fusion/Motor Alignment)
- Worth 4 Dot W4D results
- Bagolini Lens Bagolini Test Responses
VISION REHABILITATION
- Neuro-optometric Rehabilitation Association: https://noravisionrehab.com/
- Vision Training can decrease concussions: http://healthnews.uc.edu/news/?%2F26057%2F
- Collins M, Kontos A, Okonkwo D. et al. Statements of Agreement from the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion .Neurosurgery. Dec 2016;79(6):912-929.
- Katz BJ, Digre KB. Diagnosis, pathophysiology, and treatment of photophobia. Surv Ophth. 2016;61:466-477
- cdc.gov/TraumaticBrainInjury
Notes:
Please contact us with any questions you might have at bouldervt@yahoo.com.