1. Vision Rehabilitation Techniques for TBI
Carl Garbus, O.D., FAAO Neuro Vision Rehabilitation Institute Valencia, CA

2. Learning Objectives
Describe the incidence and prevalence of brain injury
Distinguish between acquired brain injury and traumatic brain injury
Identify basic brain structures and functions
Describe 2 main visual processes in the brain
Describe visual consequences of brain injury
Discuss assessments and interventions

3. Goals for the Presentation
Create awareness of what to look for in patients who have had traumatic brain injury
Stress the importance of having a neuro vision evaluation for patients with traumatic brain injury and stroke
Know that neuro vision rehabilitation exists for patients with these conditions

4. Definitions Traumatic brain injury (TBI)
An insult to the brain, not of a degenerative or congenital nature but caused by an external physical force,
That may produce a diminished or altered state of consciousness.

5. Causes of TBI: Motor vehicle accidents - whiplash Falls Gunshot wounds
Work place injuries
Shaken baby syndrome
Child abuse
Sports injuries
Military actions

6. Different ways brain can be damaged

7. Neck Trauma
Whiplash:
A simple whiplash can cause shearing of nerve fibers in the brain stem
This can occur from being rear ended by a car driving moving at 15 miles an hour
Disruption of fibers in the brainstem affects oculomotor and binocular functions.

8. Basic brain structures and functions
Lobes

9. " The eyes see only what the mind is ready to comprehend"
Henri Bergson

10. Brain and vision: the connection
Every lobe of the brain is involved in processing
visual information.
To date, researchers have identified over 300 intracortical pathways linking 32 different cortical areas involved in vision function.
More than half of our gray matter and multiple subcortical areas are involved in processing vision.
There is more area of the brain dedicated to vision than to all the other senses combined.

11. The Visual Brain

12. Vision is a Bimodal System
There are 2 main pathways that carry visual information from the eye to the brain.
Focal - the "what" system
Ambient - the "where system"
Designed to simultaneously process different types of visual information
Neither works in isolation of the other; both reinforce one another

13. Focal and Ambient Systems
Need to work in harmony
They are not isolated systems
A disconnect in the ambient
system will cause problems
with spatial orientation
Symptoms include: balance problems, bumping into things, difficulty navigating

14. Five Pillars of Function
Visual
Physical / Vestibular
Somatosensory
Cognition
Psychosocial

15. Why is vision rehabilitation so important following brain injury?
Vision is our dominant sense; we are visual beings.
Vision is pervasive throughout our brain.
Vision is represented all over our body.
Vision influences and influenced by anything and everything - the way we think, say, or do.
Visual problems are among the most common consequences of TBI and or CVA but frequently not dealt within rehab model.

16. Visual Consequences of TBI: Post Trauma Vision Syndrome (PTVS)
A constellation of symptoms that evolves as secondary injury in TBI.
This syndrome is caused by a dysfunction of the ambient visual system and has the characteristics listed below:
Binocular coordination dysfunctions - double vision
Inability to perceive spatial relationships between objects
Difficulty fixating on object and following when it moves
Abnormal posture
Dizziness and balance problems
Poor visual memory

17. Visual consequences of TBI: Post Trauma Vision Syndrome (PTVS)
Poor concentration and visual attention
Difficulty with visually guided movements (bumping/tripping, knocking things over)
Light sensitivity / photophobia
Visual midline shift syndrome
Visual spatial difficulties

18. Sense of balance
Bump into things
Difficulty with eating
Slow reading

19. What are the functional implications? Binocular Dysfunction

20. Difficulty judging distance or depth
Tendency to knock things over
Bump or trip over obstacles
Difficulty playing sports

21. What are the functional implications? Visual information processing

22. Avoidance of crowded or busy places
Short memory
Forget familiar route
Slow to process

23. Visual Midline Shift Mismatch between the perceived egocentric
visual midline and the actual physical midline
Causes an expansion on one side
Causes a contraction on the opposite side

24. Visual Midline Shift Syndrome
Signs and Symptoms
Floor may appear tilted
Walls and/or floor may appear to shift and move
Veering during mobility
Person leans away from the affected side
Feelings of imbalance or disorientation similar to vertigo

25. Cranial Nerve VIII – Auditory and Vestibular Nerve
Nerve that transmits information for hearing and balance

26. Vestibular Function
The visual system links up very closely with the vestibular system in the brainstem and midbrain
Vestibular –Ocular Reflex (VOR) is activated when there is a head movement, body movements or if the individual leans to one side

27. Vestibulo-Ocular Reflex
Maintenance of fixation of the eyes with head movements
It is activated with horizontal and vertical head movements
This intricate system links the vestibular system to the oculomotor system

28. Interventions Patient education Explain brain and vision relationship
Review individual's specific diagnosed eye condition in plain language
Why and how vision may be interfering or limiting daily functions.
Always include family members whenever possible

29. Interventions Strategies
Relieve visual discomfort from eye strain and fatigue often leading to headaches.
Take care of those dry eyes!
Reduce glare and light sensitivity - very important!
Take frequent breaks from visually demanding tasks - 20/20/20 rule

30. Interventions Limit use of computer and mobile devices
Recognize and avoid non visually- friendly reading materials
Use color filter overlays to reduce strobbing effect of black on white paper
Utilize adaptive tools to assist with visual stamina (magnifiers, Kindle, long cane)
Glasses need to be up to date
Lens is designed for the task

31. Interventions Therapy
Safety first! O&M training to improve viewing posture, balance, and stability, spatial awareness and relationships for interaction with environment with better accuracy. Long white cane training if field loss.

32. Strategies for Double Vision Techniques
Consult with an optometrist or ophthalmologist who has experience with brain injury
Provide a translucent patch (not dark opaque patch)
Spot patch
Sector patch
Binasals
Active therapy prescribed by the eye care practitioner can improve binocular function- Eye Stretches, Tactile Control, Spatial Localization, Brock String

33. Interventions
Prisms: bends light towards the base, which causes the image to move in the opposite direction---- has implications to change spatial orientation and eye alignment
Lenses: optical correction of refractive conditions helps to locate objects in space and helps with visual comfort
Filters: blocks specific light frequencies that cause visual discomfort which can improve visual performance

34. Strategies for Light Sensitivity
Turn off or avoid fluorescent lighting
Increase exposure to natural lighting
Wear prescription sunglasses with Polaroid lenses
Consider side shields
Wrap around frames

35. Strategies for Light Sensitivity
Blue-tec lens filter (indoor)
Green-blue filter for use in areas where fluorescent lighting is unavoidable
Binasal occlusion
Light therapy program

36. Strategies for Disorientation and Dizziness
Grounding techniques
Thumb and forefinger stimulation
Proprioceptive input
Breathing technique

37. Strategies for Improving Mobility
Special prescription glasses specially designed to enhance mobility
Consult with an optometrist/ophthalmologist who has experience with brain injury and vision rehabilitation
Yoked prism lenses maybe useful in therapy or as a full time prescription
Binasals can provide grounding and reduce visual confusion
Referral source is NORA

38. Yoked Prism Glasses
Special prism lenses prescribed by a rehabilitation eye doctor
Prisms bend light in a specific direction towards the base of the prism
Prisms can alter the patients visual spatial orientation and posture
Navigation can be improved over uneven or challenging surfaces

39. Yoked Prism Glasses Demonstration
The Effect of Prisms for Mobility and Navigation

40. Strategies for Improving Mobility
During mobility training observe posture, arm swing, body alignment, balance, head position and turns
Observe visual balance
When balance is a problem use the technique of eyes leading the way before making turns
Obstacle Course procedures

41. Obstacle Course Demonstration
Place 3 chairs approximately 3 feet apart
The patient is shown how to navigate around the chairs
Changing visual conditions for navigation
Adding visual stimulus to the sides
Adding auditory stimulus
Demonstration

42. Strategies for Visual Field Loss
Identify where the losses are located with visual field
Does it affect ambulation?
Does it affect reading?
Trial Peli Prisms for hemianopsia
Trial yoked prisms
Improve scanning skills
Need single vision Rx glasses (distance and near)
Progressives limit peripheral visual field function

43. Strategies to Enhance Visual and Vestibular Integration Specific Procedures
Head Rotations With Central Fixation
Chair Rotations
Body Rotations
Four Corner HART Charts
Side To Side HART Chart Rotations
GOALS: better coordination of these systems can be accomplished by using vision to support vestibular

44. Summary
Consult with an vision rehabilitation doctor to collaborate about functional treatments
Consider visual conditions that can be treated such as light sensitivity, visual balance, visual midline shift and post trauma vision syndrome
Brainstem damage will have visual and vestibular consequences
Double vision is common problem that needs to be dealt with early

45. Summary
Good referral source is the Neuro Optometric Rehabilitation Association
Avoid crowded environments
Inquire about yoked prisms and binasal occlusion
Use the grounding techniques described in this course
Don’t give up there are many solutions to improve the quality of life after a traumatic brain injury

46. Neuro Optometric Rehabilitation Conference
24th Annual Multi-disciplinary Conference
Renaissance Hotel
May 14-17, 2015
Denver, CO
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