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2021 AOA Optometry’s Meeting: TBI Visual Evaluation and Management

AOA TBI Evaluation and Management 2021 Simonson

VOMSExam

BESSmanual

brain_injury_vision_symptom_survey

KDT Baseline Pocket Card

Course Learning Objectives:

  1. Understand the impact of TBI on patients’ neurological and visual performance.
  2. Diagnose visual deficits related to TBI utilizing optometric testing including: oculomotor, eye alignment, accommodation, pupil function, contrast sensitivity, depth perception, and peripheral vision assessments.
  3. Develop management strategies for TBI-related vision disorders including the use of lenses, filters, prism, partial occlusion, and vision therapy rehabilitation.
  4. Know when to refer a TBI patient to other physicians and rehabilitation therapists.
  5. Educate patients on optometrist’s role in the prevention of further injury.
  6. Provide recommendations for appropriate accommodations to improve work and academic performance.

TBI Visual Evaluation and Management Outline:

  1. TBI is an acute brain injury resulting from mechanical energy to the head from external physical forces.
    1. TBI incidence in the US: 1.7 – 4 million (CDC, Journal of Neurology)
      1. falls (35%)
      2. motor vehicle-related injuries (17%)
      3. strikes or blows to the head from or against an object (17%), such as in sports injuries
        References: www.cdc.gov/TraumaticBrainInjury
    2. Neurology of the visual pathway
      1. diffuse axonal injury (DAI) has emerged as one of the most common and important pathological features of traumatic brain injury (TBI)
      2. diffuse axonal injury does not show up on scans.
    3. Effects of TBI on the visual system
      1. Areas of potential injury (pathways and lobes)
      2. Types of TBI
      3. Visual field defects and spatial inattention
      4. Post-traumatic vision syndrome
        1. Common symptoms
          • Headache (30 – 90%)
          • Dizziness
          • Light sensitivity
          • Blurred vision
          • Visual motion sensitivity
          • Sound (especially background noise) sensitivity
          • Insomnia
          • Mood alteration
          • Memory issues
        2. These intracellular responses are NOT directly correlated to severity of TBI
        3. Some people with mTBI can have more microtubule damage and post inflammatory damage than people who recovered from more severe TBI
        4. Diagnosis of TBI-related visual deficits (~90% of people with TBI have vision problem)

concussion infographic brain injury signs symptoms 450w

 

 

 

 

 

Expected Recovery Timeline

  1. Balance Recovery <7 days
  2. Symptom Scores 5-14 days
  3. Cognitive Recovery 7-21 days
  4. Oculomotor Recovery 21-28 days

Examination

    1. History BIVSS
      • photophobia
      • reduced concentration
      • Inattention
      • objects appear to move
      • balance and coordination issues
      • motion sickness
      • difficulty working under fluorescent lights
      • visual-perceptual motor dysfunction

Key questions to ask post-injury (Goodrich et al, 2013)

  1. What changes have you experienced in your vision?
  2. Are you light sensitive, in- or outdoors?
  3. Do you experience double vision?
  4. Have you noticed a change in your peripheral vision?
  5. Do you have blurred vision at distance or near?
  6. Has there been a change in reading?
  7. Do you lose place while reading?
  8. How long can you read before you need to take and break or stop?
  9. Do you experience Headaches?
  10. 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

concussion infographic poster kids 450w

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:

  1. Awareness, Risk assessment
  2. King-Devick Test
  3. Pre-season training protocols
  4. Vision screenings
  5. Sports training

Spectacle Prescription

    1. Small refractive errors often make a large difference
    2. Tinted lenses (Blue, grey; light and dark tints)
    3. Treating diplopia with lenses: low plus, prism, occlusion
    4. Field loss: Prism to increase field awareness
    5. Yoked prism

Environmental Accommodations

ACE_care_plan_school_version_a (1)

ACE_care_plan_returning_to_work-a

    1. Lighting
    2. Screens
      1. Reduction in screen time and near work often necessary
      2. Changing color spectrum and brightness
    3. Classroom and work accommodations: Classroom Accommodations Letter detailed
    4. Rehabilitation
      1. 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

concussion infographic children safe from brain injury 450w

General Reading References:

  1. http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/Vision.htm
  2. 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
  3. http://cpdailyliving.com/cortical-visual-impairment-cvi-cerebral-palsy-underdiagnosed-undertreated/
  4. http://www.perkinselearning.org/videos/webcast/cortical-visual-impairment-and-evaluation-functional-vision
  5. http://www.visiontherapysuccess.com/headtrauma.php
  6. Vision Therapy for Post-Concussion Vision Disorders. Gallaway, M, et al. Optometry & Vision Science: Jan 2017 – Vol 94 – Issue 1 – p. 68-73 .
  7. 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.
  8. Current and Emerging Rehabilitation for Concussion: A Review of the Evidence. Broglio, S, et al. Clin Sports Med 2015 April; 34 (2): 213-231.
  9. Concurrent Vision Dysfunctions in Convergence Insufficiency with Traumatic Brain Injury. Alvarez, T, et al. Optom Vis Sci. 2012 December: 89 (12)
  10. http://www.headcasecompany.com/concussion_info/stats_on_concussions_sports

Testing

  1. OCULOMOTOR
    1. 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
    2. 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
    3. 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.
    4. The King-Devick Test: https://kingdevicktest.com/
    5. 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
  2. PERIPHERAL VISION
    1. Tests for Neglect/Unilateral Spatial Inattention: https://www.strokengine.ca
    2. amsler-grid
  3. PERCEPTION: VISUAL/VESTIBULAR
    1. Visual Vertigo
    2. Balance Error Scoring System manual
    3. BIVSS Symptom Assessment: BIVSS_clinicalBrain_Injury_Vision_Symptom_Survey__BIVSS_.98478_08.2016
    4. http://www.braininjuries.org/traumatic_brain_injury.html
  4. BINOCULAR (Sensory Fusion/Motor Alignment)
    1. Worth 4 Dot W4D results
    2. Bagolini Lens Bagolini Test Responses

VISION REHABILITATION

  1. Neuro-optometric Rehabilitation Association: https://noravisionrehab.com/
  2. Vision Training can decrease concussions: http://healthnews.uc.edu/news/?%2F26057%2F
  3. 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.
  4. Katz BJ, Digre KB. Diagnosis, pathophysiology, and treatment of photophobia. Surv Ophth. 2016;61:466-477
  5. cdc.gov/TraumaticBrainInjury

 

 

SECO 2020 Board Review: Visual Perception, Accommodation, Vergence, and Oculomotor Function

Course Notes: SECO 2020 Board Review Simonson

Course Links and Resources:

1) Clinical Practice Guidelines from the American Optometric Association:

https://www.aoa.org/documents/optometrists/CPG-4.pdf

*Several other topics are available on the AOA website.

2) Binocular Vision Topics

Park’s 3-Step Test:Parks 3 step

https://www.eyedock.com/parks-3-step

 

Aniseikonia:

https://shawlens.com/aniseikonia/causes_of_aniseikonia/

https://shawlens.com/symptoms/symptoms_of_aniseikonia/#other_signs

3) Entopic Phenomenon:

https://www.opt.uh.edu/onlinecoursematerials/newcoursefiles/opto6124/2_Entoptic_Phenomena.pdf

https://en.wikipedia.org/wiki/Entoptic_phenomenon

Troxler Effect:

https://telanganatoday.com/troxler-effect

Scheerer’s Phenomenon:

https://upload.wikimedia.org/wikipedia/commons/7/70/Blue_field_entoptic_phen omenon_animation.gif

4) Color Vision Testing:

https://en.wikipedia.org/wiki/Color_blindness

https://ekjo.org/ViewImage.php?Type=F&aid=532955&id=F2&afn=65_KJO_29_6_359&fn=kjo-29-359-g002_0065KJO (Korean Journal of Ophthalmology)

SINRAD 1

2019 Colorado Vision Training Conference (CVTC)

Title: A New Neurofunctional Approach to the Treatment of Amblyopia and Strabismus

Registration Link: https://www.regonline.com/registration/checkin.aspx?eventId=2563295

Sanet2019b

Dr. Bob Sanet

This 2-day course will provide attendees with an understanding of amblyopia and strabismus including eccentric fixation and anomalous correspondence and effective evaluation techniques to determine the prognosis in amblyopia, exotropia and esotropia. The course will provide an overview of myths and misconceptions regarding amblyopia and strabismus and review scientific studies on the underlying cause of amblyopia and strabismus and treatment options including patching, surgery and optometric vision therapy. This course will conclude with easy-to-follow, sequential and effective vision therapy treatment procedures for amblyopia, exotropia, and esotropia.

Dates: October 11-13, 2019

Location: Barclay Lodge, YMCA of the Rockies, Estes Park, Colorado

 

 

This event is held next to Rocky Mountain National Park. The closest airport is Denver International Airport. I recommend renting a car for the 2 hr(ish) drive. Fastest route takes the E-470 Toll Road. If you have more time, take Pena to 36 and visit Pearl Street in Boulder, CO for lunch on your way up. There are also several restaurants in the City of Estes Park, Colorado. Even more time? visit the National Park for a hike or scenic drive. Our event starts with dinner at 5 pm at the Barclay lodge. YMCA of the Rockies

50th Annual Colorado Vision Training Conference

 

Bob Pub photo

ROBERT B. SANET, O.D., F.C.O.V.D.

Dr. Robert B. Sanet graduated with honors from the Southern California College of Optometry. He has served as President of the College of Optometrists in Vision Development, Chair of the A.O.A. Sports Vision Section, Board of Directors of the Neuro-Optometric Rehabilitation Association, International Clinical Director of the Special Olympics Opening Eyes Program, Staff Optometrist San Diego Rehabilitation Institute at Alvarado Hospital, Consultant to the Centro de Optometria International in Madrid, Consultant to the Domus Nova Hospital in Ravenna and Adjunct Associate Professor at the Southern California College of Optometry.

Dr. Sanet has worked with amateur and professional athletes including the USA Men’s and Women’s Olympic Volleyball teams, San Diego Chargers, San Diego Padres, and LPGA Golf Professionals.

Dr. Sanet is the developer of the Sanet Vision Integrator, an automated state of the art touch-screen biofeedback Vision Therapy instrument that is beneficial for the rehabilitation of numerous types of visual problem and the enhancement of visual performance.

Dr. Sanet’s numerous awards include the San Diego County Optometrist of the Year, COVD G.N. German Award for Excellence in Children’s Vision Care, NORA Founders Award, COVD President’s Award, OEP Ralph Barstow International Award, Guiseppe Rico Award (Italy) for Excellence in Clinical Practice, International Optometrist of the Year- SIODEC (Spain), International Optometrist of the Year (Mexico), the OEP Armand Bastein International Award (OEP). Dr. Sanet was named as a Distinguished Practitioner in the multidisciplinary National Academies of Practice. He is one of only 100 Optometrists in the USA to have received this award.

Sanet2019

 

Registration Link

Special event in 2019: Learn about the vision of Birds of Prey with Dr. Jennifer Redmond

http://www.birds-of-prey.org/

A room in the Barclay Reunion lodge or the Wind River Lodge (through the registration site) is $300 for the weekend (either 2 double beds or a double bed and bunk bed set). You can also make your own arrangements off-site if you prefer to stay in a hotel instead of a rustic lodge. Catered meals & entertainment plan is $100 for the weekend per person. Registration: Vision therapist $325, Optometrist is $395. Lecture will be in the Wind River lodge this year. Meals and entertainment will be in the Barclay lodge (our normal cabin).

Stereopsis Course for the Oregon Study Group

The Oregon COVD Study Group

presents:

017 BVVT round1

See in 3D: Stereopsis

Everything you need to know about sensory and motor FUSION

by

Jen Simonson, OD, FCOVD

Boulder Valley Vision Therapy

Registration form: Oregon-study-group-invite

Location: The Hampton Inn, 730 SW Columbia Street, Bend, OR 97702. Phone (541) 385-5045.

Lecture Schedule:

Friday August 9th 1pm-5pm
Saturday August 10th 8am-noon, 1 pm-5 pm
Sunday August 11th 8am – 10 am, 10 am – noon Vivid Vision Training

BVVT 2018 03 17 080

Building Blocks for Vision Development

Building Blocks for Vision Development

http://studtfoundation.org/

Join us Sunday February 24, 2019 at Western University College of Optometry
At this year’s practicum, Dr. Simonson will share some of her most coveted pearls and strategies for young patients with special needs/developmentally delayed and physical handicaps. She will review normal versus delayed visual development from general motor concepts to development of visual perception and motor output for reproduction. You will gain insight into a systematic approach to vision therapy procedures for these young cases.

Registration Form:

http://studtfoundation.org/Studt%20165%20Registration%20Form-.pdf

Additional resources:

Chapters visually guided gross motor

2018 Eastern States Congress of Optometry

Thank you for your interest in the 2018 Eastern States Congress of Optometry courses taught by Dr. Jen Simonson

2018 Eastern States Optometric Congress
Baby Steps to Vision
October 27-28, 2018
White Plains, New York

Additional resources:

VISION TESTING:

  1. Wach’s Analysis of Cognitive Structures testing kit:
    https://www.bernell.com/product/WACSKIT/Perceptual_Skills
  2. Gesell Copy Forms:
    https://gesellinstitute.org/products/copy-form-cards
  3. Copy Form Test:
    https://www.bernell.com/product/BC11985/Games
  4. NSUCO Oculomotor Test Summary:
    http://drboulet.com/wp-content/uploads/2012/08/NSUCO-Oculomotor-Test-via-PUCO.pdfGrab-a-Bubble (pack of 12)
  5. Standing Angels Testing:
    Standing Angels

VISION THERAPY RESOURCES:

  1. Brand of bubbles that you can catch and stack: “Grab-a-bubble”
  2. Attribute Blocks:
    1. attribute Blocks
    2. Junior-Learning-Attribute-Block-Activities
  3. Parquetry Blocks: Parquetry Blocks
  4. Emergent red/green glasses and therapy activities: https://emergentvt.com/collections/a-le-carte
  5. Red/Green Toybox http://www.redgreentoybox.com/
  6. Craft Store items:
    1. Black felt (large)
    2. Red felt sheets
    3. Green felt sheets
    4. Pom poms (red/green/white) pom poms
    5. Pipe cleaners (red/green/white) Pipe Cleaners
    6. Wood clothes pins

Please contact Dr. Jen Simonson with any other suggestions and resources to add to this list.

2018 AOA TBI Panel

Concussion/Traumatic Brain Injury Panel

Part 2: Vision Assessment after Brain Injury

AOA TBI Part2 Simonson LECTURE SLIDES

Visual problems resulting from Traumatic Brain Injury (TBI)

and

Clinical chair-side pearls when working with Post-Concussion Vision Syndrome

Additional Resources:

  1. OCULOMOTOR
    1. VOMS: Vestibular Oculo-motor ScreenSource: Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A brief vestibular andocular 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.pdf
      https://www.physiotherapyalberta.ca/files/vomstool.pdf
      VOMS Instruction Set
      https://www.youtube.com/watch?v=PJLv5zdmEns
    2. The King-Devick Test: https://kingdevicktest.com/
    3. NSUCO Oculomotor Test
      NSUCO-Oculomotor-Test Instruction Set
      Norms for Oculomotor Skills: Pursuits and Saccades: https://www.oepf.org/sites/default/files/journals/jbo-volume-3-issue-6/3-6%20Maples.pdf
  2. PERIPHERAL VISION
    1. Tests for Neglect/Unilateral Spatial Inattention: https://www.strokengine.ca
    2. amsler-grid
  3. PERCEPTION: VISUAL/VESTIBULAR
    1. Visual Vertigo
    2. Balance Error Scoring System manual
    3. BIVSS Symptom Assessment: BIVSS_clinical
      Brain_Injury_Vision_Symptom_Survey__BIVSS_.98478_08.2016
    4. http://www.braininjuries.org/traumatic_brain_injury.html
  4. BINOCULAR (Sensory Fusion/Motor Alignment)
    1. Worth 4 Dot W4D results
    2. Bagolini Lens Bagolini Test Responses
  5. VISION REHABILITATION
    1. Neuro-optometric Rehabilitation Association: https://noravisionrehab.com/
    2. Vision Training can decrease concussions: http://healthnews.uc.edu/news/?%2F26057%2F

Courses for additional training:

Neuro-optometric Rehabilitation Association: https://noravisionrehab.com/clinical-skills/fellowship-program

The College of Optometrists in Vision Developoment: https://www.covd.org/page/braininjury?

The Optometric Extension Program Foundation: http://oepf.org/education

REFERENCES:

Research supporting vision rehabilitation following head injury:

1.Vision Therapy for Post-Concussion Vision Disorders. Gallaway, M, et al. Optometry & Vision Science: Jan 2017 – Vol 94 – Issue 1 – p. 68-73 .

2.A Review of the Current Practice in Diagnosis and Management of Visual Complaints Associated with Concussion and Postconcussion Syndrome. Heinmiller, L and Gunton, K. Curr Opin Ophthalmol 2016; 27(5): 407-412.

3.Current and Emerging Rehabilitation for Concussion: A Review of the Evidence. Broglio, S, et al. Clin Sports Med 2015 April; 34 (2): 213-231.

4.Concurrent Vision Dysfunctions in Convergence Insufficiency with Traumatic Brain Injury. Alvarez, T, et al. Optom Vis Sci. 2012 December: 89 (12)

5.Website (retrieved 2/7/2017) http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/Vision.htm

6.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

7.http://cpdailyliving.com/cortical-visual-impairment-cvi-cerebral-palsy-underdiagnosed-undertreated/

8.http://www.perkinselearning.org/videos/webcast/cortical-visual-impairment-and-evaluation-functional-vision

9.http://www.visiontherapysuccess.com/headtrauma.php

ADDITIONAL INFORMATION:

What did not fit into the alloted time?

Videonystagmography

  1. Ocular Mobility: the eyes follow objects that jump from place to place, stand still, or move smoothly.
  2. Optokinetic Nystagmus: view a large, continuously moving visual image.
  3. Positional Nystagmus: You will have your head and body moved into various positions to make sure that there are no inappropriate eye movements (nystagmus), when your head is in different positions. This test is looking at your inner ear system.
  4. Caloric Testing: Your inner ears (one at a time) with be stimmulated with warm and then cold air. This test in the only test available that can decipher between a unilateral and bilateral loss.

*Please let Dr. Simonson know if there is information that we discussed not included on this page. Thank you for attending this course!

The Optometrist’s Role in Traumatic Brain Injury (TBI) Care

Additional Resources for Vision Assessment and Care after Traumatic Brain Injury:

  1. Lecture Handout: TBI presentation DMOS 2017
  2. Dr. Slotnick’s Blog: http://drslotnickblog.com/2016/08/visual-pathways-roadmaps-impacts-following-brain-injury/
  3. VOMS: Vestibular Oculomotor Screen https://www.youtube.com/watch?v=PJLv5zdmEns
  4. The King Devick Test: https://kingdevicktest.com/
  5. Tests for Neglect/Unilateral Spatial Inattention: https://www.strokengine.ca
  6. Norms for Oculomotor Skills: Pursuits and Saccades: https://www.oepf.org/sites/default/files/journals/jbo-volume-3-issue-6/3-6%20Maples.pdf
  7. http://www.braininjuries.org/traumatic_brain_injury.html
  8. Neuro-optometric Rehabilitation Association: https://noravisionrehab.com/
  9. Vision Training can decrease concussions: http://healthnews.uc.edu/news/?%2F26057%2F

 

Optometrists and Traumatic Brain Injury

Join us on May 8th for a talk about Traumatic Brain Injury (TBI) and the role Optometrists play in prevention and treatment. This 1-hour continuing education event will be headed by our very own Optometrists: Dr. Simonson, OD, FCOVD and Dr. Talaber, OD, who will provide knowledge and confidence to diagnose and treat vision conditions related to TBI.

RSVP via phone: 303-443-2257 or email: bouldervt@yahoo.com

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