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Neuro-Optometry

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

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

Ocular health

Visual field, visual neglect, egocentric localization (midline shift)

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