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Traumatic Brain Injury

College of Optometrists in Vision Development & Neuro Optometric Rehabilitation Association Issue Joint Recommendation for Optometric Evaluation Following Brain Injury

Brain injury can affect a person in many ways, extending from physical limitations to changes in perception and cognition. In the United States, an estimated 1.7 million people sustain a TBI each year1, with about 75 percent of them a result of concussions or other forms of mild traumatic brain injury2. “Studies show that at least 50 percent of TBI patients suffer from visual dysfunctions, with one such study3 finding a 90 percent incidence of post-trauma visual complications, such as blurred vision, sensitivity to light, reading difficulty, headaches with visual tasks, and difficulties with eye movements,” says NORA president Susan Daniel, O.D. “About two-thirds of stroke survivors have visual impairment that typically relates to diminished central or peripheral vision, eye movement abnormalities, or visual perceptual defects4,” she adds.

“Clinicians regularly assess a concussion or other acquired brain injury to the symptoms that an individual manifests at the time of injury but, unfortunately, vision-related problems are often overlooked during initial evaluation,” says COVD President, Dr. Christine Allison. “Some symptoms, like visual discomfort and vision-mediated functional difficulties such as slowed reading and compromised attention, may not be present until days, weeks, or even longer following the incident. The consequences of these occurrences may also include cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings and frustration, along with motor and sensory issues leading to impaired academic, work, and sport performance.”

Given the high rate of visual symptoms and known impact, both COVD and NORA urge healthcare professionals to consider the possibility that a patient’s ocular or visual signs or symptoms may have been a result of a brain injury and refer him/her to an optometrist who has special expertise in the assessment and treatment of visual disturbances associated with damage to the central nervous system. “Doctors of Optometry who have been educated and trained to diagnose and manage ocular dysfunctions and visual processing deficits related to brain injuries will examine not only the visual issues, but also other subtle factors involved in the complex visual process, such as posture, spatial awareness, visual memory, and motor output — all areas that can have wide-ranging effects on daily activities and on quality of life,” explains Dr. Allison. “Left untreated, they can have serious consequences,” she warns.

Both COVD and NORA stress the importance of an interdisciplinary, integrated team approach in the diagnosis and rehabilitation of patients with concussions, stroke or other neurological deficits. “When a person has a brain injury, often a single-approach to rehabilitation is not enough to address all of his/her needs,” says Daniel. “An integrated team approach that incorporates the training and expertise of a variety of professionals can play a vital role in rehabilitation.” In addition to optometrists, rehabilitation team members may include such specialists as neurologists, physical medicine and rehab physicians, nurses, physical and occupational therapists, speech-language pathologists, chiropractors, neuropsychologists, audiologists, and ophthalmologists.

Both COVD and NORA offer resources to help patients and caregivers find the help they need following a concussion as well as tools and resources for optometrists and other healthcare professionals. Both associations also feature doctor locaters on their websites for access to providers who specialize in brain-injury related visual problems. For more information, visit them at www.covd.org and www.noravisionrehab.org.

References

1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.

2. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2003.

3. Ciuffreda KJ, Kapoor N, Rutner D, Suchoff IB, Han ME, Craig S. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry 2007;78(4):155-61.

4. Rowe F.J. Stroke survivors’ views and experiences on impact of visual impairment. Brain and Behavior, 2017; e00778 DOI: https://onlinelibrary.wiley.com/doi/epdf/10.1002/brb3.778

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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