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Strategies for Examination and Management of
Acquired Brain Injury Patients
Suzanne Wickum, OD, FAAO
University of Houston College of Optometry
e-mail:[email protected]
Kia B. Eldred, OD, FAAO
Diplomate in Low Vision
Michael E. DeBakey VA Medical Center
University of Houston College of Optometry
e-mail: [email protected]
Course Description: A case-based approach is used to discuss the evaluation
and management of patients with acquired brain injury. Demographics, types of
brain injuries, visual/ocular sequelae, diagnostic testing, and management of this
patient population will be reviewed. Particular attention will be given to the
optometrist’s role in the rehabilitation team.
Course Objectives:
 To understand the patient populations most likely to be affected by brain injury.
 To understand the categories and severity ranking of brain injury.
 To understand the potential physical and cognitive deficits associated with
brain injury.
 To understand the specific optometric examination techniques for
evaluation of brain injury patients.
 To understand the specific ocular/visual complications associated with
brain injury and how to appropriately manage these complications.
Outline:
Introduction - TIRR
• The Institute for Rehabilitation and Research – In-patient & Out-patient Programs
• Ranked within the top 5 rehabilitation hospitals in the US for 19 years
• Affiliation with University of Houston College of Optometry for 18 years
Project Victory
• ~30,680 US soldiers wounded in Iraq & Afghanistan
– TBI is the “signature wound”
– 20% of injuries are serious ABI or SCI
– 1800 troops suffering from penetrating TBI
– 3000 soldiers being treated for severe TBI
– 30% of troops engaged in combat > 4 months are at risk for disabling
neurologic disorders from blast waves of IEDs
– 60% of injuries are due to roadside bombs & IEDs (improvised explosive devices)
– 30% of soldiers develop mental health problems (PTSD) within 3-4 months
of returning to the US
Categories of Brain Injuries
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Traumatic Brain injury
Non- traumatic brain injury
Now defined as “Acquired” (ABI) –> Includes stroke
Traumatic Brain Injury
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Closed head injury
Open head injury
Penetrating head injury
Non- traumatic Brain Injury
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Anoxic Brain Injury
Toxic-metabolic Brain Injury
Damage to General Areas of the Brain
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Occipital
Parietal
Frontal
Temporal
Brainstem
Cerebellum
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Physical Deficits with ABI
Musculoskeletal Complications
Heterotropic Ossification
Spasticity
Respiratory Complications
GI Complications
Swallowing Disorders
Bowel Incontinence
Genitourinary Problems
Dermatological Complications
Endocrine Complications
Autonomic Disturbances
Thombophlebitis
Most common causes of TBI
Epidemiology
• TBI
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1.4 million/year in US
50,000 die each year
235,000 hospitalized
1.1 million treated and released from the ER
– 5.3 million (2% of US population) need long-term help with ADL
– In 2000, $60 billion dollars in direct & indirect costs
• Stroke (CVA)
– 700,000/year in US
• 500,000 first time CVA
• 200,000 prior CVA
– 160,000 die each year
– In 2005, $57 billion dollars in direct & indirect costs
– The leading cause of serious long-term disability in US
– 3rd leading cause of death in US
Pediatric Brain Injury
• 25% of brain injuries in children younger than 2 years are from physical abuse.
• Other causes of ABI – MVA, falls, leisure or sports related injuries, and violent
crimes.
• Factors associated with increased risk include: male, nonwhite, low
socioeconomic status, family instability, peak periods for outdoor recreation,
living in a congested area.
Rehabilitation after ABI in Preschoolers
• Outcomes after ABI are difficult to predict in children at any age.
• Studies have shown – contrary to the traditional plasticity hypothesis youth is
not necessarily an advantage in outcome after ABI.
• Young children are found to be very vulnerable to the effects of ABI.
• Prefrontal injury is strong indicator of negative outcome in young children.
• Consequences of ABI in young children often worsen over the years as child
grows into the injury.
• Children can be overprotected, learn “helplessness,” and absence of peers.
A Team Approach
• The rehabilitation team may include:
– Physiatrists (Rehabilitation Physicians)
– Other physician specialists when needed
– Neuro-psychiatrists/psychologists
– Neuro-optometrists
– Pharmacists
– Nursing staff
– Physical & Occupational therapists
– Respiratory therapists
– Speech/language therapists
– Cognitive therapists
– Recreational/Music therapists
– Social workers
– The patient’s family members
The Role of Neuro-Optometry
• It is estimated that 90% of what we perceive is through the visual system.
• Vision problems may interfere with mobility, reading, writing, dressing, eating,
locating objects, grooming, social interaction, etc.
• Vision problems may go undiagnosed if we rely on the patient to express complaints.
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Goals of the functional visual evaluation:
– Diagnose and treat patients with ocular and visual deficits.
– Counsel the patient and family as to the visual sequelae resulting from the
brain injury.
– Counsel the patient, family, physicians, and therapists as to how to
compensate for the patient’s visual deficits.
Common Signs & Symptoms
• Signs:
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Eye turn (strabismus)
Closing one eye
Head tilt or turn
Bumping into objects
Abnormal posture
Balance problems
Poor depth perception
Nystagmus
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Double vision (diplopia)
Blurred vision
Inability to sustain attention on visual tasks
Dizziness
Headaches
Eye strain
Difficulty reading
Patient Case
Diplopia after TBI
Glasgow Coma Scale (GCS)
• TBI Severity Based on GCS:
– Mild TBI = GCS 13-15
– Moderate TBI = 9-12
– Severe TBI = 3-8 (patient’s score = 4)
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Communication Disorders
Aphasia: inability to express oneself &/or understand language.
Dysarthria: difficulty in forming words because of muscle weakness. Slurred speech.
Confabulation: “filling in” gaps in memory with fictitious events, people, or places.
Perseveration: inappropriate persistence of a response.
Management of Acquired Diplopia
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Occlusion
Prism
Compensatory strategies
Vision Therapy:
• Monocular pursuits, especially into affected FOG, may help restore muscle
function and prevent muscle contracture.
• In some cases where pts have fusion in at least some FOG, VT can be
aimed at expanding motor fusion ranges from that area.
• Typically not started until the acute, underlying etiology has been
treated/managed.
Botulinum Toxin Chemodenervation:
• Injected into the agonist muscle using an EMG needle to monitor muscle activity.
• Used in some cases of CN VI palsy.
• Initial effects within 1-7 days.
• Max effect in 1-2 weeks.
• Resolves over 4mos (+/- 2mos).
Surgery:
• Considered after 6-12 months.
• Only performed once the Dr. is convinced that the angle of deviation is stable.
• Botox can be utilized in cases of CN VI palsy prior to surgery.
Patient Case
• 14 year old male
• TBI secondary to ATV accident w/o helmet
• Cranial nerve III, IV, VI, VII palsies OD
• Cranial nerve III palsy
– Exotropia, hypotropia, ptosis, fixed-dilated pupil, loss of accommodation.
– Occlusion, prism, near add, surgery (lid, strabismus)
• Cranial nerve IV palsy
– Hypertropia, excyclotorsion
– If torsion is >10 degrees, suspect bilateral CN IV
– Occlusion, prism, compensatory strategies (head tilt, elevating near objects,
tilt boards), surgery
• Cranial nerve VI palsy
– Esotropia
– Occlusion, prism, compensatory face turn, Botox, surgery
• Cranial nerve VII palsy
– Lagophthalmos
– Exposure keratoconjunctivitis
– Vigorous ocular lubrication
– Eyelid taping
– Eyelid weights
– Tarsorrhaphy
Patient Case
• 54 year old CF s/p aneurysm rupture
• Bilateral cranial nerve IV palsy
• Video footage
Accommodative Disorders
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Lag of accommodation
– Use of reading Rx or BF
– May improve over time and with decrease in meds
Accommodative spasm / Traumatic myopia
– Difficult to manage
– May resolve with time
– May need BFs, vision therapy, cycloplegics
Accommodative infacility
– Vision therapy
Patient Case:
Homonymous Hemianopsia
 Fresnel Sector Prism
 Scan Course
o Place 20 numbers/letters on the wall – 10 on each side
o Place at varying heights
o Have patient walk the course and read number/letters aloud
 Subtest of The Brain Injury Visual Assessment Battery For Adults
(biVABA)
 Narrated Walk – I See …
o Identify Moveable Obstacles
o Identify # of People in each Aisle
o Read Aisle Signs
o Visual Scanning - Shelves
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Visual Field Defect versus Visual Inattention/Neglect
Hemi-inattention/neglect is often confused with visual field deficits - distinctly
different conditions.
When a visual field deficit is present, the patient attempts to compensate for
vision loss by engaging visual attention.
When a hemi-inattention is present, the patient has lost the attentional
mechanism that drives visual search for information on the left side and does
not attempt to compensate.
Combination of hemi-inattention and VFD creates severe visual inattention,
sometimes called visual neglect
Impact on Rehabilitation
Unilateral neglect has consistently been identified as a negative predictor for a
patient’s recovery of independence in daily living.
Patient Case
Hemianopsia plus neglect
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Physical Deficits
Apraxia: Inability to carry out a complex or skilled movement not due to
paralysis, sensory changes, or deficiencies in understanding.
Ataxia: A problem of muscle coordination. Caused by lesion of the cerebellum
or basal ganglia.
Adiadochokinesia: Inability to stop one movement & follow it with a movement
in the opposite direction.
Paresis: Inability to move part of the body.
Visual Field Testing
Occupational Therapy Evaluation
Clinical observations 2 weeks later:
• Would not turn head to left and look at OT
• Would hit the doorway on the left side when entering / exiting a room
• Could not follow OT to treatment room
• Did not see assessment materials on the left side
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Occupational Therapy Intervention
View Group for personal space (pen/paper tasks) and extra-personal space (mobility).
Referral to University of Houston Center for Sight Enhancement 4 months after
original stroke.
Hemi-spatial Neglect Testing
Blind-pointing procedure
Clock dial
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Line bisection
Flower
House drawing
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Dynavision
Originally designed to improve visuomotor skills of athletes
Used to increase awareness of peripheral vision
Use hand to strike point which is flashing
Number of “hits” are recorded at the end of the run
Fully programmable for quadrants, pace, etc.
Center fixation target with number for patient to call out to monitor fixation
Neglect Intervention
• Use prompts for missing side - i.e. bold color in margin for reading, move
materials in the room to the affected side.
• Use of kinesthetic feedback is helpful.
• Use of yoked prism training protocol to assist patient to compensate, possibly
a more central response.
– Rossetti et. al. Nature v395:166-169,1998
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Conclusion
By being part of the rehab team, optometrists improve patients’ overall
rehabilitation progress and help to improve the patients’ quality of life.