Vision Rehabilitation Techniques for Vision Rehabilitation Techniques for TBI TBI

Carl Garbus, O.D., FAAONeuro Vision Rehabilitation Institute

Valencia, CA

Learning ObjectivesLearning ObjectivesDescribe 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

Goals for the Presentation Goals for the Presentation Goals for the Presentation 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

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

DefinitionsDefinitionsTraumatic 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.

Causes of TBI:

Motor vehicle accidents - whiplash

Falls

Gunshot wounds

Work place injuries

Shaken baby syndrome

Child abuse

Sports injuries

Military actions

Different ways brain can be damaged

Neck TraumaNeck TraumaNeck TraumaNeck 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.

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.

Basic brain structures Basic brain structures and functionsand functions

Lobes

" The eyes see only what the mind is ready to comprehend"

Henri Bergson

Brain and Brain and vision: vision: the connectionthe 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.

The Visual BrainThe Visual Brain

Vision is a Bimodal Vision is a Bimodal SystemSystem

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

Focal and Ambient SystemsFocal and Ambient SystemsFocal and Ambient SystemsFocal 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

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

Five Pillars of Five Pillars of FunctionFunction

Visual

Physical / Vestibular

Somatosensory

Cognition

Psychosocial

Why is vision rehabilitation so Why is vision rehabilitation so important following brain injury?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.

Visual Consequences of TBI: Visual Consequences of TBI: Post Trauma Vision Syndrome Post Trauma Vision Syndrome

(PTVS)(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

Visual consequences of TBI: Visual consequences of TBI: Post Trauma Vision Syndrome Post Trauma Vision Syndrome

(PTVS)(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

Sense of balance

Bump into things

Difficulty with eating

Slow reading

What are the functional implications?

Binocular Dysfunction

Difficulty judging distance or depth

Tendency to knock things over

Bump or trip over obstacles

Difficulty playing sports

What are the functional implications?

Visual information processing

Avoidance of crowded or busy places

Short memory

Forget familiar route

Slow to process

Visual Midline ShiftVisual Midline Shift

Visual Midline ShiftVisual Midline Shift

Mismatch between the perceived egocentric visual midline and the actual physical midlineCauses an expansion on one sideCauses a contraction on the opposite side

Mismatch between the perceived egocentric visual midline and the actual physical midlineCauses an expansion on one sideCauses a contraction on the opposite side

Visual Midline Shift SyndromeVisual Midline Shift SyndromeVisual Midline Shift SyndromeVisual Midline Shift SyndromeSigns 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

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

Cranial Nerve VIII – Cranial Nerve VIII – Auditory and Vestibular NerveAuditory and Vestibular Nerve

Cranial Nerve VIII – Cranial Nerve VIII – Auditory and Vestibular NerveAuditory and Vestibular Nerve

Nerve that transmits information for hearing and balance

Nerve that transmits information for hearing and balance

Vestibular FunctionVestibular FunctionVestibular FunctionVestibular FunctionThe 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

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

Vestibulo-Ocular ReflexVestibulo-Ocular ReflexVestibulo-Ocular ReflexVestibulo-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

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

InterventionsInterventions

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

InterventionsInterventions

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

InterventionsInterventionsLimit 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

InterventionsInterventionsTherapy

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.

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 patchSector patchBinasalsActive therapy prescribed by the eye care

practitioner can improve binocular function- Eye Stretches, Tactile Control, Spatial Localization, Brock String

InterventionsPrisms: 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

Strategies for Light SensitivityTurn off or avoid fluorescent lightingIncrease exposure to natural lightingWear prescription sunglasses with Polaroid lensesConsider side shieldsWrap around frames

Strategies for Light SensitivityBlue-tec lens filter (indoor)Green-blue filter for use in areas where fluorescent

lighting is unavoidableBinasal occlusionLight therapy program

Strategies for Disorientation and Dizziness

Grounding techniquesThumb and forefinger stimulationProprioceptive inputBreathing technique

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 prescriptionBinasals can provide grounding and reduce visual

confusion

Referral source is NORA

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

Yoked Prism Glasses

Demonstration

The Effect of Prisms for Mobility and Navigation

Strategies for Improving MobilityDuring mobility training observe posture, arm swing,

body alignment, balance, head position and turnsObserve visual balance When balance is a problem use the technique of

eyes leading the way before making turns Obstacle Course procedures

Obstacle CoursePlace 3 chairs approximately 3 feet apartThe patient is shown how to navigate around the

chairsChanging visual conditions for navigationAdding visual stimulus to the sidesAdding auditory stimulus

Demonstration

Strategies for Visual Field LossIdentify where the losses are located with visual fieldDoes it affect ambulation?Does it affect reading?---------------------------------------------------------------Trial Peli Prisms for hemianopsiaTrial yoked prismsImprove scanning skillsNeed single vision Rx glasses (distance and near)Progressives limit peripheral visual field function

Strategies to Enhance Visual and Vestibular Integration

Specific ProceduresHead Rotations With Central FixationChair RotationsBody RotationsFour Corner HART ChartsSide To Side HART Chart RotationsGOALS: better coordination of these systems can

be accomplished by using vision to support vestibular

SummaryConsult 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

SummaryGood referral source is the Neuro

Optometric Rehabilitation Association

Avoid crowded environmentsInquire about yoked prisms and

binasal occlusion Use the grounding techniques

described in this courseDon’t give up there are many

solutions to improve the quality of life after a traumatic brain injury

Neuro Optometric Rehabilitation Conference

24th Annual Multi-disciplinary ConferenceRenaissance HotelMay 14-17, 2015Denver, COWebsite www.nora.cc

Email: noraoptometric@yahoo.com