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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

 

 

2018 Colorado Vision Training Conference

Optimal Vision Performance: Enhancing Visual Function from Development to Rehabilitation to High Level Athletic Skill

Friday September 21, 2018 – Sunday September 23, 2018

CVTC 2018 Brochure

Registration is now open for the 2018 CVTC featuring past-President of COVD Dr. Kara Heying! Twelve hours of CE offered in the gorgeous Rocky Mountains.

Register Here:

https://www.regonline.com/builder/site/Default.aspx?EventID=2444336

Breaking through Boundaries

Part 1 of the presentation will focus on the vision and learning testing strategies and therapeutic interventions specific to children with general binocular vision disorders, tracking delays, and visual abnormalities that are compounded due to other learning disabilities, autism, dyslexia and attention deficits. They will explore the early intervention protocols for the very young children in their practice that they utilize for establishing better visual development despite developmental delays, strabismus or risk of amblyopia. These protocols are coined “early intervention vision therapy” and delivered in a very specific manner for maximum outcome. Strabismus surgery co-management and professional opinions regarding their pre and post-operative therapeutic care will be discussed. In addition, the use of visual evoked potentials, exploration of yoked prism and use of tints for improved remediation and performance, and integration of nutrients and supplements will be explored. Coordination of care with clinical and educational psychologists, reading teachers, occupational therapists, counselors and chiropractors will be investigated.

Part 2 will focus on how we incorporate sports vision both in and outside of our office setting. We have been fortunate to have extensive experience with D1 and D3 level athletic programs in our state, and will give you a glimpse into how we deliver the very exciting performance work we do with these highly successful teams. More awareness for vision therapy is necessary when developing relationships with area colleges and universities, and we will share our strategies and triumphs in opening the minds of medical doctors, athletic trainers, coaches and student athletes. Conclusions on how the technology and tools available for sports vision are not a replacement for the knowledge of a developmentally trained optometrist and strategies for aligning yourself with more local programs will be discussed. We will also present a practice management plan for adding more sports vision work into your vision therapy practice, and help you create a template for empowering coaches as the first line of defense for undiagnosed vision problems. We recognize that sports vision is an enormous underutilized pathway to reducing the amount of undiagnosed vision problems in our country.

Part 3 encompasses our role in the multi-disciplinary care of the traumatic brain injured patient. As a busy primary care practice, we believe in fully educating our patients about the role the developmental optometrist has in the rehabilitation of these complex clinical cases. We will describe the pitfalls we encountered in developing such procedures and the current success of our baseline testing program called PEP (Prepare, Equip and Protect). This elective fee for service add-on is offered by all our doctors to all our patients during their comprehensive vision examination. Additionally we will discuss our clinical and therapeutic methods for sorting out the visual and vestibular etiologies for dizziness. We will incorporate hands-on demonstrations, review specific post-concussion and ABI cases and share our best referral successes for treating additional vestibular, medical or cervical needs of these patients.

Bridging science and common sense for better outcomes, improved clinical care, development of professional relationships and patient experience.

Dr. Kara Heying graduated from the Illinois College of Optometry in 1998. Upon graduating, Dr. Heying received highest honors in the area of pediatric clinical training and also received the Cribb Scholarship for exemplary patient care performance. After graduating, she returned to her home town of Cedar Rapids, IA and began in private practice. Building upon her interest in children’s eyecare, she developed an emphasis within the private practice she joined including children’s vision care and vision therapy.

Today, she is a fellowship trained Developmental Optometrist with the College of Optometrists in Vision Development (COVD), serves as a past president of COVD, and consults on VT related services through the Williams Consulting Group. She is married and has 3 daughters.

Featured Lecturer:

Dr. Kara Heying

Cedar Rapids Eye Care

4207 Glass Rd NE

Cedar Rapids, IA 52402

CReyeCAREcolorLOGO

CRchildrensEYEcenterlines

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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