Transcript Adult CVI/Acquired Brain Injury

Kara Gagnon, OD, FAAO
Director of Low Vision Optometry
Eastern Blind Rehabilitation Center
VA Connecticut Healthcare System
950 Campbell Avenue
West Haven CT 06516
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51 year old male
Registered Nurse/Army Medic
14 months spent in Iraq
Team diffused mines and explosives
Endured 18 IED Explosions
Twice Unconscious
Symptoms after Exposure to initial blasts:
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Headaches
Photosensitivity
Double vision
Blurred Vision
Tinnitus
These symptoms were initially transient, after repeated blasts
duration increased
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March 2007 severe blast exposure, soldier unconscious
for less than 30 minutes. Taken off duty for 2-3 days.
Symptoms:
* Headaches
 Photosensitivity
 Double vision
 Blurred Vision
 Memory Problems
 Sleep Disturbances
 Tinnitus
 All blasts exposed to after this head injury causing
unconsciousness, “recovery time from these symptoms was
significantly prolonged.”
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August 2007 he was exposed to severe blast, rendered unconscious,
for unknown period of time. Taken off duty for 10 days.
Chronic Symptoms:
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Headaches
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Extreme Photosensitivity – had to wear dark sunglasses indoors
Poor light and dark adaptation
Double vision
Blurred Vision
“Problems with reading”- would have “ burning sensation of his eyes” and “fatigue” after “10
minutes or so”, “feeling that the right eye was not processing information”
Bumping into things on his right side, “Things kept popping –up on my right side.”
Significant balance issues
Dizziness
Tinnitus
Impaired hearing in both ears, “right ear can only hear noises can not process words’
Difficulties with “organization of speech”
Problems with fine motor skills on left side
Memory Problems
Sleep Disturbances
“I tried, but I could not come back”, “I was in denial”, “I was waiting for things to get better”
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Her Husband was “ an avid reader” upon return,
“would not read at all”
Extremely light sensitive
Easily loses balance, “used to take long walks with
dogs, now takes very short walks”
Falling down stairs, bumping into things
Poor memory
Losing his temper
Sleep disturbances
His driving was unsafe, did not see things on his
right side
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Extremely Light Sensitive
Fixated above my head when conversing with me,
occasionally would fixate my eyes in primary gaze
Demonstrated Poor balance
Intermittently trailing the right side of the wall.
Turned head to right to listen to me
Searching for words, difficulty with speech
Had significant difficulty relaying history…unless I asked
very specific directed questions.
Fatigued after a very short period
Became nauseous easily during ocular motility testing
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Open Head Trauma
Direct Invasion through the skull (focal injury)
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Closed Head Trauma- most common
Blow to the head that does not cause a direct pathway
(global or diffuse injury)
* Accelerated- moving object hits the head or head hits
a stationary object causing a focal wound or trauma
* Decelerated- body is restrained, causing soft tissues
of the brain to move within the skull
* Percussion- Shock wave from IED causing diffuse axonal
injury similar to the decelerated injury
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Stretching and Sheering of axons
*Processing Speed- axons ability to neurotransmit across synapse
Above image from:
www.uihealthcare.com/topics/medicaldepartment...
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Primary Response
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Occurs at the moment of injury or insult
Lacerations, contusions, fractures, diffuse axonal tearing,
hematomas
Secondary Response
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Occurs hours to weeks post injury
Auto-regulatory physiological mechanisms disrupted
Neurotoxins are released
Cascade of biochemical reactions
Further brain damage
Post Concussion Syndrome
Post Trauma Vision Syndrome (PTVS)
Above image from: camelot.mssm.edu/~ygyu/research.html
Above image from: www.mhhe.com/socscience/intro/cafe/prof/image.htm
Above image from: psychology.wikia.com/wiki/Comparative_anatomy...
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Frontal lobe
Process visual information needed for motor
planning
 Integrating voluntary movement of skeletal muscle
and voluntary eye movements
 Abstract thinking, foresight and judgment
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Temporal lobe
Combines sensory information associated with
recognition and identification of objects
 Receives auditory stimuli and produces language
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Parietal lobe
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Involved with integrating information about
“object identification” and “object localization”
Occipital lobe
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Primary visual association area
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Right Brain
Simultaneous, Spatial –Big Picture
 Visual
“Forest”
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Left Brain
Sequential, Temporal –Detail
 Language
“Trees”
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Internal Orbital Injury: Fractured Orbital Wall
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Floor fractures cause: hypotropia; hypertropia; diplopia
Medial fractures cause: orbital emphysema- blood or air from nasal
sinuses, secondary orbital cellulitis
External Injury
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Extraocular muscle movement- comitancy
Hypoesthesia
Enopthalmos
Proptosis
Corneal Abrasions
Corneal lesions
Lid Injuries
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Post Trauma Vision Syndrome (PTVS)
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Oculomotor Imbalance: Strabismus
Oculomotor Dysfunction: Ocular Fixation and Ocular
Motor Difficulties, pursuits and saccades
Accommodative Abnormalities: amplitude and facility
Convergence Insufficiency
Visual Field Loss and Inattention
Vestibular and Disequilibrium- inability to match visual
information with kinesthetic proprioceptive and
vestibular experiences
Lagopthalmous
Pupillary Defects : Anisocoria
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Double vision
Problems with depth perception
Blurred near vision
Perceived movement of print
Asthenopia
Loss of place when reading
Reduced reading speed
Inability to read despite the ability to write
Avoidance of near tasks
Headaches
Photosensitivity
Dry Eye Symptoms -decreased blink rate
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Visual Memory Deficits
Visual perceptual processing deficits: inability to perceive spatial
relationships between and among objects
Difficulty locating/fixating on an object and pursuing the object
visually as it moves
Objects appear to move when they are not actually moving
Bumping into objects/exhibits abnormal posture
Poor concentration and attention
Inability to perceive the entire picture or to integrate it’s parts
Inability to distinguish colors
Inability to visually guide their arms, legs, hands and feet
Inability to recognize objects with their vision alone
Ocular motor
dysfunction
Most common
Vergence (56.3%)1
Convergence insufficiency
Accommodation
(41.1%)1
Version (51.3%)1
Accommodative insufficiency
Cranial nerve palsy
(6.9%)1
Cranial nerve III palsy
Strabismus (25.6%)1
Strabismus at near
Saccadic deficiency
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Visual field defects 38.75%6
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Most common:
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Scattered defects (58.06%)
Photosensitivity
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Associated with elevated dark adaptation
threshold7
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Vestibular and balance problems
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Results from mismatch of visual information
Associated with:
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Fixation disparity
Accommodative
Vergence problems
Blurred vision
Ocular motor dysfunction
Ocular disease
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Most common:
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Corneal abrasion, blepharitis, chalazion/hordeolum, dry eye,
traumatic cataract, vitreal prolapse and optic atrophy8
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Disturbances in Body Image
Disturbances in Spatial Relationships
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Visual Agnosia/difficulties in object recognition
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Right-left discrimination problems
Laterality - directionality
Visual Form Constancy
Visual Figure Ground
Visual Discrimination
Visual Memory Losses
Visual Sequential Memory
Visual Motor Skills
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Apraxia – difficulty in manipulation of objects
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Detailed case history and ocular inventory
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Description of incident
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Any loss of consciousness
Localization of injury or Diffuse Axonal Injury (DAI)
Detailed ocular inventory including:
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Missing part of visual field
Bumping into objects or walls
Asthenopia
Light sensitivity
Decreased night vision
Dry eye symptoms
Headaches
Dizziness
Reading symptoms
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Visual acuity
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Distance and near
Utilize different charts
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Snellen, ETDRS,
Feinbloom, broken
wheel, and Lea symbols
May need to isolate
lines and/or letters
Contrast sensitivity
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Pelli Robson chart
Contrast Sensitivity
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Subjectively:
Illumination
History
Objectively:
Vistek/ Pelli
Robinson
Charts
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Visual field screening
Confrontation visual fields
 FDT perimetry screening
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If defects noted on screening, then Humphrey or
Goldmann visual field testing should be performed
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Cover test
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Distance and near
Steady or unsteady fixation
Color vision
Above image from: www.michaelgaigg.com/.../
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Stereopsis
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Ocular motility
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EOMs
Pursuits and saccades
Above image from: www.good-lite.com/Details.cfm?ProdID=313
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Refraction with binocular balance
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Phoria testing
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Von Graefe (in-phoropter)
Modified Thorington (out-of-phoropter)
Maddox Rod in 9 diagnostic action fields
Park’s 3 step (if vertical deviation in primary gaze)
Vergence testing
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Risley prism (in-phoropter)
Prism bar (out-of-phoropter)
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Accommodation
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Amplitudes
Minus lens (in-phoropter)
 Push up or pull away (out-of-phoropter)
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Facility/Flexibility
NRA and PRA
 Flippers
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Monocular and binocular
Posture/Accuracy
MEM
 Fused or Unfused Cross-Cylinder
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Versions
Saccadic Fixations
Ocular Pursuits
Near Point of
Convergence
Convergence facility
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near/far change
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Accommodative
Amplitude
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binocular & monocular
Accommodative
facility
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near/far change
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Ocular health evaluation:
Pupils
 Slit lamp exam
 Dilated fundus exam
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Vestibular ocular reflex (VOR):
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Balance testing
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Dynamic visual acuity
Head thrusts
Romberg
Tandem walking
Auditory
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Basic hearing test
Caloric testing (COWS)
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Visually evoked potential
(VEP)
An objective test used to assess
the function of the visual system
beyond the retina
 Measures the response of the
visual cortex to continuous
stimulation and the conduction
of signal from the optic nerve to
the occipital cortex
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Above image from:
www.virtualmedicalcentre.com/healthinvesti
gat...
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Input of Visual Information
Ocular health problems
 Optical and Refractive problems
*lenses, prism, tints, coatings,
selective occlusion
 Neuro-optometric Vision Therapy
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Prescription of appropriate lenses for
distance and near
Anti-reflective coatings, tints to reduce glare
and photosensitivity
Correcting Prism
Convergence Insufficiency
 Vertical Deviations
 Fixation Disparities
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Deficits of saccades
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Vergence dysfunction
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Patient makes large, oblique saccades into four corners of room x 10
Increase difficulty by decreasing distance between targets
Increase vergence demand slowly and gradually until diplopia reported,
then decrease demand until single vision reported
Accommodation dysfunction
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Target is brought from arm’s length slowly and smoothly toward the patient
until it blurs, then the target is slowly and smoothly moved back to arm’s
length x 10
Patient looks at target 10ft away for 3 seconds, then looks at target 16in
away for 3 seconds x 10
Patient views target thru (-) lens for 10 seconds, then (+) lens for 10
seconds x 10
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Vestibulo-Ocular reflex (VOR) therapy
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Responsible for stabilizing visual world while head is in
motion
Dynamic fusion facility:
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Multiple Brock String with balance
Wayne Fixator with balance
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Patient uses thumb at arm’s length as target and slowly moves
head left and right while fixating thumb
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Use prisms, lenses, and filters to change input during therapy
Can increase speed of head movement as therapy progresses
Tints
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15% absorption blue
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Closed-Circuit
Television (CCTV)
CCTV Spectacles:
Habitual Working
Distance/Appropria
te add
Occlusion of Nondominant Eye
Preferred Tint to
maximize contrast
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Telemicroscope
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Magnifying Mirror
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Scanning/Awareness
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Sectoral Yoked Prism
Fresnel prism
 Tight fit: Noxious Stimulus
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Full Yoked Prism in reading RX
OD
OS
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Eye signs may be subtle
Eye signs may be intermittent
Symptoms may be masked
Symptoms may be interpreted differently
based on discipline
Patients may not attribute complaints to an
eye problem
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