Vision and ABI:

A Rehabilitation ApproachTanya Polonenko, OD, FAAO, FCOVD

Lisa Griffiths, ABI patient & ABI MomNovember 7, 2019

I see, I see

Tanya Polonenko, practitioner

I see, I see

Lisa Griffiths,

living with ABI

It’s not what you look at that matters,

It’s what you see ~ Henry David Thoreau

Lecture Outline

▪ What is Vision?

▪ Vision and ABI

▪ Symptoms of inefficient vision

▪ Vision Rehabilitation

▪ Neuroplasticity

▪ Goals and Improvements

▪ Sample Exercises

▪ Does it work?

A: Vision is the ability to make a

meaningful interpretation of what is

seen.

Q: What is vision?

We need to gather and interpret visual information.

Vision requires more than having 20/20

eyesight.

There is so much more to vision than meets the eye.

How are you supposed to read this easily if it is

moving around or going blurry?

There is so much more to vision than meets the eye.

How are you supposed to read this easily if it is

moving around or going blurry?

How does ABI affect vision?

70% of our

brain is involved

with vision

- John Streff, O.D.

“When vision is working well, it guides and

leads in all that we do; when not, it interferes.”

Visual functional skills:“how info gets into the brain”

These skills determine the speed, accuracy, endurance and

comfort of gathering visual information:

Eye Focusing (Accommodation)

Eye Teaming (Binocularity)

Eye Tracking (Ocular Motility)

Visual-Vestibular Interaction

Visual FieldAiming/Aligning

(Fixation)

Visual perceptual skills:“what the brain does with visual info”

Visual Discrimination

Visual Memory

Spatial Relations

Form Constancy

Figure Ground Visual Closure

Visual-Motor Integration

Directionality/

Laterality

The mind-eye connection

What do I do about it?

What is it? Focusing, following

Targets

Where is it? Aiming, scanning space

Background

When is it? Time judgement

context

Who am I?▪ How do I feel about it?

▪ Attention to detail

▪ Intentional movement

▪ Awareness of context

▪ Habitual/anticipatory

movement

Where am I?▪ Electrical signals

How Am I?▪ Chemical signals

MIND

BODY

The OBIA Impact Report 2012 https://www.ontario.ca/img/ontario@2x-print.png

Politzer, T. (2015, April 22) Introduction to Vision and Brain Injury. Retrieved from Neuro-Optometric Rehabilitation

Association website https://nora.cc/for-patients-mainmenu-34/vision-a-brain-injury-mainmenu-64.html

26-50% of those with ABI reported trouble with

their vision most of the time.

Reduced ability to use vision

Either:

Vision getting to the brain

Brain processing visual info

…or both

The visual component to post concussion

syndrome

Post Trauma Vision Syndrome

Post Traumatic Vision Syndrome

Blur (sometimes intermittent)

Trouble focusing

Double vision

Eye strain/fatigue

Headaches

Difficulty tracking

Slow visuomotor performance

Difficulties with balance and posture

Glare sensitivity and photophobia

Accommodative dysfunction

Vergence issues / misalignment

Oculomotor abnormalities

Visual field defects

Perception deficits

Visual inattention (Neglect)

Perceived visual midline shift

Visual-vestibular

Dry eye

Symptoms Deficits

Kapoor N, Ciuffreda KJ. Vision Disturbances Following Traumatic Brain Injury.

Current Treatment Options in Neurology. 2002:4: 271-280

Ciuffreda KJ et al. Occurrence of oculomotor dysfunction in acquired brain

injury: A retrospective analysis. Optometry. 2007:78(4): 155-161.

Behavioural Implications to Vision

Fatigue

Reduced confidence

Anxiety & uncertainty

Passive in decision making

Difficulty with dynamic environments

Fear of falling

Community activities become challenging: Driving

Shopping

Working

Sports, leisure interests

Accommodation

How well our eyes can change its focus for different distances

Ability

Flexibility

Sustained over time

Symptoms

Headache

Blurred vision

Eye strain

Fatigue

Vergence

How well the eyes are working together as a team

Symptoms:

Double vision

Eyestrain

Depth perception struggles

Clumsiness

Vergence

Coping Mechanisms

Falls asleep while reading

Avoids visual tasks

Squints

Closes an eye

Nausea/dizziness

Oculomotor

There are many areas of the

brain needed for tracking:• Control of

saccades and pursuits

Cerebral

• Horizontal and Vertical Gaze Centers

Brainstem

• Control of eye muscles

Cranial Nuclei

• Execute the eye movements

Extra-ocular Muscles

Associated Symptoms

Reading difficulties:

Slower reading speed

Loss of place / skipping lines

Missing words

Poor comprehension

Print seems to move / swim / jumble

Nausea / dizziness

Oculomotor and Vestibular Systems

Vision integrates with balance through the Vestibular

Ocular Reflex (VOR)

Keeps vision stable when you are moving

Associated Symptoms

Imbalance and sensitivity to visually-stimulating

environments

Grocery stores

Malls

Restaurants

Dizziness/Nausea/Vertigo with visual tasks

TV

Reading, computer

Driving

Visual Field Loss in ABI

Vision loss in 32-65% of ABI

May occur due to damage to the

eye, optic nerve, or brain

stroke

Cerebral Hemorrhage

Head Trauma

Implications of Visual Field Loss

Missing Information

More time needed

Visual Midline Shift Syndrome

Abnormal Egocentric Localization

Deviated perception of visual midline

Poor eye/hand coordination

Postural changes

Diminished ability to navigate environment

Houston K E. Measuring visual midline shift syndrome & disorders of

spatial localization: A literature review & report of a new clinical

protocol. J Behav Optom. 2010:21(4): 87-93.

Visual Information Processing

Prognosis guarded with

severe ABI

Goal of therapy:

create strategies that

maximize performance

Strategies:

Auditory strategies

repetition

different viewing perspectives

Photosensitivity

Elevated sensitivity to lights

Dark and light adaptation problems

Tints/Filters beneficial

Treatment Options

http://www.algaecal.com/wp-content/uploads/options-treatment-guidelines-of-osteoporosis.jpg

Treatment: Vision

Balanced Prescription

Glasses or Contact Lenses

Filters

Yoked prism

Occlusion

Vision Therapy

What is Vision Rehabilitation?

An individualized treatment regimen prescribed to a patient in order to:

Provide medically necessary treatment to normalize diagnosed visual dysfunctions◼ Vergence

◼ Accommodation

◼ Oculomotor

Improve visual comfort, ease, efficiency, and processing

Neuroplasticity and Therapy

Brain (visual system) is able to create new connections

and fortify old ones by experience

Learning and plasticity can occur by myelination

formation or re-modeling white matter

Neurogenesis continues throughout lifetime

1-4

Goals of Vision Therapy

Alleviate signs and symptoms

Achieve desired visual outcomes

Improve quality of life

Return to daily activities

5-26

Improvements to Expect

Oculomotor Skills Accuracy and speed

Span of recognition

Reduced re-fixations and regressions while reading

Vergence & Accommodation Ability, speed, flexibility

Quality and stability of vision

Reduced symptoms

Comfort Efficiency Accuracy Performance

5-26

Managing Expectations

Rehabilitation is a process that takes time

Initially can cause exacerbated symptoms

Manage the increased symptoms while

strength training

General Therapy Sequence

• Awareness

Phase 1

• Monocular

Phase 2

• Bi-ocular

Phase 3

• Binocular

Phase 4• Integration

• Flexibility

• Stamina

Phase 5

Eye Focusing Training

Train by using lenses or changing distances

Eye Teaming Training

Space matching

Scanning

Scanning

Scanning

Scanning

Scanning

Visual-Spatial Organization

Yoked Prism

More efficient information processing

Influences plasticity of multi-sensory integration processes and cognitive processes related to mental representation of visual space (Rode 2001)

Alters body posture

Changes center of gravity

Improve higher cognitive levels

Assists in judging distance and stabilization

Life Therapy

Meal Times Prep

Eating arrangement

Navigation Walk, maps

Website

Recreational Virtual Reality

Board Games

Bocce Ball

Mini Golf

DOES IT WORK?

VT improves Vergence and Accommodation

in Adults with mTBI

12 non-strabismic individuals with mTBI and diagnosed vergence and accommodative disorders participated

6 weeks (2 sessions/wk, 3 hours each); half did oculomotor training (OMT) and half did placebo (P) training

Results:

Improved amplitude and peak velocity of

vergence (pfv and nvf)

accommodation (monocular and binocular)

Improved stereoacuity

Improved visual attention

Reduced near symptoms (CISS score)

No change in patients that did placebo VT

Thiagarajan P, Ciuffreda KJ. Effect of oculomotor rehabilitation on vergence responsivity in mild traumatic brain injury. J Rehabil Res Dev. 2013: 50(9): 1223-40.

Thiagarajan P, Ciuffreda KJ. Effect of oculomotor rehabilitation on accommodative responsivity in mild traumatic brain injury. J Rehabil Res Dev. 2014; 51(2): 175-92.

VT improves eye movements,

reading rate, visual attention

12 subjects with mTBI participated in either oculomotor training (OMT) or sham training (ST).

6 weeks, 2 sessions a week. Trained vergence, accommodation, version in randomized order across sessions.

Visual attention assessed by VSAT

Results:

Over 80% of abnormal parameters significantly improved

Reading rate improved

Amplitudes of vergence, accommodation improved

Saccadic eye movements improved in rhythmicity and accuracy

Improved visual attention and CISS score

Thiagarajan P, el al. Oculomotor neurorehabilitation for reading in mild traumatic brain injury (TBI): An integrative approach. NeuroRehabilitation. 2014. 34: 129-146.

VT improves eye movements

and reading ability

5 adults with stroke and 9 adults with TBI

8 weeks of training, 2 sessions/week

Training included single- and multiple-line simulated reading, as well as basic versional tracking (fixation, saccade, and pursuit) using infra-red eye movement recording technology

Internal oculomotor visual feedback in isolation (4 weeks) or concurrent with external oculomotor auditory feedback (4 weeks)

Results:

Improved objective accuracy with versional tracking

Improved reading ability

Ciuffreda KJ, et al. Oculomotor rehabilitation for reading in acquired brain injury.NeuroRehabilitation. 2006. 21: 9-21.

VT improves clinical and fMRI measures

in Adults with CI

13 control normal BV adults; 4 convergence insufficiency adults

All participated in 18 hours of VT

Results: Reduction in NPC and NPC recovery point

Reduction in Near Phoria

Improved PFV, average peak velocity of convergence

Significant increased functional activity within the frontal areas, cerebellum, and brain stem significantly

Alvarez TL, et al. Vision Therapy in Adults with Convergence Insufficiency: Clinical and fMRI Measures. Optom Vis Sci. 2010; 87(12): E985–1002.

fMRI shows brain changes with vergence

training

Functional activity and vergence eye movements were quantified from 7 BV normal and 4 CI patients before and after 18 h of vergence training.

Results: CI patient measurements after vergence training were more similar to levels observed with BV normal Increased fMRI activity levels

Increased speed in convergence response

Improvement in CISS score

Alvarez TL et al. Functional activity within the frontal eye fields, posterior parietal cortex, and cerebellar vermis significantly correlates to symmetrical vergence peak velocity: an ROI-based, fMRI study of vergence training. Front. Integr. Neurosci., 2014; http://dx.doi.org/10.3389/fnint.2014.00050

Vergence peak velocity and phoria

improves with VT

12 BV normal patients and 4 CI patients. CI patients underwent 18 hours of VT.

Results: After VT, peak velocity and exophoria magnitude improved significantly in CI patients

Alvarez TL. A pilot study of disparity vergence and near dissociated phoria in convergence insufficiency patients before vs. after vergence therapy. Front. Hum. Neurosci.2015; http://dx.doi.org/10.3389/fnhum.2015.00419

Professional team collaboration

Family Physician

Occupational Therapist

Physical Therapist

Speech and Language Therapist

Case manager

Psychologist

Classroom Teacher and

TutorsWorkplace

Referral Process

Can book directly for

• ABI Exam

• MVA Exam

Medical history is helpful

385 Fairway Rd S, Unit 202

Kitchener, ON

Phone: (519) 208-2040

Fax: (519) 208-2045

Email: info@visual-sense.ca

Summary

ABI can impact many aspects of vision

The brain is neuroplastic

Research shows VT improves vision function & quality of life

In-office VT is most effective; at-home is an option

ABI is multi-faceted and benefits from a health team

References

Bolognini, N et al (2005). Visual search improvement in hemianopic patients after audio-visual stimulation. Brain. 128:2830-2842

Bowers AR el al (2012). Clinical study: A pilot evaluation of on-road detection performance by drivers with hemianopia using oblique peripheral prisms. Stroke Research and Treatment Volume 2012, Article ID 176806, 10 pages. doi:10.1155/2012/176806

Ciuffreda KJ (2002). The scientific basis for and efficacy of optometric vision therapy in nonstrabismic accommodative and vergence disorders. Optometry. 73: 735-62.

Ciuffreda KJ et al. (2007) Occurrence of oculomotor dysfunction in acquired brain injury: A retrospective analysis. Optometry. 78(4): 155-161.

Houston K E. (2010) Measuring visual midline shift syndrome & disorders of spatial localization: A literature review & report of a new clinical protocol. J Behav Optom. 21(4): 87-93.

Kapoor N, Ciuffreda KJ. (2002) Vision Disturbances Following Traumatic Brain Injury. Current Treatment Options in Neurology. 4, 271-280

Kasten, E. et al. (2001). Stability of visual field enlargements following computer-based restitution training – results of a follow-up. Journal of Clinical and Experimental Neuropsychology, 23(3), 297-305.

Kerkhoff, G., et al (1994). Neurovisual rehabilitation in cerebral blindness. Archives of Neurology, 51 (5), 474-481.

Margolis, N et al. (2006). Visual field defects and unilateral spatial inattention: diagnosis and treatment. J Behav Optom. 17(2):31-37.

Nelles, G et al. (2007). Saccade induced cortical activation in patients with post-stroke visual field defects. Journal of Neurology, 254 (9), 1244-1252

Pambakian, ALM and Kennard C. (1997). Can visual function be restored in patients with homonymous hemianopia? British Journal of Ophthalmology. 81:324-323.

Perez C and Chokron S. (2014). Rehabilitation of homonymous hemianopia: insight into blindsight. Frontiers in Integrative Neuroscience. Volume 8 Article 82.

Pizzamiglio, L et al. (2006). Development of a rehabilitation program for unilateral neglect. Restorative Neurology and Neuroscience 24: 337–345

Politzer, T. (2015, April 22) Introduction to Vision and Brain Injury. Retrieved from Neuro-Optometric Rehabilitation Association website https://nora.cc/for-patients-mainmenu-34/vision-a-brain-injury-mainmenu-64.html

Romano, JG. (2011). Rehabilitation of hemianopic visual field defects. ACNR. 11 (1): 31-33.

Rowe et al. (2013) A prospective profile of visual field loss following stroke: prevalence, type, rehabilitation, outcome. Biomed Research International. http://dx.doi.org/10.1155/2013/719096

Sutter P and Harvey LH (editors). Vision Rehabilitation: Multidisciplinary Care of the Patient Following Brain Injury. 2011. Taylor and Francis Group, Florida

Questions?

Thank you!

dr.tpolonenko@gmail.com