Download I - American Academy of Optometry

2012 AAO Residents Day Case Submission
Jenna Leber, O.D.
Northport VAMC, Northport, NY
08/31/2012
[email protected]
Abstract: Evaluation and management of returning soldiers from the current war
involves many health professionals. The following case highlights the optometrist’s
role in rehabilitation while discussing the other specialists that also play an important
part.
I.
Case History
a. 29-year-old Indian-American male
b. Member of the United States Marine Corps; active duty from September 5,
2001 through January 4, 2006. Deployed to Iraq from February 2003
through July 2003 and to Japan from 2004 through 2005.
c. Patient at Northport VAMC from June 2012 to present. Referred to the
Center of Balance by his PCP after complaints of a dizzying sensation
when ascending in an elevator and when eyes are closed.
d. Ocular history: mild myopia OD/emmetropia OS
e. Medical history: (+) Tobacco use (cigarettes) (+) Hx of alcohol use
(stopped drinking 6 months prior) (+) Hx of suicidal tendencies in 2008
(+) PTSD
f. Medications: Zoloft 100 mg/day for PTSD
g. TBI history: While serving in the military, patient reported being close
enough to multiple (more than 10) blasts in order to feel a shockwave
radiating from them. Patient was never directly hit by an explosive
device. Patient also experienced a brief loss of consciousness in 2005
when a tailgate of a military vehicle fell from above and hit him on the
head.
II.
Pertinent findings
Patient presented for an optometric evaluation in the Center of Balance on 7/31/11.
Patient was alert and well oriented to time and person. When presented with a
questionnaire on symptoms of traumatic brain injury and acquired brain injury
(TBI/ABI), patient scored a 46 out of a possible 96 points. Scores greater than 15
generally warrant concern and further investigation into symptoms. Notable responses by
the patient included that he has severe difficulty moving/turning eyes, pain with
movement of eyes, slow to shift focus between distance and near, eyestrain, light
sensitivity, irritation to noises in his environment, and difficulty remembering things he
has just read.
BCVA was 20/20 OD and OS. Versions were full but slightly jerky. Confrontation
testing was full to finger counting OU. Pupils were round, equal, and reactive to light
with no afferent defect. Monocular fixation assessment for 10 seconds per eye showed
constant saccadic intrusions OD and OS.
Patient was able to fuse and appreciate luster when looking at both distance and near
targets. Distance cover test revealed orthophoria while near cover test revealed a mild
exophoria. Near point of convergence (NPC) was within normal limits.
Phoria and vergence testing within the phoropter gave the following information:
distance phorias were 1 XP horizontally and isophoria vertically, distance vergence
ranges were x/7/4 BI and x/8/4 BO, near phorias were 2 XP horizonally and isophoria
vertically, near vergence ranges were x/18/9 BI and x/12/1 BO. Near vergence ranges
were also tested using a vectogram. Patient had very fragile fusion and restricted ranges
in both BI and BO directions.
Negative relative accommodation and positive relative accommodation test results were
+1.75 and -1.50 respectively.
To test oculomotor function, patient completed a King Devick test and performed
generally worse than what would be expected for a 14-year-old which is the oldest age
that normative values have been calculated for. A 14-year-old is expected to complete
card 1 in 14.86 seconds, card 2 in 16.87 seconds, and 18.73 seconds. Our patient
completed card 1 in 22 seconds and cards 2 & 3 in 18 seconds each.
III.
Diagnoses
a. Significant oculomotor dysfunction
b. Binocular instability
c. Accommodative insufficiency
d. Suspected perceptual difficulties (did not test at this examination)
IV.
Discussion
The Center of Balance is a cooperative effort between optometrists, audiologists, and
physical therapists to work together to treat and manage patients with balance complaints
and vestibular conditions. Interestingly, the optometric evaluation was the only specialty
in the Center of Balance that yielded any significant results (see diagnoses above);
nothing of note was detected in the audiologic or the physical therapy evaluation.
Optometry is linked to vestibular conditions through the vestibulo-ocular reflex (VOR).
VOR provides a connection between the vestibular system and the extraocular muscles.
Injury to the neuronal connections in the VOR interrupts this link which in turn throws
off the proprioceptive system and creates feelings of disorientation which the patient
interprets as being “off balance”.
The above diagnoses are commonly found in patients who have experienced mild
traumatic brain injury. Mild traumatic brain injury has become the hallmark injury of
veterans of the current Iraq and Afghanistan wars. Eye tracking problems are so common
in returning Iraq/Afghanistan vets that the military was awarded a $4.6 million grant in
order to develop a portable eye tracking device to be used as a screening tool on veterans
while deployed. Patient admits that since returning from active duty, his life has been
significantly altered. Most notably, he is now having much difficulty managing a regular
college course load compared to before his military service when he had a 4.0 GPA.
Taking the above diagnoses into account, especially oculomotor dysfunction and
accommodative insufficiency, may at least partially explain patient’s recent difficulties
with academic work.
In addition to optometrists, other professionals involved in managing war veterans
include but are not limited to: psychologists, psychiatrists, speech pathologists,
audiologists, physical therapists, neurologists, social workers, and primary care
physicians.
V.
Treatment and management
Patient educated on our test findings and how they may relate to some of his symptoms.
Veteran is to enter a program of vision therapy. Therapy will primarily focus on treating
the accommodative insufficiency and on scanning and fixation therapy to treat the
oculomotor dysfunction. The veteran will also return for perceptual testing. If diagnosed
with deficits, therapy will also be done for his visual perceptual system. Other treatment
options include prescribing reading glasses to alleviate symptoms from accommodative
dysfunction and also using tints on glasses to combat light sensitivity.
Other medical professionals involved in this veteran’s care will treat conditions
respective to their specialities as they see fit. This patient is currently under the care of a
psychiatrist, psychologist, primary care physician, and speech pathologist.
VI.
Conclusion
In the past 7 years, the incidence of mild traumatic brain injury has increased
considerably. Those returning from serving in the current war need more than just a
physical examination. Often times they appear to be fine on the surface, but further
examination can uncover serious problems. As more and more of these young men and
women return from military service, optometrists need to be well versed in the potential
ocular sequelae that can occur as a result of physical and percussive trauma. Knowing
the proper screening questions, applicable therapy techniques, and appropriate referral
services ensures that our nation’s veterans receive the best care possible.
VII.
References
Ciuffreda, Kenneth J., Neera Kapoor, Daniella Rutner, Irwin B. Suchoff, M. E. Han, and
Shoshana Craig. "Occurrence of Oculomotordysfunctions in Acquired Braininjury: A
Retrospective Analysis." Journal of the American Optometric Association 78.4 (2007):
155-61. Print.
"DoD Worldwide Numbers for TBI - Totals at a Glance." Health.mil. Department of
Defense, n.d. Web. 28 Aug. 2012.
<http://www.health.mil/Research/TBI_Numbers/TBI_Numbers_Totals.aspx>.
Hoge, Charles W., Dennis McGurk, Jeffrey L. Thomas, Anthony L. Cox, Charles C.
Engel, and Carl A. Castro. "Mild Traumatic Brain Injury in U.S. Soldiers Returning from
Iraq." New England Journal of Medicine 358 (2008): 453-63. Print.
"Military & TBI." The Brain Trauma Foundation. N.p., n.d. Web. 28 Aug. 2012.
<https://www.braintrauma.org/tbi-faqs/military-tbi/>.