Download Let Vision Therapy Take A Look

Vision Problems Hiding
in Plain Sight
Vision and ABI/TBI
Dan Bowersox, OD, FCOVD
Bowersox Vision Center, Shelbyville, KY
Post doctorate residency supervisor and adjunct faculty for
Southern College of Optometry
External rotation supervisor and adjunct faculty for
Indiana University – School of Optometry
No financial disclosures on this topic
"Herein lies the paradox of coherence. The
pattern of raw data sent to the brain is a
shaky, fragmented picture . The brain
processes the data, combining input from both
eyes, and filling in the gaps in spatial vision
with parallel streams of multisensory
information. The result is a happy and
competent human being living under the
compelling illusion that vision is clear, single,
simultaneous and stable. Compelling, that is,
until brain injury shatters the illusion"
(Mlodinow 2008)
What is this about?
1. The brain / vision link
2. Post Trauma Vision Syndrome
3. Vision Therapy in Rehab
4. Visual Midline Shift Syndrome
5. Veteran’s Vision Program
6. Questions
Why Do Visual Deficits Occur
After ABI/TBI?
There are over 1,900,000 nerve fibers
that exit each eye.
This represents 70% of the sensory
nerve fibers in the body.
80% of everything we learn is visual.
90% of people with ABI that are
symptomatic after 1 month have an
ABI/TBI related visual issue.
The Brain / Vision Link
֎ System Theory of Motor Control
֎ Bernstien (1967) Shumway-Cook and Woollacott (2007)
֎Movement results from interplay between
֎ Cognition
֎ Action systems
֎ Perception!
The Brain / Vision Link

Perception
 Vestibular, Proprioceptive &
 Vision!
 Need intact pathways to:
 Superior Colliculus
 Posterior Parietal Lobe
 Lateral Geniculate Nuc. (LGN)
 What do they do?
The Brain / Vision Link
 Superior Colliculus
 Spatial Orientation (maps),
 Ocular Orientation (eye movement)
 Input also from auditory and
somatosensory systems. (hearing and
body input)
The Brain / Vision Link
 Posterior Parietal Cortex
 Attention
 Conscious & Ambient
 Awareness and direction of movement
 Localizing objects in space rel. to
ourselves
 This is where “Neglect” comes from
The Brain / Vision Link
 Lateral Geniculate Nucleus (LGN)
 90% of Visual information
 Separates roughly into peripheral and
central
 Peripheral: Hard lines, positions, movement
 Central: Detail, texture, color
 Has direct connections to most of the
brain.
 !! Decreases input to Visual cortex by 90%!!
The Brain / Vision Link
 For normal vision all pathways must
be in tact.
The Brain / Vision Link
 The normal flow of information works
well.
The Brain / Vision Link
 But what happens when there is a
neuro insult?
Visual Deficits After TBI
 35 areas of the brain
are totally involved
with the processing of
visual information
 There are a least 305
intra-cortical pathways
linking the 35 areas
This Leads us to….
Post Trauma Vision Syndrome
(PTVS)
Visual Midline Shift Syndrome
(VMSS)
 (Not to be confused with Midline Shift
Syndrome)
Post Traumatic Vision Syndrome
(PTVS) Characteristics
– To identify the bi-modal visual processing dysfunction
affecting posture, balance and movement.
– To understand the organization of the bi-modal visual
process in development affecting posture and balance.
– To understand the interaction of the spatial visual
process and organization with the proprioceptive base
of support (BOS) affecting the development of
binocularity and visual skills.
– To understand the use of yoked prisms prescribed for
rehabilitation and appropriate therapeutic rehabilitative
prism systems into the therapy regimen.
Post Trauma Vision Syndrome
Characteristics and symptoms of Post-Trauma Vision Syndrome
Common Characteristics
Common Symptoms
Exotropia
Diplopia (Double vision)
Exophoria
Blurred near vision (Problems reading)
Convergence Insufficiency
Perceived movement of print or stationary objects
(Aliasing)
Accommodative Insufficiency Asthenopia (Eye strain, fatigue, eye pain)
Oculomotor Dysfunction
Headaches
Increased Myopia
Photophobia (Light sensitivity)
 William V. Padula, Stephanie Argyris (1996) Post Trauma Vision
Syndrome & Visual Midline Shift Syndrome. NeuroRehabilitation (6),
pp. 165-171.
Warning!!
The next 2 slides will may make some
people motion sick, give an instant
headache or have the sensation of
movement!
If you are susceptible to these
problems please look away!
Bowen Aliasing
 30% of
normals and
70%+ ABI/TBI
patients have
some positive
response.
“Everything
looks like its
moving, but I know its not!”
Post Trauma Vision Syndrome
Often treated
with:
– Small amounts of
prism (Base in)
– Changes in refractive
power
– Bi-nasal occlusion
Naveen K Yadav; Kenneth J Ciuffreda. (2014) Effect of Binasal Occlusion and
Base-In Prisms on the Visual-Evoked Potential (VEP) in the VisuallyNormal and Mild Traumatic Brain Injury Populations. Investigative
Ophthalmology & Visual Science April 2014, Vol.55, 3498.
Post Trauma Vision Syndrome
– Vision therapy




Effective refractive correction
Convergence
Saccadic movement
Visual information processing
– (Next 4 slides warning!)
Effect of oculomotor vision rehabilitation on the visual-evoked potential and visual attention in mild
traumatic brain injury
Naveen K. Yadav, Preethi Thiagarajan, and Kenneth J. Ciuffreda
Brain Injury Vol. 28 , Iss. 7,2014
Versional eye tracking in mild traumatic brain injury (mTBI): Effects of oculomotor training (OMT)
Preethi Thiagarajan and Kenneth J. Ciuffreda
Brain Injury Vol. 28 , Iss. 7,2014
Eyes Have to Point
to the Same Place
Once upon a time, there was a very ugly
duckling. One day a beautiful princess
came along and rescued him from a
horrible fate. She picked him up into
her hands and was ready to kiss him
when….
Post Trauma Vision Syndrome
Visual Midline Shift Syndrome
 Post Trauma change in placement of perceived midline
 Padula WV1,2, Subramanian P3, Spurling A1, Jenness J1. Risk
of fall (RoF) intervention by affecting visual egocenter
through gait analysis and yoked prisms.
NeuroRehabilitation. 2015;37(2):305-14.
 An example of normal
Visual Midline Shift Syndrome
 Changes in ambient visual system causes
flexion away from affected side in 85% of
cases.
 Anterior or posterior changes are common.
 Increases frustration from OT and PT with
good posture during therapy and loss of
posture during rest of day. Resulting in lack
of progress and discharge.
Visual Midline Shift Syndrome
 What does that look like? Right shift.
Visual Midline Shift Syndrome
Anterior / posterior (Lean forward or
back)
Proximity issues
Visual midline shift on the Z axis
– Increased anxiety crowds
– Increased anxiety in big box stores
– Grocery store isles closing in
– Driver braking too late
– Depth issues
– Also treated with prism
The Use of Prisms
> What do they do?
>Prisms move an image toward the apex
and away from the base.
The Use of Prisms
Which change where objects appear.
Example of Yoked Prism
“You know, I have this
patient and I have been
scratching my head trying to
figure him/her out.”
Untreated vision disorders can slow
down the rehabilitation process.
THE VETERANS VISION
PROGRAM AT BVC
Any military veteran with post 9/11 service
related TBI will be treated for that TBI at my
office for FREE until s/he has reached their full
capability.
We reserve 4 slots per week for these heroes.
Feel free to refer these vets to my office.
GREAT BOOK!
The Ghost in My Brain
Clark Elliott, Ph.D.
Thank you!
Questions?
Dan Bowersox, OD, FCOVD
Cell 502 544 1600
Stuart Young, OD
Cell 502 780 2815
[email protected]
Bowersox Vision Center
403 Washington St.
Shelbyville, KY 40065
This is Skeffington, the therapy dog at our office.
Different type of lecture!
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