Strategies for Examination and Management of
Acquired Brain Injury Patients
Suzanne Wickum, OD, FAAO
University of Houston College of Optometry
e-mail:
Kia B. Eldred, OD, FAAO
Diplomate in Low Vision
Michael E. DeBakey VA Medical Center
University of Houston College of Optometry
e-mail:
Course Description: A case-based approach is used to discuss the evaluation and management of patients with acquired brain injury. Demographics, types of brain injuries, visual/ocular sequelae, diagnostic testing, and management of this patient population will be reviewed. Particular attention will be given to the optometrist’s role in the rehabilitation team.
Course Objectives:
· To understand the patient populations most likely to be affected by brain injury.
· To understand the categories and severity ranking of brain injury.
· To understand the potential physical and cognitive deficits associated with brain injury.
· To understand the specific optometric examination techniques for evaluation of brain injury patients.
· To understand the specific ocular/visual complications associated with brain injury and how to appropriately manage these complications.
Outline:
Introduction - TIRR
? The Institute for Rehabilitation and Research – In-patient & Out-patient Programs
? Ranked within the top 5 rehabilitation hospitals in the US for 19 years
? Affiliation with University of Houston College of Optometry for 18 years
Project Victory
? ~30,680 US soldiers wounded in Iraq & Afghanistan
– TBI is the “signature wound”
– 20% of injuries are serious ABI or SCI
– 1800 troops suffering from penetrating TBI
– 3000 soldiers being treated for severe TBI
– 30% of troops engaged in combat > 4 months are at risk for disabling neurologic disorders from blast waves of IEDs
– 60% of injuries are due to roadside bombs & IEDs (improvised explosive devices)
– 30% of soldiers develop mental health problems (PTSD) within 3-4 months of returning to the US
Categories of Brain Injuries
? Traumatic Brain injury
? Non- traumatic brain injury
? Now defined as “Acquired” (ABI) –> Includes stroke
Traumatic Brain Injury
? Closed head injury
? Open head injury
? Penetrating head injury
Non- traumatic Brain Injury
? Anoxic Brain Injury
? Toxic-metabolic Brain Injury
Damage to General Areas of the Brain
? Occipital
? Parietal
? Frontal
? Temporal
? Brainstem
? Cerebellum
Physical Deficits with ABI
? Musculoskeletal Complications
? Heterotropic Ossification
? Spasticity
? Respiratory Complications
? GI Complications
? Swallowing Disorders
? Bowel Incontinence
? Genitourinary Problems
? Dermatological Complications
? Endocrine Complications
? Autonomic Disturbances
? Thombophlebitis
Most common causes of TBI
Epidemiology
? TBI
– 1.4 million/year in US
– 50,000 die each year
– 235,000 hospitalized
– 1.1 million treated and released from the ER
– 5.3 million (2% of US population) need long-term help with ADL
– In 2000, $60 billion dollars in direct & indirect costs
? Stroke (CVA)
– 700,000/year in US
? 500,000 first time CVA
? 200,000 prior CVA
– 160,000 die each year
– In 2005, $57 billion dollars in direct & indirect costs
– The leading cause of serious long-term disability in US
– 3rd leading cause of death in US
Pediatric Brain Injury
? 25% of brain injuries in children younger than 2 years are from physical abuse.
? Other causes of ABI – MVA, falls, leisure or sports related injuries, and violent crimes.
? Factors associated with increased risk include: male, nonwhite, low socioeconomic status, family instability, peak periods for outdoor recreation, living in a congested area.
Rehabilitation after ABI in Preschoolers
? Outcomes after ABI are difficult to predict in children at any age.
? Studies have shown – contrary to the traditional plasticity hypothesis youth is not necessarily an advantage in outcome after ABI.
? Young children are found to be very vulnerable to the effects of ABI.
? Prefrontal injury is strong indicator of negative outcome in young children.
? Consequences of ABI in young children often worsen over the years as child grows into the injury.
? Children can be overprotected, learn “helplessness,” and absence of peers.
A Team Approach
? The rehabilitation team may include:
– Physiatrists (Rehabilitation Physicians)
– Other physician specialists when needed
– Neuro-psychiatrists/psychologists
– Neuro-optometrists
– Pharmacists
– Nursing staff
– Physical & Occupational therapists
– Respiratory therapists
– Speech/language therapists
– Cognitive therapists
– Recreational/Music therapists
– Social workers
– The patient’s family members
The Role of Neuro-Optometry
? It is estimated that 90% of what we perceive is through the visual system.
? Vision problems may interfere with mobility, reading, writing, dressing, eating, locating objects, grooming, social interaction, etc.
? Vision problems may go undiagnosed if we rely on the patient to express complaints.
? Goals of the functional visual evaluation:
– Diagnose and treat patients with ocular and visual deficits.
– Counsel the patient and family as to the visual sequelae resulting from the brain injury.
– Counsel the patient, family, physicians, and therapists as to how to compensate for the patient’s visual deficits.
Common Signs & Symptoms
? Signs:
– Eye turn (strabismus)
– Closing one eye
– Head tilt or turn
– Bumping into objects
– Abnormal posture
– Balance problems
– Poor depth perception
– Nystagmus
? Symptoms:
– Double vision (diplopia)
– Blurred vision
– Inability to sustain attention on visual tasks
– Dizziness
– Headaches
– Eye strain
– Difficulty reading
Patient Case
Diplopia after TBI
Glasgow Coma Scale (GCS)
? TBI Severity Based on GCS:
– Mild TBI = GCS 13-15
– Moderate TBI = 9-12
– Severe TBI = 3-8 (patient’s score = 4)
Communication Disorders
? Aphasia: inability to express oneself &/or understand language.
? Dysarthria: difficulty in forming words because of muscle weakness. Slurred speech.
? Confabulation: “filling in” gaps in memory with fictitious events, people, or places.
? Perseveration: inappropriate persistence of a response.
Management of Acquired Diplopia
? Occlusion
? Prism
? Compensatory strategies
Vision Therapy:
? Monocular pursuits, especially into affected FOG, may help restore muscle function and prevent muscle contracture.
? In some cases where pts have fusion in at least some FOG, VT can be aimed at expanding motor fusion ranges from that area.
? Typically not started until the acute, underlying etiology has been treated/managed.
Botulinum Toxin Chemodenervation:
? Injected into the agonist muscle using an EMG needle to monitor muscle activity.
? Used in some cases of CN VI palsy.
? Initial effects within 1-7 days.
? Max effect in 1-2 weeks.
? Resolves over 4mos (+/- 2mos).
Surgery:
? Considered after 6-12 months.
? Only performed once the Dr. is convinced that the angle of deviation is stable.
? Botox can be utilized in cases of CN VI palsy prior to surgery.
Patient Case
? 14 year old male
? TBI secondary to ATV accident w/o helmet
? Cranial nerve III, IV, VI, VII palsies OD
? Cranial nerve III palsy
– Exotropia, hypotropia, ptosis, fixed-dilated pupil, loss of accommodation.
– Occlusion, prism, near add, surgery (lid, strabismus)
? Cranial nerve IV palsy
– Hypertropia, excyclotorsion
– If torsion is >10 degrees, suspect bilateral CN IV
– Occlusion, prism, compensatory strategies (head tilt, elevating near objects, tilt boards), surgery
? Cranial nerve VI palsy
– Esotropia
– Occlusion, prism, compensatory face turn, Botox, surgery
? Cranial nerve VII palsy
– Lagophthalmos
– Exposure keratoconjunctivitis
– Vigorous ocular lubrication
– Eyelid taping
– Eyelid weights
– Tarsorrhaphy
Patient Case
? 54 year old CF s/p aneurysm rupture
? Bilateral cranial nerve IV palsy
? Video footage
Accommodative Disorders
? Lag of accommodation
– Use of reading Rx or BF
– May improve over time and with decrease in meds
? Accommodative spasm / Traumatic myopia
– Difficult to manage
– May resolve with time
– May need BFs, vision therapy, cycloplegics
? Accommodative infacility
– Vision therapy
Patient Case:
Homonymous Hemianopsia
§ Fresnel Sector Prism
§ Scan Course
o Place 20 numbers/letters on the wall – 10 on each side
o Place at varying heights
o Have patient walk the course and read number/letters aloud
§ Subtest of The Brain Injury Visual Assessment Battery For Adults (biVABA)
§ Narrated Walk – I See …
o Identify Moveable Obstacles
o Identify # of People in each Aisle
o Read Aisle Signs
o Visual Scanning - Shelves
Visual Field Defect versus Visual Inattention/Neglect
? Hemi-inattention/neglect is often confused with visual field deficits - distinctly different conditions.
? When a visual field deficit is present, the patient attempts to compensate for vision loss by engaging visual attention.
? When a hemi-inattention is present, the patient has lost the attentional mechanism that drives visual search for information on the left side and does not attempt to compensate.
? Combination of hemi-inattention and VFD creates severe visual inattention, sometimes called visual neglect
Impact on Rehabilitation
? Unilateral neglect has consistently been identified as a negative predictor for a patient’s recovery of independence in daily living.
Patient Case
Hemianopsia plus neglect