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Concussion/Traumatic Brain Injury Panel

Vision Assessment after Brain Injury

Jennifer Simonson OD, FCOVDBoulder Valley Vision Therapy

1790 30th Street, Suite 311Boulder, CO 80301

303.443.2257www.bouldervt.com

Course OverviewModerator: Brenda Montecalvo, ODPresenters: Michael Earley, OD, PhD, Jennifer Simonson, OD, FCOVD, Jacqueline Theis, OD

Abstract: Traumatic brain injury (TBI) can have prolonged recovery classified as post-concussive syndrome (PCS). Optometry can play a role in assessment and treatment of patients with TBI and PCS. Several visual conditions can result from PCS including difficulties with accommodation, convergence, eye movements and visual perceptual and cognitive delays. This panel will discus optometry’s role in helping improve outcomes with this population.

Disclosures: Dr. Simonson has no disclosures for this presentation.

V. Visual problems resulting from Traumatic

Brain Injury (TBI)

Vision is a SENSORY and MOTOR system.

• What is it?• Where is it?• What do I name it?• How do I interact with it?

Sensory – Visual Processing

• Pupil reflex• Tracking• Vergence• Focusing

Motor – Muscles in and around the eye

Visual disorders may not be fully expressed or understood by the patient.

Visual problems resulting from TBI

A. Eye movementsB. AccommodationC. Binocular vision/VergenceD. PhotophobiaE. Visual Figure-groundF. Visual ClosureG. Visual Reaction TimeH. Visual Memory

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Traumatic Brain Injury can happy at ANY age.ADULT CHILD ADOLESCENT

n Headaches with visual tasks

n Blurred vision

n Double Vision

n Loss of Depth Perception

n Loss of Visual Field

n Aching eyes

n Visual Overload

n Poor Attention/Concentration

n Reading difficulties

OCULAR MANIFESTATIONS OF NEUROLOGICAL INSULT:

Patients may have difficulty describing their dysfunction.

They may have normal acuity, but greatly reduced visual function.

Treatment of Post-concussion Vision Syndrome

“The eyes tell the brain what they see, but the brain tells the eyes

what to look for”

FixateFixateFollow

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FixateFollowFocus

FixateFollowFocusFuse

FixateFollowFocusFuseFigure-out

Visual Problems resulting from TBI:

Ocular-Motor Dysfunction – Deficiencies in eye movement abilities are quite common following concussions and other forms of mild traumatic brain injuries. These eye movement deficits can pose challenges with many activities of daily life including reading and driving.

A. EYE MOVEMENTS: (51%)

1. SACCADES:

Fixate: Maintain gaze (eye contact, stability)

Reading (accuracy, efficiency, fluency)

2. PURSUITS:

Follow: Tracking moving targets (sports)

Visual Problems resulting from TBI:

3. VESTIBULAR-OCULAR REFLEX (VOR):

Reflexive gaze stabilizing reflex.

Sensory information from the vestibular system due to head movement creates a motor command to make compensatory eye movements.

Many patients complete Vestibular Physical Therapy

4. VISUAL MOTION SENSITIVITY

AKA “Visual Vertigo”

Dizziness experienced from moving patterns/environment.

Nystagmography is often completed with Functional Neurology Chiropractors

Visual Problems resulting from TBI:

Focusing Problems – A reduction in eye focusing ability results in blurry vision at near, even in young athletes. Near vision may be constantly blurry or may pulse in and out of clarity during near activities.

Blurry Vision - Blurry vision following a concussion can occur at distance, near or both.

B. ACCOMMODATION

1. ACCOMMODATION INSUFFICIENCY (41%)

2. ACCOMMODATIVE SPASM

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Visual Problems resulting from TBI:

C. BINOCULAR VISION

- MOTOR FUSION (VERGENCE) (55%)

1. CONVERGENCE INSUFFICIENCY2. CONVERGENCE EXCESS3. VERGENCE INFACILITY4. DIPLOPIA

- SENSORY FUSION (SUPPRESSION)

Visual Problems resulting from TBI:

Light Sensitivity – Photophobia, or light sensitivity, can result from various types of acquired brain injuries (including concussions).

D. PHOTOPHOBIA (LIGHT SENSITVITY)

Visual Problems resulting from TBI:

Reduced Cognitive Abilities with Visual Tasks - Visual perceptual deficits can be caused by concussions and have dramatic effects on academic, occupational and even athletic success.E. VISUAL FIGURE GROUND – Finding objects in a crowded area, working with spreadsheets on a computer. Crowded stores and restaurants can be overwhelming also. F. VISUAL CLOSURE –◦ Visual Discrimination –Seeing small detailed differencesbetween objects

Visual Problems resulting from TBI:

Reduced Visual Processing Speed or Reaction Time – Prolonged visual processing speed can slow down an athlete both on and off the field. The speed with which an athlete processes visual information affects many aspects of athletic competition, including: reading the field of play, judging the speed of a moving ball or puck, and judging the speed of other players on the field.

G. VISUAL REACTION TIME H. VISUAL MEMORY – Keeping a visual image in your head in order to retain information better◦ Visual Sequential Memory – Remembering a sequence of information,

like a phone number, or several items on a to-do list

VI. Clinical chair-side pearls when working with

Post-Concussion Vision Syndrome

Case History

Key questions to ask post-injury (Goodrich et al, 2013)

1. What changes have you experienced in your vision? 2. Are you light sensitive, in- or outdoors? 3. Do you experience double vision? 4. Have you noticed a change in your peripheral vision?5. Do you have blurred vision at distance or near? 6. Has there been a change in reading? 7. Do you lose place while reading? 8. How long can you read before you need to take and break or

stop? 9. Do you experience Headaches?10.Do you have trouble remembering what you’ve read?

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Detailed Questionnaire: 0-3 ScaleEmergent Visual Conditions

Flashes of light

Floaters in field of view

Restricted field of vision

"Curtains" billowing into field of view

Urgent Visual Conditions

Inability to completely close eyes

Difficulty moving or turning eyes

Pain with movement of the eyes

Pain in or around eyes

Wandering eye

Double vision

Vision Rehabilitation Conditions

Blurred vision for distance viewing / Blurred vision for near viewing

Slow shift of focus from near to far to near

Difficulty copying or taking notes

Pulling or tugging sensation around eyes / Discomfort while reading/ Eyes get tired while reading / Headaches while reading

Unable to sustain near work or reading for periods of time / General fatigue while work/reading

Covering, closing one eye

Loss of place while reading / Easily distracted when reading / Difficulty remembering what has been read

Decreased attention span / Reduced concentration ability

Dr. Allen Cohen at SUNY

Detailed Questionnaire: 0-3 Scale

Disorientation

u Loss of balance

u Poor posture

u Face, head turn or head tilt

u Bothered by movement in environment

u Bothered by crowded environments

u Light sensitivity

u A sensation of the floor, ceiling or walls tilting

u Dizziness

u A sensation of the room spinning

u A sensation of not feeling grounded

u Postural shifts/ veering off when walking

Dr. Allen Cohen at SUNY

Case History1. Consider the time it will take the patient to complete your history forms.

2. Fatigue level of patient before you start the examination.

3. Is the patient a good historian? q Is information sequential, concise, detailed? q Some patients are missing a considerable amount of

time surrounding their injury. q They may be very tired and have sleep deprivation.qMemory may be impaired.

Case History“I take a water-pill, a sugar-pill, and a sleeping-pill”

Case History1. When was the injury?

2. How were you injured?

3. Did you wear glasses before your injury?

4. Bring a list of your medications with you.

Brain Injury Vision Symptom Survey

Dr. Hannu Laukkanen

1040-5488/16/9300-0000/0 VOL. 93, NO. 00, PP. 00Y00 OPTOMETRY AND VISION SCIENCE Copyright * 2016 American Academy of Optometry

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Predictive score is

31+

A. ACHIEVING ACCURATE VISUAL ACUITY1. CROWDING 2. SINGLE LETTER PRESENTATION

3. DR. THEIS RECOMMENDS CYCLOPLEGIC REFRACTION FOR ACCOMMODATIVE SPASM

Functional Visual Acuity:FUNCTIONAL1. When does fluency and speed slow?

2. When does the patient start to guess?

3. Can the patient sustain that level?

POTENTIAL1. How is target modified?

2. How is direction of gaze modified?

3. How is the contrast modified?

4. How is the lighting modified?

Visual information processing problems

• Figure Ground• Symptoms:

• Problems with clutter

• Computer work (spreadsheets)

• Crowded places

B. VISUAL FIELDSConfrontations

Tangent Screen

Automated Perimeters

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Visual FieldsGulden Automated Confrontation Field TesterThis product was developed by Jeffrey Cooper, MS, OD, FAAO and evaluated and standardized by Sherry J. Bass, MS, OD, FAAO, SUNY State College of Optometry

Amsler Grid

Campimeter

Functional Color Fields1. Detection of

motion

2. Detection of target color

BINOCULAR DYSFUNCTION

Symptoms:◦ Tired eyes with reading / computer ◦ Inability to work on the computer◦ Difficulty sustaining near work◦ Words appear to move around◦ Poor concentration ◦ Reduced reading comprehension

Very common: convergence insufficiency (~45%)

C. MEASURING QUANTITY OF BINOCULARITY1. FUSIONAL VERGENCE RANGES 2. NEAR POINT OF CONVERGENCE

C. MEASURING QUALITY OF BINOCULARITY1. FUSIONAL STABILITY 2. NEAR POINT OF COMFORT

Stereopsis suppression check: { + } { |--- } { __|} { | or --} ?

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Modified Thorington Testing: Prism Testing:

Allows you to observe the patient’s level of effort.

Measuring quality of binocularity1. Does it float?

2. Does it blink on and off?

3. Does it drift?

4. Do you localizecorrectly?

5. Any pain?

Is the patient self-aware?

Even SMALL vertical deviations can make the patient symptomatic.

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D. ASSESSMENT OF ACCOMMODATION SYSTEM1. ACCURACY 2. FLEXIBILITY

Assessment of the accommodative system

Stability over time?

Near Retinoscopy

Symptoms:◦ Headaches with near work ◦ Computer work is particularly

straining◦ Tired eyes ◦ Difficulty copying from one place to

another◦ Intermittent blurred vision

Habitual focal distanceWHAT DISTANCE RANGE DO THEY NEED TO VIEW?

We do not typically hold smart phones at 16 inches.

WHAT POSTURAL ADAPTATIONS DO THEY MAKE?

Did they experience a spinal injury?

OCULOMOTOR DYSFUNCTION

Testing:

• Pursuits:

• Smooth eye movements

• Saccades:

• Quick jumps between

targets

• King-Devick Test King-Devick: Speed and Accuracy

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OCULOMOTOR DYSFUNCTION

Symptoms:◦ Hard to follow a

moving target ◦ Difficulty tracking

when reading◦ Reduced reading

comprehension ◦ Motion sickness ◦ Dizziness /

nausea with eye movement

OCULOMOTOR DYSFUNCTION

Quantitative Testing: There are three aspects to be counted:

1. Pursuit ability (the number of rotations made on pursuits)

2. Saccadic ability (the number of successful round trips made on saccades)

3. Accuracy of pursuits (the number of target losses or refixations on pursuits)

NSUCO:Northeastern State University College of Optometry’s Oculomotor Test

OCULOMOTOR DYSFUNCTION

Qualitative TestingThe five qualitative aspects to be graded include: 1. Head movement of pursuits

2. Head movement of saccades

3. Body movement of pursuits

4. Body movement of saccades

5. Accuracy of saccades (amount of over and undershooting)

Based on a five point scale (five being the highest and one the lowest), the clinician makes an assessment as to how much of the time the patient showed motor overload type behaviors.

NSUCO:Northeastern State University College of Optometry’s Oculomotor Test

VOMS: Vestibular/Ocular-Motor ScreeningFor more detailed instructions, visit www.bouldervt.com.

E. VOMS

4. VOR (VESTIBULAR-OCULAR REFLEX)

5. VISUAL MOTION sensitivity

1. PURSUITS

2. SACCADES

3. CONVERGENCE

F. SUBJECTIVE REFRACTION1. MYOPIC PROGRESSION

- OR SPASM OF ACCOMMODATION?

HYPERBARIC OXYGEN TREATMENT?

MEDICATION SIDE-EFFECT?

TRAUMATIC CATARACT?

Trial frame lenses for comfort over clarity.

Trial frame prism for fusion, comfort, balance.

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Subjective refractionPrismPartial OcclusionTints/Filters

G. EYE HEALTH1. ANTERIOR SEGMENT

- OCULAR SURFACE DRY EYE

- TRAUMATIC IRITIS

- ANGLE RECESSION

- ORBITAL BLOW-OUT

G. EYE HEALTH

2. POSTERIOR SEGMENT

- RETINAL DETACHMENT - HEMORRHAGE

- COMMOTIO RETINAE - TRAUMATIC MACULOPATHY

Observations

Ø How does the patient move, walk, sit?

Ø Any facial asymmetries, ptosis?

Ø Head tilt or turn?

Ø Chin position?

Ø Pupil response?

Ø Blink rate?

PhotophobiaResponse to illumination in my examination room (over-head fluorescent lights, window open, desk lamp)◦ 1. Request overhead lights off?◦ 2. Put on hoodie, hat and sunglasses?◦ 3. Can they tolerate just the desk lamp?

Reaction to penlight and slit lamp beam? Do the eyes maintain constriction (alpha-omega pupil?)

EGOCENTRIC LOCALIZATION (AKA: MIDLINE SHIFT) Space Projection

◦ Symptoms: ◦ Falling over or losing balance ◦ “Straight lines aren’t straight.” ◦ “It looks like things are moving.”

◦ Assessment: ◦ Check vertical and horizontal planes

◦ Balance / Posture assessment ◦ Balance Error Scoring System (BESS)

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Egocentric localization assessment Images courtesy of William Padula’s paper: Post Trauma Vision Syndrome & Visual Midline Shift Syndrome. NeuroRehabilitation 6 (1996) 165-171

Visual Thinking1. Hand/eye Coordination and

Reaction time2. Laterality3. Directionality4. Visual Figure Ground5. Visual Memory and

Sequential memory6. Orientation7. Organization

Visual Perception and Processing:1. Wach’s Parquetry

2. Visualization Test

3. Sanet Vision Integrator

4. VTS-4 Motor Field

5. Monroe III Visual Recall

Testing with Multi-step Instructions1. Tell me if the image starts to blur.2. Let me know when it separates into two pieces or drifts to the side.3. Say “one” when you see it go back into one piece.

Post-traumatic vision syndrome definition

Characteristics: q photophobiaq reduced concentrationq Inattentionq objects appear to moveq balance and coordination issuesqmotion sicknessq difficulty working under

fluorescent lightsq visual-perceptual motor

dysfunction

BEST QUESTIONS TO ASK:1. Are there any activities that you wishyou could do?2. What are your visual needs to return to school, your sport or work? 3. What are your recovery goals?

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Please refer to your colleagues for neuro-optometric rehabilitation and vision therapy

Vision Therapy is Neuro-Muscular Therapy

Vision Therapy is Sensory Integration Therapy

Resources

Please visit my website for links, articles, test instructions and references:

www.bouldervt.comNews and Events“2018 AOA TBI Panel”