Download Vision Center of Excellence - AMSUS Continuing Education

EYE AND VISION CARE FOLLOWING BLAST
EXPOSURE AND/OR TRAUMATIC BRAIN INJURY (TBI)
A Clinical Recommendation
Felix M Barker II OD, MS, FAAO, Associate Director of Research
Rehabilitation and Reintegration Directorate
AMSUS 2015 | San Antonio, TX
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Disclosures
• The presenter has no financial relationships to disclose.
• This continuing education activity is managed and accredited by
Professional Education Services Group in cooperation with AMSUS.
• Neither PESG, AMSUS, nor any accrediting organization support or
endorse any product or service mentioned in this activity.
• PESG and AMSUS staff has no financial interest to disclose.
• Commercial support was not received for this activity.
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Learning Objectives:
At the conclusion of this activity, the participant will be able to:
1. Recognize “invisible” nature of blast-related eye injury and visual
dysfunction
2. Identify eye injuries and TBI related vision losses in combat and
blast-related casualties
3. Manage combat eye injury and TBI-related vision loss and
dysfunction
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Presenter – Felix Barker
Felix Barker, II, OD, MS, FAAO
 Graduate of the Indiana University
School of Optometry and the
University of Houston Visual Sciences
Program
 Emeritus Professor of Salus
University, having served there as
Dean of Research
 Veteran of the U.S. Army
 VA Optometrist at the Salisbury
VAMC
 Associate Director of Research of the
DoD/VA Vision Center of Excellence
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Vision Center of Excellence Mission
To be a leader in the
prevention, diagnosis,
mitigation, treatment
and rehabilitation of
military vision and eye
injuries
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Vision Center of Excellence (VCE)
• National Defense Authorization Act (NDAA) 2008
– Vision Center of Excellence Established by Congress - To continuously improve
the health, readiness, and quality of life for members of the Armed Forces and
Veterans through advocacy and leadership in the development of initiatives
focused on the prevention, diagnosis, mitigation, treatment and rehabilitation of
disorders of the visual system
– Joint Department of Defense (DoD) and Department of Veterans Affairs (VA)
operations
•
•
•
•
Care coordination
Education
Research
Policy support
– Develop a Defense and Veterans Eye Injury & Vision Registry
U.S. Department of
Defense
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U.S. Department of
Veterans Affairs
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Centers of Excellence Alignment
Army
DCoE PH/TBI
Air Force
Navy
VCE
HCE
EACE
Army
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VCE Governance
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VCE Stakeholder Engagement
Keeping Service members,
Veterans, and their families
at the center of our
mission, VCE links together
a network of DoD and VA
clinical and research
centers around the world
and encompasses a vast
array of other strategic
partners.
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Defense and Veterans Eye Injury and Vision
Registry (DVEIVR)
• DVEIVR is populated using both electronic
and manual data collection methods from
DoD and VA Sources
• Over 20,000 records of Service members
with eye related problems.
DoD Medical
Systems
VA Eye Injury
Data Store
Other DoD Data
Sources (i.e. DoD
Registries and
Data
Warehouses)
DVEIVR
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Defense and Veterans Eye Injury and Vision
Registry (DVEIVR)
Creating Opportunities to Improve Vision Health
Longitudinal analysis of conditions, treatments, and outcomes data
Expand best practices and clinical guidelines for vision injuries
and dysfunction
Guide eye injury related research
Inform DoD and VA policy regarding vision care
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VCE Research Advocacy & Gap Analysis
2015 VRP Priorities
– Improved First Response
to Eye Injuries
– Improved Surgical
Management
– Improved Rehabilitation
– Improved Restoration
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Clinical Recommendations
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VCE Educational Programs
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Visual Dysfunction and Psychological Health
Epidemiology/Scope of the Problem – TBI,
Psychological Health, Visual Dysfunction and
Impairment in Veterans
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Shields Save Sight Campaign
• “Shields Save Sight” launched on October 1, 2013…
– To raise awareness leading to an increase in the use of DoD-approved
eye protection listed on the Authorized Protective Eyewear List
(APEL) among active duty Service members
– To encourage proper procedures following an eye injury by
promoting the proper use of rigid eye-shields and discouraging the
common technique of applying pressure following an injury
– “Shields Save Sight” communicated best
practices to active duty Service members,
front line leadership and medical first
responders
• Message sent out via: over 1000 TV & radio
airings on Armed Forces Network; VCE
Facebook® & Twitter® pages; VCE website; blogs
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Rigid Eye Shields
In close collaboration with Joint Trauma System, Committee on Tactical
Combat Casualty Care (TCCC) and Defense Health Agency-Medical
Logistics - spearheaded effort to include use of protective eye shield on
DD Form 1380, TCCC card - approved June 2014
Led the way to initial inclusion of protective
(Fox) eye shield in joint first aid kits (JFAKs);
coordinating with Services to expand into
individual first aid kits (IFAKs)
Disposition / Instructions:
Immediately discontinue use, remove, and destroy {First
Aid Kit, Eye Dressing}
“The Joint Trauma System (JTS) Clinical Practice
Guidelines, Tactical Combat Casualty Care
Guidelines, and the Vision Center of Excellence's
recommendations advocate the use of a rigid
eye shield and rapid evacuation to an eye care provider
when treating traumatic eye injuries. This is the only
authorized clinical practice guideline for treating
traumatic eye injuries.”
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DHA MEDLOGS notice, 22 Jul 14
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Continuum of Care for Eye and Vision Injury
Ocular Trauma
• Globe
• Orbit
• Eyelids
Brain (TBI-associated Vision Dysfunction)
• Optic nerve injuries
• Diffuse brain injury affecting visual processing
• Cranial nerves (eye movement)
• Visual field losses
• Photosensitivity
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History of Eye Injuries in Modern Combat
Ocular Injuries as Percentage of Total War Injuries
GWOT
10-16%,
high >20%
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Contemporary War Casualties
• Current war casualties are driving changes in healthcare needs and changes in R&D
• Specific types of casualties driving changes:
• Blast Injuries
• Eye and Vision Injuries
• Ear and Hearing Injuries
• Traumatic Brain Injury (TBI)
• Post Traumatic Stress Disorder (PTSD)
• Amputations
% Body Area
WWII
Korea
Vietnam
OIF/OEF
Head & Neck
12%
21%
21%
16%
29%
Chest
16%
14%
10%
13%
6%
Abdomen
11%
8%
8%
9%
11%
Extremities
61%
58%
60%
61%
54%
Owens, J Trauma FEB 2008
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Vision Impairment vs Visual Dysfunction
• Physical Injuries --> anatomical damage --> Acuity loss, blindness
• "Invisible" injuries --> 20/20 eye with visual complaints often
associated with TBI
- Reading difficulties
- Difficulty concentrating
- Trouble with glare and
brightness of lights
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Blindness and Low Vision
• Total blindness (no light perception)
– Loss of the eye(s)
– Nerve damage/cortical blindness
• Legal blindness is defined as:
– Worse than 20/200* acuity in the better eye
– Less than 20 degrees of visual field (tunnel
vision)
• Low vision
– No defined acuity range but a patient who has
impaired visual function
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Combat Ocular Trauma-Related Blindness
• MAJ Marcus Colyer, MD, USA, Interim Chief Ophthalmology, WRNNMC
• Studied a cohort of OEF/OIF Service members returning from deployment
in the period 2002-2007
• Age: 27.44 years +/- 7.67 (19-53 range)
• 265 eyes of 239 patients
• Reports on the causes of legal blindness resulting from these injuries
– Visual acuity = or < 20/200
J Trauma Acute Care Surg Vlasov et al 2015
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Combat Ocular Trauma-Related Blindness
• 265 eyes of 239 patients
– Laterality
• Right eye blindness
• Left eye blindness
• Bilateral blindness
– Enucleations
• 108 (40.6%)
129 (48.5%)
133 (50.0%)
26 (9.77%)
J Trauma Acute Care Surg Vlasov et al 2015
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Combat Ocular Trauma-Related Blindness
Mechanism of Injury
–
–
–
–
–
IED
RPG
Gunshot
Grenade
Other
170 (64.2%)
29 (10.9%)
27 (10.2%)
9 (3.4%)
30 (11%)
Anterior
Equator
Posterior
J Trauma Acute Care Surg Vlasov et al 2015
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Blind/Low Vision Rehabilitation
• Blind Rehabilitation
– Text: Braille and text to speech systems
– Mobility-cane walking and GPS
– Smart phone/tablet technologies
• Low Vision Rehabilitation- uses remaining vision
– Magnification
•
•
•
•
Spectacle telescopes/microscopes
Hand/Stand magnifiers
CCTVs
New wave of “smart systems”: smart phones, tablets, computers
– Field expanding prisms
• Field awareness training
• Low Energy Bluetooth Beacon
– Occupational therapy/mobility training
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Smart Phone Technologies
•
•
•
•
•
•
Voice control
Voice-to-text
Camera capture
Clock/alarm
GPS
Bluetooth Beacon
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Looking Forward. Seeing the Future.
Presentation to the
First VCE BVA “Industry Day” Forum on Assistive Technologies
26 March 2015
Felix M Barker II OD, MS, FAAO and William Boules
Associate Directors
Rehabilitation and Reintegration Directorate
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The Horus Vision Restoration Project
• US Army Medical Research & Materiel Command (USAMRMC)
R&D program investigating use of artificial vision to restore
sight to those w/traumatic ocular injuries
– Can technology be used to circumvent traumatic visual loss such that a
prototype to restore sight can be produced within five years?
• Goal is to provide prototype technology for human testing
within 5 years that provides:
– Ability to navigate, identify faces and objects critical to daily life, and
read large print; and
– Is economically feasible
• Public/private partnership
– National Eye Institute, Government, academia and industry
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Optical Implants
Keratoprosthesis (KPro): Artificial
cornea useful in cases where
conventional keratoplasty
impractical
Implantable Mini-Telescope (IMT):
Intraocular telescope in use by a
number of patients; necessary
rehabilitation strategies still being
developed
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Retinal Implants
Use micro-array chips (either epiretinal or sub-retinal) to
stimulate remaining retinal
architecture of persons with
conditions photoreceptor loss
(e.g.: retinitis pigmentosa,
macular degeneration
Must have intact eye and
functioning inner neural layers of
the retina.
There are now patients who have
achieved “score board” vision
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Neural Implants
For patients blinded by the loss
of the eye it is necessary to
approach implanting a prosthesis
higher in the visual pathway.
• Optic Nerve implants
• Thalamic implants
• Cortical implants
Cortical Blindness will require
higher order inputs
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Non-Visual Adaptive Inputs
There is evidence that non-visual inputs
that are tactile representations of the
patient’s mobility arena may be effective
and may invoke some aspects of visual
reality via a visual memory phenomenon
e.g.: Brainport oral electronic vision aid
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Vision Loss Associated with Combat Eye Injury
and TBI
• Eye injury: blindness and low vision
• Optic nerve injury: blindness and low vision
• Orbital and eye muscle injury: restricted eye movement and strabismus
• Eye lids: disfigurement and future dry eye
• Brain focal contusion/hemorrhage: central and or peripheral visual field
loss
• Diffuse brain injury: eye movement coordination loss
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Eye Injury & TBI Clinical Recommendation
for Eye Care Providers
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Algorithm of Care
Three levels of triage
• Urgent medical eye problems
• Non-urgent medical eye
problems
• TBI-related visual
dysfunctions
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Recommended Testing
•
•
•
•
•
•
•
•
•
•
History
Visual Acuity
Refractive Error
Ocular examination
 Internal
 External
Pupil Testing
Ocular Alignment
Ocular Motility
Visual Field
Tonometry
Gonioscopy
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Management Considerations
•
•
•
•
Condition
Additional testing
Management
Referral
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Typical Causes of Non-Military TBI
 There are an estimated
1.7 Million TBIs in the US
annually
http://www.cdc.gov/traumaticbraininjury/get_the_facts.html
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Visual Field Loss
•
•
•
•
Peripheral
Central
Hemianopic
Monocular
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Eye Movements and TBI
Eye movement problems are a
signature of concussion.
Athletic “sideline” testing for
concussion often involves
checking eye movements
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Visual Dysfunctions Associated with TBI
• Even when vision is normal, TBI is associated with visual
dysfunctions such as:
– Eye position anomalies due to impaired eye muscle function
• Strabismus (crossed eyes)
• Heterophorias (tendency for eyes to turn in or out)
– Eye movement anomalies due to eye coordination problem
• Saccadic dysfunction – Point to point eye movement
• Eye Tracking dysfunction – Smooth eye movement
– Eye teaming anomalies
• Converging to near reading distance
• Divergence to distance objects
– Accommodation anomalies (eye focusing difficulty)
– Photosensitivity – or even an aversion to light
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Visual Complaints in TBI
Visual Complaint
PRC Inpatient (%)
Self-Report Visual Complaint
Blind/Severe Visual Impairment (VA < 20/100)
Monocular
Strabismus
Accommodative Insufficiency
Convergence Insufficiency
Pursuit/Saccade Insufficiency
Fixation Insufficiency
Diplopia
Suppression
Visual Neglect
Reading Difficulty
75
26
10
32
31
40
29
13
19
11
5
57
PNS Outpatient (%)
75
<2
<2
8
47
48
23
7
6
5
0
63
PNS = Polytrauma Network Site, PRC = Polytrauma Rehabilitation Center.
(J Rehabil Res Dev. 2009;46(6):811-8. Eye and visual function in traumatic brain injury. Cockerham GC, Goodrich GL, Weichel ED,
Orcutt JC, Rizzo JF, Bower KS, SchuchardRA).
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Correction/Rehabilitation of Eye Misalignments
• Prism correction
• Oculomotor Rehabilitation
– Orthoptics
– Visual training
• Surgical management
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Disorders of Accommodation
• Focusing issues due to age-related changes
– Lens correction
• Other treatments for accommodative dysfunction (spasm,
insufficiency, infacility)
– Accommodation training
– Lenses correction
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Eye Movement Coordination Treatment
• Eye movement rehabilitation training
– Saccadic training
– Tracking training
• Rehabilitation for convergence/divergence disorders
– Computer-based therapy
– In-office therapy techniques
• Free space activities
• Instrument activities
– Home therapy
– Spectacle/Prism correction
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Photosensitivity
• Triggers
– Indoor overhead lighting
– Outdoor daytime glare
– Outdoor night time glare
• Treatment/Management
– Tinted lenses
– Transitional lenses
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Mental Health Considerations
 Blast-related injuries
- Brain Injury
- Eye Injury
- PTSD
 The overlapping nature of
these neuro-traumas often
cause:
- Diagnostic confusion
- Ineffective
treatment/rehabilitation
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Conclusions
• The problem of combat eye injury, concussion and TBI
presents a complicated set of evaluation and management
requirements
• Such injuries range from blindness to low vision as well as
non-blinding visual dysfunctions also requiring rehabilitation
by a team oriented approach that involves:
–
–
–
–
–
–
Optometrists
Ophthalmologists
Occupational Therapists
Vision Rehabilitation Specialists
Nurses
Other specialists
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Obtaining CME/CE Credit
If you would like to receive continuing education credit
for this activity, please visit:
http://amsus.cds.pesgce.com
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