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Paul Koons, M.S., C.O.M.S., C.L.V.T., C.B.I.S. Email: [email protected] Background/Experience Pa. College of Optometry /Salus Univ 1999 Graduate studies Orientation & Mobility , Low Vision Therapy Experience: NYC Lighthouse International State Blind Rehab agencies (Pa, CO, Va) Presently Veteran’s Affairs – Polytrauma center blindness and vision loss specialist (Palo Alto & currently Richmond) Goals of Presentation Define Polytrauma with emphasis on vision loss Discuss Mechanism of Injury causing Brain Injury Types of visual deficits / anomalies Rehabilitation Timelines Multi-Discipline therapies addressing deficits Part of Team: MD, OD, PT, KT, OT, SLP, RT, Psych, RN, LPN, MSW Case studies Resources Audience goal - think about your networks for addressing brain injury and visual deficits Disclaimer statement This presenter has no financial interest in any of the makes, models of rehab equipment, devices, sunwear or assessment tools Brain Injury: TBI – an acquired brain injury caused by an external physical force, resulting in partial functional disability or psychosocial impairment, or both, adversely affecting educational performance. TBI – Traumatic Brain Injury (MVA, Fall, GSW, IED blast) ABI – Acquired Brain Injury (Stroke, Brain Tumor, Anoxia, Hypoxia, Seizures, Blood clots) TBI Severity and Prognosis Index Mild Moderate Severe GCS 13-15 9-12 <8 LOC <30 min <6 hours >6 hours Duration of 0-24 hours 1-7 days PTA Permanent Likely none Likely neurologic some but & neuroare often psychologi quite cal sequela functional >7 days Likely to have severe deficits Severity of Brain Injury Mild TBI / Concussion – Loss of Consciousness less than 30 minutes (or NO loss)- Post Traumatic Amnesia for less than 24 hours. Post Concussion Symptoms Moderate TBI – Coma more than 20-30 minutes, but LESS than 24 hours. Some long term problems in one or more areas Severe TBI – Coma longer than 24 hours, often lasting days or weeks, Longer term impairments Estimates of TBI Severity Mild TBI / Concussion – up to 80% of all cases. Moderate TBI Severe TBI 10% - 30% 5% - 25% According to Brain Injury Assoc of America Traumatic Brain Injury in America Not “just” a VA problem Polytrauma highlighted because of high incidence of occurrence in Iraq / Afghanistan (OEF/OIF) Relevance to community services (Brain injury Association of America) 1.4 – 1.7 million Americans sustain TBI Annually ○ One every 21 seconds 700,000 Americans experience stroke annually ○ One every 45 seconds Annual incidence of TBI per Age group 0-4 years old (1121 per 100,000 cases) 15-19 years old (814 per 100,000 cases) 5-9 years old (659 per 100,000 cases) 75 years and older (659 per 100,000 cases) Often times any brain injury during initial years not realized until later years ○ According to Brain Injury Assoc of America Highest incidence of death due to TBI 75 years and older (51 per 100,000) 20-24 years old (28 per 100,000) 15-19 years old (24 per 100,000) -According to Brain Injury Assoc of America Multiple TBI Risk Factors After 1 TBI, the risk for a 2nd is 3x greater After 2 TBIs, the risk is 8x greater Brain Injury Association of America Brain Injury Recovery timeline General 2 Year “Window” for Recovery Try to “Estimate” degree of recovery in initial 6 months since Injury Severity of Brain Injury a factor, also Anoxic/Hypoxic Brain Injury may kill off more brain cells unable to regenerate Bottom Line – Recovery has been seen several years later, but initial 2 year timeline is a “benchmark” Ophthalmologic and Optometric Interventions Ocular Health Exam Prescription of appropriate corrective lenses Use of occlusion – complete or partial Prisms – yoked, Fresnel Medical and surgical intervention when warranted Optometric plan of care for ocular motor, accommodative dysfunctions Polytrauma Polytrauma is currently defined as multiple injuries of which one (or a combination) is life threatening. Co-Morbidities associated with TBI Vision, Hearing, Physical, Cognitive, Behavioral, PTSD, Sleep, etc Mechanism of Injury Motor Vehicle Accident Sports Concussions Falls Physical Altercations Stroke, Brain Tumor (multiple TIA’s) Gun Shot Wound (could be self-inflicted) Anoxia / Hypoxia Cranial Depression to relieve brain swelling prior to Cranioplasty procedure Bullet Wound: Entering Left Frontal-Temporal area, Passing through parietal, midline into Right Occipital area Possibly resulting in: Contre coupe: Motor Vehicle Accident, trauma etc. Possible watershed effect: damage to frontal lobe, Occipital lobe, extensive bleeding, extensive swelling etc Haemorrhage: Parietal/Temporal: Specific site indicative of stroke, Frontal: typical blunt object trauma Occipital: Tumour Improvised Explosive Devices (IEDs) IED Blast • • • • “Global” damage to brain and body Described as “PRESSURE” Wave “Torsional” effect or twisting of brain within skull IED's also cause damage due to projectile bomb fragments, debris and individual being ‘thrown’ • Penetrating vs. non-penetrating injuries Polytrauma Veterans Affairs 5 Main Polytrauma VA Hospitals in U.S.A. Tampa, Florida Minneapolis, MN Palo Alto, CA Richmond, Va San Antonio, Tx Richmond VAMC Population (Mechanism of Injury) since 2007 70 60 50 40 Blast/ Explosion Vehicle 30 Bullet 20 Other 10 0 Richmond TBI rehab Population (Injury Location) *since Sept. 2007 90 80 70 60 50 40 30 20 10 0 Iraq Afghanistan Stateside Other Some Emerging Characteristics of Polytrauma Patients They are a unique population with unique, long term issues They may not be good self-advocates Many are young and have full lives ahead They are “tech-savvy” They may not want services Most have family involvement and maintain military culture Most commonly reported visual symptoms related to TBI Headaches Diplopia / double vision Vertigo / Vestibular issues Asthenopia Weakness or fatigue of the eyes, usually accompanied by headache and dimming of vision (may affect training in am / p.m.) Accommodation - Inability to focus Movement of print when reading Difficulty with visual tracking and fixations Photophobia / Photosensitivity (night glare) Site of Lesion Visual Pathway numbers indicate how lesion affect visual field(s) Red/Blue = image seen Gray = blind area Left Vs Right Brain Functions Left Brain Functions uses logic detail oriented facts rule words and language present and past math and science can comprehend knowing acknowledges order/pattern perception knows object name reality based forms strategies practical safe Right Brain Functions uses feeling "big picture" oriented imagination rules symbols and images present and future philosophy & religion can "get it" (i.e. meaning) believes music Facial recognition spatial perception knows object function fantasy based presents possibilities risk taking Visual Anomalies of Brain Injury Binocular dysfunction Visual Field Loss often seen: Convergence Accommodation Saccadic/Pursuit Ocular motor Fixation Quadranopia Hemianopia macular sparing? General Peripheral loss Methods to create success and independence through rehabilitation 1. “Fix / Improve Vision” – vision therapy or surgery 2. Use devices/lenses to improve vision (Magnifiers, Telescopes, Rx, Readers, Prisms, white cane) 3. Compensatory Strategies (eccentric fixation, scanning to blind visual field, place reading stand in better visual field) Role of Vision Specialist Consultative for Mild TBI patients: performs diagnostic screening as needed and requests referral to the appropriate Eye specialist provides recommendations for use of optical and non-optical devices to the other therapies; monitors client’s level of visual functioning and provides intermittent screening provides intermittent follow-up services Role of Vision Specialist Interventional Therapist/ moderate to severe TBIs Provides daily intervention as per recommendation of the evaluating eye specialist and based on an established plan of care – duration, Frequency of treatment and functional goals are preestablished prior to commencement of treatment Progression and discharge from this service will be based on outcome and/or discharge from facility Provide follow-up plan (use of readers, visual search, compensatory strategies) Intervention Strategies Implemented by Vision Specialists Follow-up education and training in use of prescribed corrective lenses Training and education on the use of occluders and prism glasses to promote independence and safety during completion of ADL functions Education on use of appropriate glare remediation Intervention Strategies Graded static and dynamic training to improve use of an organized and systematic scanning strategy Training in the use of non-optical aids Orientation and mobility training Intervention Strategies Manipulation of the environment a. reduction of background pattern b. use of adequate illumination c. increase in background contrast d. anchoring and boundary marking strategies Intervention Strategies Environmental modification to improve awareness of missing visual space I.e.: bed placement to improve awareness/scanning to auditory stimuli – hallway I.e.: Place reading stand and material into/out of remaining visual field Screening and Assessment Process Physician’s Referral Screening by Vision Specialist Follow-up by Vision Program Referral to Eye Specialist Vision Program F/U SLP/OT/PT Intervention Glossary Accommodation Version Saccade Pursuit Convergence Divergence Visual Fields Photosensitivity changizi.wordpress.com Research articles on Binocular Dysfunctions in TBI population (military & civilian) Stelmack et al., 2009 (all levels of TBI in Hines VA hospital) 47% accommodative disorders 28% convergence insufficiency Brahm et al., 2009 (all levels of TBI in Palo Alto VA hospital) 39.6% of accommodative insufficiency 42.6% of convergence insufficiency Goodrich et al, 2007 (all levels of TBI in Palo Alto VA hospital) 21.7% had accommodative dysfunction 30.4% had convergence insufficiency Ciuffreda et al., 2007 (Civilian, TBI rehabilitation) 41 % had accommodative dysfunction 42.5% had convergence insufficiency Lew et al., 2007 (mild TBI) 21% accommodative insufficiency 46% convergence insufficiency *all patients diagnosed in Optometric clinics within 3 months post trauma RIC Eye/TBI Clinic n=100 (2007-2009) Most Common Vision Disorders following TBI Photosensitivity Convergence Insufficiency Saccadic Dysfunction Dry Eye Accommodative issues Tropia (Eye Turn) Visual Field defects 34% 31% 24% 23% 18% 13% 10% *research design was conservative as these are primary dx but many of these overlap such as photosensitivity and accommodation Accommodation Definition: ability to focus near and distant targets Measure Accommodation monocularly (diopter) Our eyes ‘bending’ power Rehab strategies for Accommodation insufficiency Ms. V Visual Dysfunctions 28 yr old with left Sylvian fissure AVM embolization left cerebral hemisphere ischemia Accommodation insufficiency Reduced near point of convergence Saccadic dysfunction Dry eye Floaters OS per patient Photosensitivity Reading with +/- power flippers can be performed monoc. / binoc. Hart Chart Activities (Saccades and Accommodation therapy) Version / Eye movement Definition: smooth eye movements in the same direction Saccade - efficient eye movement from one fixation point to another Pursuit - two eyes ability to follow a target Fixation-eyes’ ability to stop on an object and bring it into focus (fixate and focus) Large and Small Saccades Large Visual Saccades Reading with small visual saccades Rehab strategies for Saccades Developmental Eye Movement (DEM) Test A + B = C (time measured) Saccadic Reading Exercises Wayne Saccadic Fixator Rehab strategies for Saccades HTS (Home Therapy System) Rehab strategies for Ocular motor issues (Versions) Vergence Eye Movement Definition: smooth eye movements in opposite directions Types: Convergence and divergence Strabismus: phoria (tendency to…) tropia (fixed). Can be subtle or intermittent, dependent on gaze, fatigue, distance www.petsadrift.com/grfx/crosseyed.jpg Rehab strategies for Convergence/Divergence Brock string for Convergence & Divergence - may include fusional prisms Vectogram activity for Convergence / Divergence Neurological Field Loss Strategies Reading with R hemianopia Reading with Left Hemianopia Brahm et al., 2009 & Dougherty et al., 2010 Visual field loss testing is recommended for patients with a history of TBI Visual Field Loss Accurately Assess Visual Fields Monocularly Confrontation, Finger counting ARC Perimeter / Hand held disc perimeter Goldmann, Humphries, Octopus (eye clinic) Educate Patient and Family! Show best use of remaining field placement Establish full perimeter scan (overshoot) or staircase visual search methods Increase complexity of environments, reducing cues Visual Search & Scanning with Visual Field Loss Chedru et al., 1973 Ishiai, et al., 1987 ○ Meienburg, et al., 1981 Gassel et al., 1963 Recorded eye movements & visual search in TBI patients with hemianopia Patients paradoxically concentrated on the blind side (compensation strategy) Patients with additional neglect/inattention lacked this compensation strategy Scanning Training with Hemianopia Dr. Josef Zihl, 1988 Trained 30 hemianopes (w/out inattention/neglect) Practice large saccades into blind field Visual search field increased 10-30 degrees 4 – 8 sessions Kerkoff et al, 1992 Validated similar results in 92 hemianopic patients & 30 with additional inattention/neglect Following 6 weeks of scanning training (30 sessions) Hemianope group: Mean search field increased from 15 degrees to 35 degrees Additional Inattention/Neglect group; required 25% more training over 2-3 months to achieve similar result Visual Field Search training • Goals: Increase awareness, establish compensatory scanning pattern into the deficit field which become automatic and accurate Technique: Start with a small number of targets in the affected field and increase the number as proficiency improves • Continual verbal reinforcement to scan into the affected field is required • Field enhancing prisms may be used (OD) Types of visual search strategies with Hemianopia Staircase Strategy (general compensation strategy without training) Overshoot strategy: place remaining visual into blind field further than target expected (R visual field loss) X Hemianopia and Reading Success Dr. Poppelreuter, German Neurologist Brain injured Vets -- WWI (1917) Hemianopia and Reading Success Dr. Poppelreuter, 1917 (early in century) Interested in studying reading deficits in R & L hemianopic WW1 veterans Left visual field loss handicaps return eye movement to find beginning of a new line Right visual field loss handicaps eye movement to next word/letter in sentence Right hemianopia more challenging since we read left to right (trained to overshoot each word to successfully read) Field Cut and Inattention/ Neglect neuropolitics.org/hemineglect.gif www.yvonnefoong.com/.../homonymoushemianopia.jpg VISUAL INATTENTION / Neglect: Figure Copying – What pieces of info is missed? Describe room in balanced format? Photosensitivity Definition: Intolerance of light History: Patients complain they can’t transition quickly I.e..: glare on floor, lights while driving, tearing, frequent blinking, squinting, headaches, irritability with visual activities Types: photophobia vs. photosensitivity Photosensitivity exists in the absence of true pain, distinct from the photophobia seen in patients with inflammatory ocular disease Glare at night – trial 54% yellow tint and 40% Plum tint to reduce “halo” Night Driving Glare Other types of materials and equipment used Parquetry Block tasks train systematic visual search and building concept HTS Visual Closure Therapy Zoom text Speech, Colors, Size, Internet Reverse screen polarity for light sensitivity and increased font Regular laptops, computers, iPads have screen light reduction, font adjustment, etc My Reader Patients who can read the text but need higher level of text manipulation Breaks up text to word-by-word, letter-by-letter, line-by-line, and ticker tape scrolling for problems with saccades or visual field cuts CON: Not adaptable to the internet and not as portable, no speech KNFB Reader (Kurzweil and National Federation for the Blind) Speech and limited text manipulation such as line-by-line Portable but small screen A.L. Could not process print due to disorders of accommodation and seccades. She spent so much effort trying to read that she could not process the information. CASE STUDIES Acute TBI Case Study mod to severe TBI (IED blast, 1 month post trauma) Sgt. Frank 26 year old Army Sergeant IED blast related injury November 2004 with right hemisphere injury General constricted visual fields Needs assistance with food, dressing, etc. Relearning to walk Memory deficit Speech Problems Left visual inattention Partial paralysis left side Checking the daily schedule (note yellow reminder sheet of therapy sessions taped to left arm rest) A to Z Visual Scanning Game Reinforcing Speech Therapy Paul cueing to Pt. left area of neglect Pt. points to and names target letter Pt. hesitates while searching Target identified and named Training Visual Tracking (head and eye movement) Training can be monocular Cueing centering Or binocular Tracking in a Dynamic Setting Pt. scanning, finding, pointing and identifying targets Transfer to O&M Pt. checking for cross traffic Pt. practicing scanning and obstacle identification Physical Therapy and Vision Therapy co-tx Paul cueing to correct Pt. centering body and gaze Pt. practicing centering and gait Awareness of Patient endurance Fatigue is common Multiple short (10 to 20 minute) lessons per day Frequent rest breaks Time for “fun” activities