1. Visual Anomalies from Brain Injury and Rehabilitation Strategies
Paul Koons, M.S., C.L.V.T., C.B.I.S., O&M Specialist

2. Background/Experience
O&M Specialist / Low Vision Therapist
NYC Lighthouse International
State Blind Rehab agencies (Pa, CO, Ca, Va)
Polytrauma Blind/Vision Rehabilitation (BROS)
2 of 5 Polytrauma Veterans Affairs Hospitals
Palo Alto Veterans Affairs
Richmond (McGuire) Veterans Affairs

3. Goals of Presentation
Review Brain Injury information & modes of injury
Discuss general Brain Injury statistics
Identify types of visual deficits due to Brain Injury
Evaluating vision function & visual perceptual deficits
Training strategies for neuro-visual deficits
Resources and materials for your “toolbox”
“Macular” or “Peripheral”
If time at end of presentation, explore some of the BV devices, Assessments, Sunwear, etc.

4. Disclaimer statement
This presenter has no financial interest in any of the makes, models of rehab equipment, devices, sunwear or assessment tools

5. Audience Goal Networks for addressing brain injury and visual deficits
Differentiate between brain or eyes?

6. Acronyms TBI –Traumatic Brain Injury ABI – Acquired Brain Injury
GCS – Glascow Coma Scale
LOC – Loss of Consciousness
PTA – Post Traumatic Amnesia

7. 1st Lady Visit to our Polytrauma Rehab Unit 2012

8. Review of Brain Injury Info/Stats

9. Brain Injury:
TBI – an acquired brain injury caused by an external physical force, resulting in partial functional disability or psychosocial impairment, or both, adversely affecting educational performance.
TBI – Traumatic Brain Injury (MVA, Fall, GSW, IED blast)
ABI – Acquired Brain Injury (Stroke, Brain Tumor, Anoxia, Hypoxia, Seizures, Blood clots)

10. TBI Severity and Prognosis
Index
Mild
Moderate
Severe
GCS
13-15
9-12
<8
LOC
<30 min
<6 hours
>6 hours
Duration of PTA
0-24 hours
1-7 days
>7 days
Permanent neurologic & neuro-psychological sequela
Likely none
Likely some but are often quite functional
Likely to have severe deficits

11. Severity of Brain Injury
Mild TBI / Concussion – Loss of Consciousness less than 30 minutes (or NO loss)
- Post Traumatic Amnesia/Post Concussion Symptoms for less than 24 hours
Moderate TBI – Coma more than minutes, but LESS than 24 hours.
- Some long term problems in one or more areas
Severe TBI – Coma longer than 24 hours, often lasting days or weeks, Longer term impairments
* According to Brain Injury Assoc of America

12. Estimates of TBI Severity
Mild TBI / Concussion – up to 80% of all cases
Moderate TBI – 10-30%
Severe TBI – 5-25%
*According to Brain Injury Assoc of America

13. Traumatic Brain Injury in America
Not “just” a VA problem
Polytrauma highlighted because of high incidence of occurrence in Iraq/Afghanistan
Relevance to community services
1.4 – 1.7 million Americans sustain TBI annually
One every 21 seconds
700,000 Americans experience stroke annually
One every 45 seconds
235,000 hospitalizations
According to Brain injury Association of America

14. Annual incidence of TBI per Age group
0-4 years old (1121 per 100,000 cases)
15-19 years old (814 per 100,000 cases)
5-9 years old (659 per 100,000 cases)
75 years and older (659 per 100,000 cases)
‘Often times any brain injury during initial years not tested until later years’
*According to Brain Injury Assoc of America

15. Highest incidence of death due to TBI
75 years and older (51 per 100,000)
20-24 years old (28 per 100,000)
15-19 years old (24 per 100,000)
*According to Brain Injury Assoc of America

16. Multiple TBI Risk Factors
After 1 TBI, the risk for a 2nd is 3x greater
After 2 TBIs, the risk is 8x greater
Brain Injury Association of America

17. Polytrauma Definition
Polytrauma is currently defined as multiple injuries of which one (or a combination) is life threatening.
IEDs usually cause the most complicated cases
Co-Morbidities associated with TBI
Vision, Hearing, Physical, Cognitive, Behavioral, PTSD, Sleep, etc

18. Mechanism of Injury Motor Vehicle Accident Sports Concussions Falls
Physical Altercations
Stroke, Brain Tumor
Hypoxia/Anoxia
Gun Shot
IED Blast
Penetrating vs. Non-Penetrating wounds

19. PTRP Population (#s) (Mechanism of Injury)
EES - VAKN
4/20/2017
PTRP Population (#s) (Mechanism of Injury)
Other category includes fall, assaults, other forms of acquired BI
Bob 1

20. Injury Location for Veterans
Data Source: Richmond VAMC PTRP Tracking Log, October 2011-September 2012

22. Frontal - Problem solving, judgment, motor function, filter
LOBES
Frontal Problem solving, judgment, motor function, filter
Parietal – manage sensation, handwriting and body position in space
Temporal – memory and hearing
Occipital – Visual Processing Center
Brain’s Specialized areas working together
Cortex is outermost area of brain cells, thinking and voluntary movement
Brain Stem is between spinal cord and rest of brain, Basic functions like sleep and breathing
Basal ganglia are a cluster of structures in centre of brain. Coordinate messages throughout brain
Cerebellum is at base and back of the brain, coordination and balance

23. Brain’s Specialized areas working together Cortex is outermost area of brain cells, thinking and voluntary movement Brain Stem is between spinal cord and rest of brain, - Basic functions like sleep and breathing Basal ganglia -cluster of structures in centre of brain. -Coordinate messages throughout brain Cerebellum is at base and back of the brain, coordination and balance

24. Left vs Right Brain Functions
Left Brain Functions
Right Brain Functions
  uses logic detail oriented facts rule words and language present and past math and science can comprehend knowing acknowledges order/pattern perception knows object name reality based forms strategies practical safe
  uses feeling "big picture" oriented imagination rules symbols and images present and future philosophy & religion can "get it" (i.e. meaning) believes
music
Facial recognition spatial perception knows object function fantasy based presents possibilities risk taking

25. Visual Pathway - numbers indicate how lesion affects visual field(s) Red/Blue = image is seen Gray = blind area

26. Most commonly reported visual symptoms related to TBI
Diplopia or double vision
Inability to focus
Movement of print when reading
Difficulty with tracking and fixations
Photosensitivity (day/night/indoor glare)
Often associated with Headaches
Dry Eye
Loss of place while reading / Saccadic
Visual Fatigue
Vertigo

27. Asthenopia Eye strain with nonspecific symptoms:
pain in or around the eyes,
blurred vision,
Headache
fatigue
occasional double vision.
Symptoms often occur after reading, computer work, or when concentrating on a visually intense task, causing ciliary muscle tightening
Resolve: Giving the eyes a chance to focus on a distant object at least once an hour usually alleviates the problem.

28. Visual Inattention / Neglect
Decreased ability to attend to visual info on the side opposite to the lesion/damage
According to Wolter et al, 2006
Unilateral neglect is more commonly seen in R hemisphere strokes (82%) than in L hemisphere strokes (65%)
Left hemisphere directs attention to R side visual world
Right hemisphere directs attention to both R and L visual worlds

29. Visual Anomalies being addressed in rehab program
Photosensitivity / Photophobia
Convergence / Divergence Insufficiency
Saccadic / Pursuit Dysfunction (ocular motor)
Dry Eye
Accommodative issues (near focusing)
Tropia / Phoria / Strabismus (eye turns)
Visual Field defects
Hemianopsia, Quadransopsia, general Field Constrictions
Macular Sparing / Macular Splitting
*many of these overlap such as photosensitivity and accommodation

30. Possible Barriers to Intervention
Cognitive deficits (attention/concentration)
Medical issues requiring medical intervention
Anosagnosia – unawareness of deficit
Low endurance / Decreased level of arousal
Poor Initiation or Motivation
Anxiety (PTSD) and / or Poor sleep patterns
Sensorimotor deficits
Memory
visual, auditory, recall, sequential, facial
(Thurs a.m. Dr. Iskow, fellow Poly BROS at RIC VAMC addressing memory deficits in RT strand)

31. RIC Eye/TBI Clinic n=100 (2007-2008) Most Common Vision Disorders following TBI
Photosensitivity 34%
Convergence Insufficiency 31%
Saccadic Dysfunction %
Dry Eye %
Accommodative issues 18%
Tropia (Eye Turn) 13%
Normal binocular findings 12%
Visual Field defects 10%
*research design was conservative as these are primary dx but many of these overlap such as photosensitivity and accommodation

32. Ophthalmologic and Optometric Interventions
Prescription of appropriate corrective lenses
Use of occlusion – complete or partial
Prisms – yoked, Fresnel
Medical and surgical intervention when warranted (6 month window post injury)
Optometric/vision therapy intervention for ocular motor dysfunctions

33. Scoring charts to monitor improvement or decline in task performance
Scoring charts to monitor improvement or decline in task performance * me if you are interested in copies

34. Functional Autonomy Score (FAS)
Based on overall expected general functional levels in areas of:
self care, independent living skills, mobility, communication, psycho social adjustment, operational skills.

35. FAS scoring chart
7. Complete Independence. Patient able to resume competitive employment, or if a homemaker, resumes home management responsibilities. As a student, patient is prepared to return to school with little adaptive needs. Patient able to perform skills necessary to live alone safely.  
6. Modified Independence. Patient may need adaptations to job/school (including adjusted workload or assistive devices). May require vocational services to resume competitive employment. If a homemaker or retired, able to arrange assistance for selected intermittent tasks (eg. Shopping, transportation etc.) Patient has the ability to live alone, but may need brief occasional visits (1-2 times per week).  
5. Supervision. Patient needs daily limited supervision/assistance (2-4 hours) to perform specific functional tasks. May live alone, but needs job or school setting accommodations.  
4. Minimal Direction. Can be alone for extended periods of time (6-10 hours) when others in household are absent. Needs supervision/assistance with several tasks for function in home. Can participate in sheltered workshop. Needs a job coach. Could participate in work/school in structured environment.  
3. Moderate Direction. Can be alone 2-4 hours. Unable to work or needs special education in school. May need adapted mode of communication to access assistance.  
2. Maximal Direction. Patient requires 24 hour supervision/assist with someone present in the home at least distant supervision.  
1. Total Direction. Patient needs 24 hour direct supervision/assist. Cannot be alone or perform any activity without assistance or cues. May wander or engage in unsafe behaviors.

36. MAYO Portland Inventory Scale (MPAI) www. tbims
MAYO Portland Inventory Scale (MPAI) Income / Outcome Scoring for 30 areas measuring: Ability / Adjustment / Participation
0 No problems in this area 1 Mild problem but does not interfere with activities; may use assistive device or medication 2 Mild problem; interferes with activities % of the time 3 Moderate problem; interferes with activities % of the time 4 Severe problem; interferes with activities

37. Priority Rating Scale - Student driven
Priority: 1= not a priority; 2 = low priority; 3 = medium priority; 4 = high priority; 5 = very high priority Difficulty with task: 1= no difficulty; 2 = occasional; 3 = minimal; 4 = moderate; 5 =maximum

38. Break Rehab goals down deficits into 3 paradigms
Physical Function
Cognitive
Behavioral

39. Dr. Kerkhoff 2000 research article
Relevance of different visual abilities for four main types of activities (binocular vision, reading, mobility, visual memory) in a neuro-rehabilitative context
Dr. Kerkhoff research article

40. 3 Rehabilitation Strategies for Success

41. Intervention Strategies
Use of sensory strategies:
a. Prisms – optometric intervention
b. Vibration to the neck muscles – used to prime the system to attend and to improve postural control
c. Limb activation
d. Trunk exercises
e. Vestibular stimulation

42. Intervention Strategies
Manipulation of the environment
a. reduction of background pattern
b. use of adequate illumination
c. increase in background contrast
d. anchoring and boundary marking strategies
Recommendation on environmental modification to improve awareness of missing visual space

43. Screening and Assessment Process
Definitive
Treatment
Vision
Program
F/U
OT/PT
Intervention

44. Optometry Glossary Review
Accommodation
Version
Saccade
Pursuit
Photosensitivity
Vergence
Strabismus
Visual Fields
changizi.wordpress.com

45. Definition and training strategies for each

46. Accommodation Definition: ability to focus on different planes
Practice with your pencil/pen print

47. Optometric Visual Therapy
Dysfunction: Accommodative dysfunction
Goal: Decrease blurry vision
Technique: Exercise accommodation by alternating near and far focus, increasing the distance as able and focusing on the most problematic distance or functional task

48. Accommodation insufficiency Rehabilitation strategies

49. Hart Chart Activities (Saccades and Accommodation therapy)

50. Reading with +/- power flippers can be performed monoc / binoc / bi-ocularly

51. Optometric Visual Therapy:
Dysfunction: Deficits of pursuit (version)
Ie.: Saccades and Pursuits
Goal: move eyes conjugately and smoothly with a target
Technique: Move eyes smoothly and accurately on targets in any direction and at any distance from center based on symptomatology
Gradually increase target velocity

52. Saccades with Points of Fixation - larger and smaller

53. NEAR SACCADIC EXERCISES Pen and Paper tasks near visual search

54. Indoor Saccades

55. Developmental Eye Movement (DEM)
Developmental Eye Movement (DEM) Timed Reading Test A + B = C (time measured)

56. Saccadic work sheets

57. Reading with Right hemianopia

58. Reading with Left Hemianopia

59. Question for You ?
Does research show more reading difficulty with Left or Right visual field loss ?

60. Dr. Georg Kerkhoff,
J Neurol Neurosurg Psychiatry 2000;68: doi: /jnnp
Review
Neurovisual rehabilitation: recent developments and future directions
Georg Kerkhoff

61. Bálint's (Holmes) syndrome
Acute onset of two or more strokes the same place in each hemisphere of brain
Damage to temporal, occipital and sometimes parietal lobes
Impairs visual and language functions
Uncommon and incompletely understood
inability to perceive the visual field as a whole
difficulty in fixating the eyes (ocular apraxia)
inability to move the hand to a specific object by using vision (optic ataxia)
Reading difficulty / Poor depth perception
Severe visual spatial disorders
*Per Dr. Kerkhoff - Estimated up to 30% of Alzheimers patients show full range of these symptoms

62. Stats per Dr. Kerkhoff
About 20-30% of all those in neuro rehab centers have homonymous hemianopia visual field disorders
Of these, 70% show a visual field sparing of 5 degrees or less
Partial recovery occurs in the first 2-3 months in 10%-20% of the patients
After 3 months, visual field recovery ‘very rare’
Functional deficits due to Homonymous hemianopia
Reading issues due to field loss and saccadic eye movement
Spatially disorganized visual search patterns

63. / = “perceptual window”
Per Dr. Kerkhoff
Some 50%-90% of all patients with visual field disorders have hemianopic alexia, resulting in loss of a “perceptual window” for reading & letter identification.
In western societies this reading window extends 3–4 characters to the left of fixation and
7–11 letter spaces to the right of it.
BARKEEPERS
B/ARK/EEPERS /
/ = fixation
/ = “perceptual window”
Schematic display of the perceptual window for reading (A) in a normal subject, (B) a patient with a homonymous, left sided hemianopia (field sparing: 2°), and (C) a patient with a homonymous, right sided hemianopia (field sparing: 2°); (D) right sided, homonymous paracentral scotoma (between 2°-15° eccentricity on the right horizontal meridian). Note that the drawings are schematic and not drawn to scale.
©2000 by BMJ Publishing Group Ltd
Kerkhoff G J Neurol Neurosurg Psychiatry 2000;68:

64. Hemianopia and Reading Success
Dr. Poppelreuter, German Neurologist
Brain injured Vets WWI (1917)

65. Hemianopia and Reading Success
Dr. Poppelreuter, 1917 (early in century)
Interested in studying reading deficits in R & L hemianopic WW1 veterans
Left visual field loss handicaps return eye movement to find beginning of a new line
Right visual field loss handicaps eye movement to next word/letter in sentence
Right hemianopia more challenging since we read left to right (trained to overshoot each word to successfully read)

66. Visual Field Loss

67. Visual Pathway Review - numbers indicate how lesion affects visual field(s) Red/Blue = image is seen Gray = blind area

68. Visual Field Loss assessment & training strategies
Accurately Assess Visual Fields Monocularly
Confrontation, Finger counting
ARC Perimeter / Hand held disc perimeter
Goldmann, Humphries, Octopus (eye clinic)
Educate Patient and Family!
Show best use of remaining field placement
Establish full perimeter scan (overshoot) or staircase visual search methods
Increase complexity of environments, reducing cues

69. Visual Field Search training
Goals: Increase awareness, establish compensatory scanning pattern into the deficit field which become automatic and accurate
Technique: Start with a small number of targets in the affected field and increase the number as proficiency improves
Continual verbal reinforcement to scan into the affected field is required
Field enhancing prisms may be used (OD)

70. White Board Scanning Training (A to Z drill)

71. Scanning Training with Hemianopia
Dr. Josef Zihl, 1988
Trained 30 hemianopes (w/out inattention/neglect)
Practice large saccades into blind field
Visual search field increased degrees
4 – 8 sessions
Kerkoff et al, 1992
Validated similar results in 92 hemianopic patients & 30 with additional inattention/neglect
Following 6 weeks of scanning training (30 sessions)
Hemianope group: Mean search field increased from 15 degrees to 35 degrees
Additional Inattention/Neglect group; required 25% more training over 2-3 months to achieve similar result

72. Brahm et al, 2009 & Dougherty et al., 2010
Visual field loss testing is recommended for patients with a history of TBI
Also discuss possible State DMV requirements for visual field documentation for TBI/ABI/Stroke, etc.

73. Types of visual search strategies with Hemianopia

74. Staircase Strategy (general compensation strategy without training)

75. Overshoot strategy: place remaining visual into blind field further than target expected (Right visual field loss) X

76. Field Cut and Inattention/ Neglect
neuropolitics.org/hemineglect.gif

77. VISUAL INATTENTION / Neglect: Figure Copying – What pieces of info is missed? Describe room in balanced format?

78. ‘Search for Sputnik’ circle one item and instruct student to circle all others, give difft color pens

79. Visual Search & Scanning with Visual Field Loss
Chedru et al., 1973
Ishiai, et al., 1987
Meienburg, et al., 1981
Gassel et al., 1963
Recorded eye movements & visual search in TBI patients with hemianopia
Patients paradoxically concentrated on the blind side (compensation strategy)
Patients with additional neglect/inattention lacked this compensation strategy

80. Photosensitivity day / night / indoor / screen
Definition: Intolerance of light
History: Patients complain they can’t transition quickly
I.e..: glare on floor, lights while driving, tearing, frequent blinking, squinting, headaches, irritability with visual activities
Types: photophobia vs. photosensitivity
Photosensitivity exists in the absence of true pain, distinct from the photophobia seen in patients with inflammatory ocular disease

81. Skylight glare

82. Night Driving Glare (simulate in dark office w/ flashlights)

83. Glare at night – trial 54% yellow tint and 40% Plum tint to reduce “halo”