Gregory L. Goodrich, Ph.D.Western Blind Rehabilitation Center & Psychology ServiceSupervisory Research PsychologistVA Palo Alto Health Care System

It’s a pleasure to be here! The top ten best places to be born

in 2013: 1. Switzerland 2. Australia 3. Norway 4. Sweden 5. Denmark 6. Singapore 7. New Zealand 8. Netherlands 9. Canada 10. Hong Kong

I have no financial interest in any product discussed The views expressed are my own and do not

necessarily reflect those of the Department of Veterans Affairs or the Palo Alto Health Care System

My research colleagues Jennine Kirby, O.D. Heidi Flyg, O.D. Karen Brahm, O.D. Gary Martinsen, O.D. Glenn Cockerham, O.D.

The Department of Veterans Affairs (VA) is a federal program serving veterans 22.2 million veterans (Denmark ~5.5 million)

Serves36% of all veterans 55% of 1.5 million Iraq and Afghanistan veterans receive

VA services; 94% outpatient & 6% hospitalized) Total US population ~ 313 million (EU ~ 503,679,730)

152 medical centers, over 1100 clinics 13 Blind Rehabilitation Centers, 54 Low Vision

Clinics Currently serve veterans from WWII, Korea,

Vietnam, Gulf War, and wars in Afghanistan and Iraq as well as peacetime intervals

Brief history of how I got here What do traumatic brain injury and stroke

have in common (and differences)? Review of our research on TBI and vision

loss Studies of vision loss/dysfunction

Inpatient Outpatient

Mechanism of injury Rehabilitation

What we know and don’t know Summary

Most of my career in low vision research (reading, mobility, technology, etc.)

2003 WBRC admitted first military patient with TBI-related vision loss Not a happy story We learned that individuals with TBI-related vision

loss didn’t fit well into “traditional” low vision rehabilitation

This led to research to characterize the vision injury and co-existing conditions

Which, in turn, led to clinical rehabilitation programs

Stroke Binocular/oculomotor

problems Visual field loss Visual acuity loss

(rare) Visual processing Light sensitivity Co-morbid loss

(paresis, paralysis, cognitive, emotional, etc.)

TraumaBinocular/oculomotor

problems Visual field lossVisual acuity loss (rare)Visual processingLight sensitivityCo-morbid loss (paresis,

paralysis, cognitive, emotional, etc.)

In brain injury from both stroke and trauma vision loss/dysfunction are frequently undiagnosed

Vision rehabilitation is usually only one of numerous types of rehabilitation needed by the patient

Vision loss/dysfunction degrades education, vocation and quality of life

Caregivers play an important role in recovery We know much less than we would like! Similarities aside “the devil may be in the details”

Danish

English

Stroke often occurs to specific brain areas Traumatic brain injury may lack this specificity Some differences in co-morbidities

Post traumatic stress disorder (PTSD) May reflect that PTSD is not assessed in civilian settings

Dual sensory impairment (DSI): hearing & vision (blast) Severity may be assessed on different scales

Glasgow Coma Scale vs NIH Stroke Severity Commonalities and differences in visual

loss/dysfunction between stroke- and trauma-related injury have not been well studied

~85% of TBIs are mild ~15% of TBIs are moderate/severe/penetrating In our studies severity of TBI does not correlate

with severity of vision loss/dysfunction, but mTBI generally associated with

binocular/occulomotor dysfunction in outpatients Inpatients exhibit vision loss and binocular/

occulomotor dysfunction In TBI vision loss may relate to severity of injury, damage

to eye, orbit, optic tract, etc.

Traumatic Brain Injury http://www.cdc.gov/traumaticbraininjury/statistics.html Incidence = 1.7 million/yr. (not treated hence not reported = ???) 1.365 million treated; 275,000 hospitalized

Cost = $76.5 billion/yr. Causes

Falls ~ 523,000 Stuck by/against (sports, accidents, etc.) ~ 271,000 Motor Vehicle Accident ~ 218,000 Assault ~ 148,000 Other/Unknown ~202,000

Aquired brain injury: stroke/anoxia/tumor/etc. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5619a2.htm

Stroke ~ 795,000/yr. Cost ~ $62.7 Billion/yr.

Traumatic Brain Injury Incidence = 1.6 million/yr. Ribbers, G.M. Int Encyl Rehab

(http://cirrie.buffalo.edu/encyclopedia/en/)

18% of US incidence (reporting or just less accident prone?)

Cost = € 2.9 billion/yr. Causes similar to US data

Aquired brain injury: stroke/anoxia/tumor/etc. (http://www.escardio.org/communities/EHRA/publications/papers-interest/Documents/ehra-stroke-report-recommend-document.pdf)

Stroke ~ 2 million/yr. Cost ~ € 38 Billion/yr.

Visual Acuity Interestingly, visual acuity is not often impacted

(~3% - 14% in inpatients; ~1% – 2% in outpatients) may be most affected by non-blast injury or more

severe level of injury Blast events result in enucleation (18%) or blindness

(6%) in polytrauma patients Visual acuity often considered “gold standard” of

visual function – “status”may hinder identification of patients with visual abnormalities

Visual Field 14% - 33% found in our studies of

polytrauma patients Hemianopia most common field loss

usually homonimous but may be bitemporal

Monocular or binocular Quadrant loss or field constriction

Binocular/Oculomotor Dysfunctions Accommodation Vergence Strabismus Pursuits Fixation

Very good documentation that dysfunctions negatively affect quality of life, for example, Reading

Schuett, S. Neuropsychologia, 2008

Mobility & Driving Hatt, S. J Ophthal, 2007; Chen, S. Top Stroke Rehab, 2009; DVBIC, July 2, 2009

Communication and social interaction Babbage, D., Neuropsych, 2009

Visual Processing Mckenna, K. et al, 2005, Brain Inj

Recovery and reintegration Saunders, et al, JRRD, 2012

Quality of life Cockerham, NEJM, 2009

Goodrich, et al. JRRD, 2007 Lew, et al. JRRD, 2007 Stelmack, et al. Optom, 2009 Cockerham, et al. JRRD, 2010 Lew, et al. (DSI) NeuroRehab, 2010 Cockerham, et al. NEJM, 2011 (occult eye injury) Dougherty, et al. Brain Inj, 2011 Capo’-Aponte, et al. Mil Med, 2012 Goodrich, et al. Opt Vis Sci 2013, (in press) Goodrich, et al. JRRD, 2013 (in press)

The following slides summarize our studies on VA outpatients Majority diagnosed with mTBI Majority male ~95% Mean age ~ 29 years Served in Afghanistan and/or Iraq

The data presented will address mechanism of injury (blast vs other trauma such as motor vehicle accidents, falls, assault, etc.)

Polytrauma Networks Site (outpatient clinic) Referred to clinic if answered yes to any

one question 1. Have you ever been in a blast/explosion (or

close proximity), vehicular crash, or fall? (79% blast, 21% other) 2. Have you ever been rendered unconscious?

(50%) 3. Have you ever had head trauma (98%)

Visual status pre-injury unknown

Visual Symptom PercentVision-related complaints following injury

79%

Light sensitivity 69%

Blurred distance vision 63%

Floaters 61%

H/O Refractive error 49%

Blurred near vision 47%

Flashes 38%

Pain in or around eyes 32%

Loss of peripheral vision 22%

Pain with eye movement 16%

Diplopia 11%

H/O Strabismus/amblyopia 4%

Reading Symptom PercentReading difficulty 84%

Difficulty remembering what was read

78%

Reduced ability to concentrate while reading

77%

Symptoms new since injury 75%

Loses place while reading 71%

Eyes tire while reading 71%

Unable to do sustained reading 65%

Falls asleep while reading 64%

Easier to read when rested 42%

Covers/closes one eye to read 12%

Alphabet Pencils Read 1st letter on

left pencil then first on left pencil

second on first pencil then second on left pencil, etc.

Study/ Deficit Goodrich1 Brahm2 Stelmack3 Ciuffreda4 Capo-Aponte5

Reading* 61% 87% 50% - 65%

Convergence 30% 48% 28% 42% 55%

Accommodation 22% 49% 47% 41% 65%

Strabismus - 7% 8% 25% 0%

Pursuits/Saccades 20% 23% 6% 39% 60%

*includes both symptoms and measured deficits 1. Goodrich GL et al. JRRD. 2007;44:929-36.2. Brahm KD et al. Optom Vis Sci 2009;86:817-25.3. Stelmack JA et al. Optometry 2009;80:419-24.4. Ciuffreda KJ et al. Optometry 2007;78:155-61.5. Capo-Aponte JE et al. Mil Med 2012;177:804-13.

Findings from studies of military/veteran and civilian populations following TBI suggests spontaneous recovery may occur in accommodation, strabismus and pursuits/saccades, to a lesser degree in convergence. Self-reported and measured reading difficulties may persist

Limitations of these conclusions is that we don’t know the visual status of patients prior to injury and that the comparison study (Capo-Aponte) was a controlled study with small N

The question of mechanism of injury is an over-arching one for us since blast significantly differs from other mechanisms of injury primarily from the primary blast wave (over-pressure wave) and likelihood of injury due to burns and injury from projectiles/shrapnel (including infection risk)

In civilians: motor vehicle accidents, falls, assaults, struck by/against, other most frequent causes

In military personnel: blast event, motor vehicle accident, falls, assaults, gunshot, struck by/against, other

There is some evidence that traumatic brain injury due to a blast event differs from other causes. Blast events are also associated with higher rates of eye injury and loss of one or both eyes which is consistent with our findings. Svetlov, S, et al. (2009) J Neurotrauma; Hurley, R. et al (2006), NEJM

Polytrauma ~ multiple, simultaneously occurring injuries usually involving TBI

Populations studied were inpatients of a polytrauma rehabilitation center outpatients with diagnosed mild traumatic

brain injury (mTBI) or Most common injury: blast-related (~50%) Median age ~ 29 years (range 19 to 59) ~95% male

Comprehensive Eye/Vision Examination (now mandated by VA for all Polytrauma Rehabilitation Center patients) Patient history Visual acuity (ETDRS, Feinbloom Number Chart)* Visual field (Goldman, Arc Perimeter, Tangent

Screen, Confrontation)* Binocular/occulomotor

Fixation, accommodation, vergence, saccades, etc. Reading ability assessed* Test selection determined by pt. capacity (i.e., mobile, bed-ridden, etc.)

75% self-reported visual symptoms 84% self-reported reading difficulties

59% Light sensitivity Optometric findings - Dysfunctions

Over-all 70% presented with one or more findings 46% Convergence 25% Pursuit and/or saccadic 21% Accommodation 11% strabismus 5% fixation or nystagmus

Reported by 59% of patients More common in mTBI Most commonly reported by patients with PTSD Statistical analysis concludes that “light

sensitivity” is due to PTSD not visual condition Important in that it suggests that not all visual

symptoms generated by vision change Need to ensure we “sort out” visual from non-visual

symptoms

All InjuriesN = 68

Blast injuryN = 57

Non-blastN = 11

Visual Dysfunctions:

Convergence Insufficiency

42.6% (26/61) 42.3% (22/52) 44.4% (4/9)

Pursuit/Saccadic Dysfunction

30.2% (19/63) 33.3% (18/54) 11.1% (1/9)

Accommodativ3 Insufficiency (for subjects less than 40 years)

35.5% (22/62) 37.7% (20/53) 22.2% (2/9)

Fixation Instability 9.5% (6/63) 9.3% (5/54) 11.1% (1/9)

Strabismus 25.0% (17/68) 24.6% (14/57) 27.3% (3/11)

Reading Difficulties (observed )

65.6% (40/61) 63.5% (33/52) 77.8% (7/9)

Rates of visual acuity and field loss <3%

All InjuriesN = 68

Blast injuryN = 57

Non-blast N = 11

Subjective Visual Complaint

75.4% (46/61) 77.4% (41/53) 62.5% (5/8)

Ocular Injuries 38.2% (26/68) 43.9% (25/57) 9.1% (1/11)

Visual acuity (20/70 – 20/100)

6.3% (4/63) 7.4% (4/54) 0

Legally Blind (< 20/100)

12.7% (8/63) 9.3% (5/54) 33.3% (3/9)

No Light Perception 3.2% (2/63) 3.7% (2/54) 0

Significant Visual Field Defects

34.4% (21/61) 31.4% (16/51) 50.0% (5/10)

Monocular 18.2% (12/66) 20.0% (11/55) 9.1% (1/11)

Numbers and cost 244,217 TBIs as of May 16, 2012

http://www.health.mil/Libraries/TBI-Numbers-Current-Reports/dod-tbi-worldwide-2000-2012Q1-as-of-120516.pdf

187,539 mild; 56,678 moderate, severe, penetrating Causes: blast, MVA, fall, assault, gunshot, etc.

Cost from 2000 to 2010 yearly cost = $2.3 billion for military eye injuries including TBI NAEVR Report, K.Frick, PhD Professor, Johns Hopkins Bloomberg School of Public Health, May 2012

54,291 service members had some degree of visual impairment

Total cost to military, VA, & society over remainder of service members lifetime = $24.3 Billion

Area contains a good deal of controversy regarding effectiveness of interventions Prisms Vision Restoration Therapy

Vision Rehabilitation Therapy Scanning Training

NVT Scanning Therapy

Prisms relocate image from affected field to intact field

Training requirements extensive Fixation spot (minimize eye movement) and

presentation of image in intact field Training in office/outdoors (weekly visits up to a

period of weeks) Patient “success” – 27% to 81% (Bowers, et al, Arch Ophthal, 2008)

Patient “discontinuance” a concern

Nova Vision Therapy (NVT) Based on concept of brain plasticity Initial office visit with computer assessment Home training

In home computer Two 30 minute sessions per week for 3 to 6 months Weekly “results” uploaded to NVT computer and a

new training program download to patient computer based upon prior week’s performance

Some literature suggests a small 3 to 5 degree improvement while other reports little improvement

NVT Systems Computer assessment on scanning bar Computer suggests initial training program Additional training components include paper

and pencil tests, indoor/outdoor mobility lessons

Assessment of both static (NVT scanning bar) and dynamic training (Mobility Assessment Course)

Little formal study of effectiveness

Review articles Riggs, et al. Am J Phys Med Rehabil, 2007 Pelak, et al. Curr Treat Options Neurol. 2007

Conclude that scanning training is currently the most promising option for rehabilitation of field losses such as hemianopia

Both reviews highlight the need for controlled trials to determine rehabilitation potential

Casualties for the wars in Afghanistan and Iraq have highlighted vision loss/dysfunction following TBI and the need for: Better access to care, and Additional research to understand the

loss/dysfunction and to improve rehabilitation In TBI the mechanism of injury does not

change the resulting visual loss/dysfunction

All forms of brain injury (e.g. trauma, stroke) may involve visual loss or dysfunction

Estimates of the number of people affected represent a “best guess” Vision not routinely assessed in most settings

dealing with brain injury thus it is likely that current estimates under-report

Cost estimates based on incidence suggest that society pays a very heavy price

Additional research is needed to understand the effects of trauma to the brain on the visual system and how these interactions affect the “whole” individual

And, we lack “gold standards” for rehabilitation therapies for the visual deficits caused by brain injury

Other than that we’re good

I look forward to learning more at this conference

My contact address: Gregory.Goodrich@va.gov

www.vision2014.org

31 March – 3 April 2014

The 11The 11thth International Conference International Conference on Low Visionon Low Vision

Advancing research • Upgrading practice • Improving participation