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

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

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.

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

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

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

1st Lady Visit to our Polytrauma Rehab Unit 2012

Review of Brain Injury Info/Stats

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)

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

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 20-30 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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)

RIC Eye/TBI Clinic n=100 (2007-2008) Most Common Vision Disorders following TBI Photosensitivity 34% Convergence Insufficiency 31% Saccadic Dysfunction 24% Dry Eye 23% 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

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

Scoring charts to monitor improvement or decline in task performance Scoring charts to monitor improvement or decline in task performance * email me if you are interested in copies paul.koons@va.gov

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.

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.

MAYO Portland Inventory Scale (MPAI) www. tbims MAYO Portland Inventory Scale (MPAI) www.tbims.org/combi/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 5 - 24% of the time 3 Moderate problem; interferes with activities 25 - 75% of the time 4 Severe problem; interferes with activities

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

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

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 2000 research article

3 Rehabilitation Strategies for Success

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

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

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

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

Definition and training strategies for each

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

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

Accommodation insufficiency Rehabilitation strategies

Hart Chart Activities (Saccades and Accommodation therapy)

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

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

Saccades with Points of Fixation - larger and smaller

NEAR SACCADIC EXERCISES Pen and Paper tasks near visual search

Indoor Saccades

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

Saccadic work sheets

Reading with Right hemianopia

Reading with Left Hemianopia

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

Dr. Georg Kerkhoff, J Neurol Neurosurg Psychiatry 2000;68:691-706 doi:10.1136/jnnp.68.6.691 Review Neurovisual rehabilitation: recent developments and future directions Georg Kerkhoff

Bálint's (Holmes) syndrome Acute onset of two or more strokes at @ 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

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

/ = “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;68:691-706

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

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)

Visual Field Loss

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

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

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)

White Board Scanning Training (A to Z drill)

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 10-30 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

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.

Types of visual search strategies with Hemianopia

Staircase Strategy (general compensation strategy without training)

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

Field Cut and Inattention/ Neglect neuropolitics.org/hemineglect.gif www.yvonnefoong.com/.../homonymoushemianopia.jpg

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

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

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

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

Skylight glare

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

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