Download Visual Deficits Following Acquired Brain Injury

Visual Deficits Following
Acquired Brain Injury
Bradley K. Farris, M.D.
Professor, Ophthalmology
Adjunct Professor, Neurology &
Neurosurgery
University of Oklahoma
Dean A. McGee Eye Institute
Types of Visual Deficits in ABI
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Decreased Visual Acuity
 Decreased Visual Field
 Diplopia
 Pain
Anatomy of the Visual System
Types of Visual Deficits in ABI
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Decreased Visual Acuity:
– Subjective complaints:
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My vision is blurry
My vision is distorted
I am blind
– I am going blind
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I lose things in my vision
I cannot see well in my right eye
My vision comes and goes
My eye hurts
Types of Visual Deficits in ABI
– Causes of Decreased Visual Acuity:
 Refractive error
– Pre-existing or decompensated
– Obtaining an accurate visual acuity can be challenging
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Structural damage to eye
– Corneal, lenticular, retinal, optic nerve
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Traumatic cortical visual loss bilaterally
– Anatomical correlation to occipital lobes
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Papilledema
Dry eye syndrome
Right Eye
Papilledema
Optic Atrophy OD
Types of Visual Deficits in ABI
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Decreased Visual Field
– Unilateral:
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Ocular damage to retina, optic nerve
– Unilateral, may be altitudinal
– Bilateral:
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Homonymous Hemianopia:
– Right vs. Left
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Bitemporal Hemianopia:
– Optic Chiasm contusion (basilar skull fracture)
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Tunnel Visual Field:
– Emotional overlay
Anatomy of the Visual System
*Diagrams of Visual Field
Defects
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Unilateral defects:
– Papilledema, trauma, altitudinal
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Homonymous Hemianopias:
– Right vs. Left
– Paracentral
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Bitemporal Hemianopias:
– Basilar skull fractures
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Quadrantic Defects
The “Classic” Homonymous
Hemianopia in Occipital Lesions
Tangent Screen: Left Inferior
Homonymous Quadranopia
Tangent Screen Test
Right Occipital Tip Infarct
Tangent Screen Test: Bilateral
Paracentral Homonymous
Hemianopias
Bilateral Occipital Tip Infarcts:
“Watershed”
Types of Visual Deficits in ABI

Diplopia
– Monocular:
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Not eliminated closing one eye
Refractive, cataract, dry eyes
– Binocular:
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Eliminated closing one eye
Restrictive:
– Orbital or facial fractures (entrapment)
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Paretic:
– Cranial nerve palsies
Types of Visual Deficits in ABI

Diplopia
– Restrictive:
 Enophthalmous, “restricted” movement
– Paretic:
 Third Cranial Nerve palsy
– Dilated pupil, ptosis, vertical + horizontal

Fourth Cranial Nerve palsy
– Vertical diplopia worse to one side

Sixth Cranial Nerve Palsy
– Horizontal diplopia worse to one side
Goals of surgery
-Single vision in primary
-Single vision at near
-Downgaze more crucial
than upgaze
-Improve torticollis
-Increase field of SBV
-Achieve good cosmesis
Types of Visual Deficits in ABI

Ocular Pain:
– Post-traumatic Trigeminal Neuralgia:
 Throbbing, sharp/shooting, “tooth-ache of the eye”
 Radiates from behind the eye to ipsilateral ear
– Migraine Headache:
 Post-traumatic
 Exacerbation of pre-existing condition
 Muscle contraction overlay
Types of Visual Deficits in ABI
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Emotional Overlay:
– The effects of stress, anxiety , and depression
on the nervous system and body:
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Which affects the character and pattern of
complaints,
Which affects the examination and treatment plan,
Which affects the approach to the patient,
Which affects the patient expectations,
Which affects the rehabilitative success
Important Points
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Traumatic visual loss is not progressive
There is a reason for blurred vision
You don’t have to live with diplopia
Visual field defects may improve
Neurological patients require time and patience
There is not one patient that cannot be helped
– “Seldom heal, comfort always”
Treatment Options
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Glasses for refractive errors/bifocals
Diplopia treatment:
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Wait 6 months (force fusion)
Patch therapy (no need to alternate)
Prismatic glasses
Strabismus surgery (realistic expectations)
Spend time with the patient:
–
Address physical, emotional, and spiritual needs
ML #317185
 53 YO WF
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CC: Visual loss OU
HPI: Plane crash 4 mos ago
– Depressed skull fx
– Multiple reconst surg, R orbit
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PMH: Otherwise nl
EXAM: 2/700 OD, 20/30 OS
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Dense bitemp vf defect
3mm enophth OD
Complete ext ophth OD
ON pallor OU
KM #316707
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41 YO F
 CC: Headaches/blurred vision
 PMH: Negative
 EXAM: 20/20 OU
– + L-N dissociation
– + svp’s, vf’s bilat arcuates, OS>OD
QUESTIONS?
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Case Presentations?
 Complex patient issues?
 Ethical dilemmas?