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Diagnosis and Management of TBI-Related Vision Problems

Mitchell Scheiman, OD

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Objectives

• To understand the impact of TBI on the visual system

• To review the evaluation of binocular vision, accommodation, and eye movements in the TBI patient

• To review the treatment of TBI-related vision problems

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Introduction

• Patients surviving acquired brain injury generally experience multiple problems:– Cognitive– Psychological– Motor – Sensory

• BV, ACC and EM problems tend to be more complicated

Overview of Traumatic Brain Injury

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Traumatic Brain Injury (TBI)

• Definition:– Injury to the head that is documented in a

medical record with one or more of the following conditions attributed to head injury:

• Observed or self-reported decreased level of consciousness

• Amnesia• Skull fracture• Objective neurological or neuropsychological

abnormality• Diagnosed intracranial lesion

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Epidemiology of TBI

• 175 to 200 per 100,000 population or about two million head injuries each year

• Over 1.5 million Americans suffer nonfatal traumatic brain injuries each year that do not require hospitalization

• Another 300,000 individuals suffer brain injuries severe enough to require hospitalization

• 100,000 resulting in a lasting disability• Prevalence of TBI is estimated to be 2.5

million to 6.5 million individuals

TBI: Iraq and Afghanistan Wars

• Every war produces a characteristic injury that becomes that conflict's "signature wound".

• WWII– radiation-induced cancer from atomic

bombs

• Vietnam war– Post Traumatic Stress Disorder (PTSD)

• Iraq War– TBI

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Classification of TBI

• Mild• Moderate• Severe

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Judging Severity of TBI

Post Traumatic Amnesia Scale (PTA)• The time between injury and recovery

of continuous memory for day-to-day events

• Best measure of quantity of brain tissue destroyed by TBI

• Can be used months or even years after TBI

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Post Traumatic Amnesia (PTA) Scale

PTA Score Severity of Injury

< 10 minutes Very mild

10 to 60 minutes Mild

1 to 24 hours Moderate

1 to 7 days Severe

> 7 days Very severe

TBI: Prevalence of Vision Problems in Civilian Population

• 160 records of patients with TBI (160) reviewed – 90% had BV/ACC/EM disorders

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Ciuffreda KJ, Kapoor N, Rutner D, et al. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry 2007;78:155-61

Results

• TBI– Accommodative insufficiency: 41.1%– Convergence insufficiency: 56.3%– Strabismus:

25.6%– Cranial nerve Palsy: 10.0%

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Recent Prevalence Studies in Military/VA Populations

Goodrich, G et al.- 2007

• 50 patients admitted to Polytrauma Rehab Center (PRC) from December 2004 to November 2006

• Mean age of subjects 28.1 years • All subjects had experienced a TBI• Blast injuries accounted for half of all

injuries

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Goodrich, G et al. Visual function in patients of a polytrauma rehabilitation center: A descriptive study. Journal of Rehabilitation Research & Development 2007; 44: 929–936

Results

Problem All Subjects

(n=46)

Blast

(n=21)

NonBlast

(n=25)

Convergence Insufficiency

30% 24% 36%

Accommodative Dysfunction

22% 24% 20%

Pursuit/Saccade Dysfunction

20% 5% 32%

Visual Field Defects

21% (100 Eyes)

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Brahm, et al. - 2009

• Frequency of visual impairment in combat-injured service members with TBI– Polytrauma Rehab Center (PRC) inpatient (n=68)

– Polytrauma Network Site (PNS) outpatient (n=124)• Mean age : 28years old

– 84% of PRC patients: TBI associated with blast event

– 90% of PNS patients: TBI associated with blast event

Brahm KD, et al. Visual impairment and dysfunction in combat-injured servicemembers with TBI. Optom Vis Sci 2009;86:817-825 16

Brahm et al.

• Convergence insufficiency (CI):42%

• Accommodative Insufficiency: 42%• Pursuit/Saccadic Dysfunction: 33%• Visual Field Defects: 32%• Bilateral poor visual acuity: 4%

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Stelmack - 2009

• Retrospective record review performed for 103 patients with polytrauma

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Joan A. Stelmack, O.D., M.P.H. Visual function in patients followed at a Veterans Affairs Polytrauma Network Site: An electronic medical record review. Optometry 2009;80:419-424

Results

Problem TBI PolytraumaAccommodative disorder 47% 30%Convergence disorder 28% 13%Visual field loss 14% 23%Pursuits/saccade disorders 6% 9%Diplopia 8% 15%

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Prevalence of CI in the TBI Population

• Ranges from 13% to 44%• In 2 of 3 studies of military population, CI

most prevalent vision disorder and in the third study, CI, 2nd most common vision problem

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Common Vision Problems after TBI?

• Binocular Vision– Convergence Insufficiency (CI)

• Accommodative Problems– Accommodative Insufficiency (AI)

• Eye Movement disorders• Visual Field Disorders• Low vision?

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Optometric Role

TBI-Related Vision Disorders

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Significance

• Vision problems common after TBI• Significant negative impact ability to

return to active duty• Effect on:

– Reading– Writing– Driving

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Optometric Role

• Historically ODs not been part of the rehabilitation team in civilian and military hospitals

• Team typically includes:– Physicians – Occupational therapists– Physical therapists – Speech language pathologists

• Eyecare usually provided by an ophthalmologist– Emphasis on acuity and eye disease

• Common for some vision problems associated with TBI to be left undetected or untreated

• Unique opportunity for Military ODs

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Military Optometric Role

• Primary Care Military ODs– Because of high prevalence of TBI-

related vision disorders• Assessment and diagnosis of vision

problems of patients with TBI

– Vision Rehabilitation • Passive treatment

– Lenses, prism, occlusion

• Active treatment – Vision rehabilitation

Vision Rehabilitation Models

Civilian Model• Diagnosis: Primary Care

OD• Passive Tx: Primary Care

OD• Vision Therapy

– Refer to specialist– Performed by “vision

therapist”

Military Model• Diagnosis: Primary Care

OD• Passive Tx: Primary Care

OD• Vision Rehabilitation

– Prescribed by Primary care OD

– Performed by occupational therapist

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Model of Care

Vision Rehabilitation Team

• Eye Care Professionals– Optometrists – Ophthalmologists

• Rehabilitation Professionals– Occupational Therapists (OTs)

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Occupational Therapist (OTs)

• Education– Master's degree or higher is minimum

requirement for entry into the field– All States regulate the practice of occupational

therapy

• American Occupational Therapy Association:– “OTs help people across the lifespan participate

in the things they want and need to do through the therapeutic use of everyday activities (occupations)”

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Proposed Model

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TBI Protocol

• Should include mandatory vision examination by primary care optometrist

• Minimum data base– Visual acuity– Eye health– Accommodation– Binocular vision– Eye movements – Visual field

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Optometrist

• Role of Optometrist – Primary Care Role– Eye Disease

• Medical treatment• Refer to Ophthalmologist

– Advanced medical treatment– Surgical treatment

• Refractive, Binocular, Accommodative, Eye Movement Disorders– Assessment– Diagnosis– Prescribe treatment

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Optometrist

• Intervention plan• Prescribe lenses• Prescribe prism• Prescribe occlusion• Prescribe vision rehabilitation

• Supervise treatment• Periodic follow-up

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Occupational Therapist

– Identification of patients at risk for vision problems

– Screening• Accommodation• Binocular vision• Eye Movements• Visual Processing

– Administration of vision rehabilitation

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Three Component Model of Vision

Visual IntegrityVisual Efficiency

Visual Information Processing

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Visual Integrity

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Visual Efficiency Skills

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Visual Information Processing Disorders

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Summary

• 3 component model

– Important for optometrists and rehabilitation specialists to conceptualize and use same model of vision

Conclusions

• Prevalence of vision disorders after TBI is very high

• Soldiers returning after TBI deserve the very best vision care– Comprehensive evaluation– Appropriate and timely vision rehabilitation

• Lenses

• Prism

• Occlusion

• Vision rehabilitation40

For Model to Work

• Military ODs:– Evaluation– Diagnosis– Treatment

• Passive• Active

– Must know enough about vision rehab to supervise OTs

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