1. Kara Gagnon, OD, FAAO Director of Low Vision Optometry Eastern Blind Rehabilitation Center VA Connecticut Healthcare System 950 Campbell Avenue West Haven CT 06516

2.  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:  Headaches  Photosensitivity  Double vision  Blurred Vision  Tinnitus  These symptoms were initially transient, after repeated blasts duration increased

3.  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.”

4.  August 2007 he was exposed to severe blast, rendered unconscious, for unknown period of time. Taken off duty for 10 days.  Chronic Symptoms: * Headaches  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”

5.  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

6.  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

7.  Open Head Trauma Direct Invasion through the skull (focal injury)  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

8.  Stretching and Sheering of axons *Processing Speed- axons ability to neuro- transmit across synapse Above image from: www.uihealthcare.com/topics/medicaldepartment... www.uihealthcare.com/topics/medicaldepartment...

9.  Primary Response  Occurs at the moment of injury or insult  Lacerations, contusions, fractures, diffuse axonal tearing, hematomas  Secondary Response  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)

10. Above image from: camelot.mssm.edu/~ygyu/research.htmlcamelot.mssm.edu/~ygyu/research.html Above image from: www.mhhe.com/socscience/intro/cafe/prof/image.htmwww.mhhe.com/socscience/intro/cafe/prof/image.htm

11. Above image from: psychology.wikia.com/wiki/Comparative_anatomy...psychology.wikia.com/wiki/Comparative_anatomy...

12.  Frontal lobe  Process visual information needed for motor planning  Integrating voluntary movement of skeletal muscle and voluntary eye movements  Abstract thinking, foresight and judgment  Temporal lobe  Combines sensory information associated with recognition and identification of objects  Receives auditory stimuli and produces language

13.  Parietal lobe  Involved with integrating information about “object identification” and “object localization”  Occipital lobe  Primary visual association area

14.  Right Brain  Simultaneous, Spatial –Big Picture  Visual “Forest”  Left Brain  Sequential, Temporal –Detail  Language “Trees”

15.  Internal Orbital Injury: Fractured Orbital Wall  Floor fractures cause: hypotropia; hypertropia; diplopia  Medial fractures cause: orbital emphysema- blood or air from nasal sinuses, secondary orbital cellulitis  External Injury  Extraocular muscle movement- comitancy  Hypoesthesia  Enopthalmos  Proptosis  Corneal Abrasions  Corneal lesions  Lid Injuries

16.  Post Trauma Vision Syndrome (PTVS)  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

17.  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

18.  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

19. Ocular motor dysfunction Most common Vergence (56.3%) 1 Convergence insufficiency Accommodation (41.1%) 1 Accommodative insufficiency Version (51.3%) 1 Saccadic deficiency Cranial nerve palsy (6.9%) 1 Cranial nerve III palsy Strabismus (25.6%) 1 Strabismus at near

20.  Visual field defects 38.75% 6  Most common:  Scattered defects (58.06%)  Photosensitivity  Associated with elevated dark adaptation threshold 7

21.  Vestibular and balance problems  Results from mismatch of visual information  Associated with:  Fixation disparity  Accommodative  Vergence problems  Blurred vision  Ocular motor dysfunction  Ocular disease  Most common:  Corneal abrasion, blepharitis, chalazion/hordeolum, dry eye, traumatic cataract, vitreal prolapse and optic atrophy 8

22.  Disturbances in Body Image  Disturbances in Spatial Relationships  Right-left discrimination problems  Laterality - directionality  Visual Agnosia/difficulties in object recognition  Visual Form Constancy  Visual Figure Ground  Visual Discrimination  Visual Memory Losses  Visual Sequential Memory  Visual Motor Skills  Apraxia – difficulty in manipulation of objects

23.  Detailed case history and ocular inventory  Description of incident  Any loss of consciousness  Localization of injury or Diffuse Axonal Injury (DAI)  Detailed ocular inventory including:  Missing part of visual field  Bumping into objects or walls  Asthenopia  Light sensitivity  Decreased night vision  Dry eye symptoms  Headaches  Dizziness  Reading symptoms

24.  Visual acuity  Distance and near  Utilize different charts  Snellen, ETDRS, Feinbloom, broken wheel, and Lea symbols  May need to isolate lines and/or letters  Contrast sensitivity  Pelli Robson chart

26. Contrast Sensitivity Subjectively: Illumination History Objectively: Vistek/ Pelli Robinson Charts

28.  Visual field screening  Confrontation visual fields  FDT perimetry screening  If defects noted on screening, then Humphrey or Goldmann visual field testing should be performed

29.  Cover test  Distance and near  Steady or unsteady fixation  Color vision  Stereopsis  Ocular motility  EOMs  Pursuits and saccades Above image from: www.michaelgaigg.com/.../www.michaelgaigg.com/.../ Above image from: www.good-lite.com/Details.cfm?ProdID=313www.good-lite.com/Details.cfm?ProdID=313

30.  Refraction with binocular balance  Phoria testing  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  Risley prism (in-phoropter)  Prism bar (out-of-phoropter)

31.  Accommodation  Amplitudes  Minus lens (in-phoropter)  Push up or pull away (out-of-phoropter)  Facility/Flexibility  NRA and PRA  Flippers  Monocular and binocular  Posture/Accuracy  MEM  Fused or Unfused Cross-Cylinder

33.  Versions  Saccadic Fixations  Ocular Pursuits  Near Point of Convergence  Convergence facility  near/far change  Accommodative Amplitude  binocular & monocular  Accommodative facility  near/far change

34.  Ocular health evaluation:  Pupils  Slit lamp exam  Dilated fundus exam

35.  Vestibular ocular reflex (VOR):  Dynamic visual acuity  Head thrusts  Balance testing  Romberg  Tandem walking  Auditory  Basic hearing test  Caloric testing (COWS)

36.  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 Above image from: www.virtualmedicalcentre.com/healthinvesti gat... www.virtualmedicalcentre.com/healthinvesti gat...

37.  Input of Visual Information  Ocular health problems  Optical and Refractive problems *lenses, prism, tints, coatings, selective occlusion  Neuro-optometric Vision Therapy

38.  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

39.  Deficits of saccades  Patient makes large, oblique saccades into four corners of room x 10  Increase difficulty by decreasing distance between targets  Vergence dysfunction  Increase vergence demand slowly and gradually until diplopia reported, then decrease demand until single vision reported  Accommodation dysfunction  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

40.  Vestibulo-Ocular reflex (VOR) therapy  Responsible for stabilizing visual world while head is in motion  Dynamic fusion facility:  Multiple Brock String with balance  Wayne Fixator with balance  Use prisms, lenses, and filters to change input during therapy  Patient uses thumb at arm’s length as target and slowly moves head left and right while fixating thumb  Can increase speed of head movement as therapy progresses  Tints  15% absorption blue

41.  Closed-Circuit Television (CCTV) CCTV Spectacles: Habitual Working Distance/Appropria te add Occlusion of Non- dominant Eye Preferred Tint to maximize contrast

42.  Telemicroscope  Magnifying Mirror

43.  Scanning/Awareness  Sectoral Yoked Prism  Fresnel prism  Tight fit: Noxious Stimulus  Full Yoked Prism in reading RX

44. ODOS

47.  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

48. 1. Ciuffreda KJ, Kapoor N, Rutner D, et al. Occurrence of oculomotor dysfunctions in acquired brain injury: A retrospective analysis. Optometry 2007;78:155-161. 2. Hoge CW, McGurk D, Thomas JL, et al. Mild traumatic brain injury in U.S. soldiers returning from Iraq. The New England Journal of Medicine 2008;358(5):453-463. 3. Cohen AH and Rein LD. The effect of head trauma on the visual system: The doctor of optometry as a member of the rehabilitation team. Journal of the American Optometric Association 1992;63:530-536. 4. Ciuffreda KJ, Rutner D, Kapoor N, et al. Vision therapy for oculomotor dysfunctions in acquired brain injury: A retrospective analysis. Optometry 2008;79:18-22. 5. Kapoor N and Ciuffreda KJ. Vision disturbances following traumatic brain injury. Current Treatment Options in Neurology 2002;4:271-280. 6. Suchoff IB, Kapoor N, Cuiffreda KJ, et al. The frequency of occurrence, types, and characteristics of visual field defects in acquired brain injury: A retrospective analysis. Optometry 2008; 79:259-265. 7. Du T, Cuiffreda KJ, Kapoor N. Elevated dark adaptation thresholds in traumatic brain injury. Brain injury 2005;19(13):1125-1138. 8. Rutner D, Kapoor N, Cuiffreda KJ, et al. Occurrence of ocular disease in traumatic brain injury in a selected sample: A retrospective analysis. Brain Injury 2006;20(10):1079-1086. 9. Newcombe VFJ, Williams GB, Nortje J, et al. Analysis of acute traumatic axonal injury using diffusion tensore imaging. British Journal of Neurosurgery 2007;21(4):340-348.