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Clinical Care and Practice Advancement
Pediatrics and Binocular Vision

Optometric Care of the Patient with Acquired Brain Injury



Vision dysfunctions are among the most common sequelae associated with acquired brain injury (BI). The anatomy and physiology of the vision system, the vascular and neural network of the brain, and the dynamics of head trauma all contribute to the high incidence of visual dysfunction with brain injury. Causes of brain injury which may contribute to visual dysfunction include blunt, penetrating, or acceleration/deceleration trauma; suffocation/hypoxia; pharmacological toxicity; and cerebral vascular accidents.

Injury to the eye or the sensory, motor or associated areas of the visual system of the BI patient may result in the development of the following:

  • Strabismus
  • Reduced visual acuity at far
  • Reduced visual acuity at near
  • Visual field loss
  • Ocular motility disorders
  • Binocular vision dysfunctions
  • Accommodative disorders
  • Difficulties in visual perception
  • Deficits in visual motor integration

Since activities of daily living involve effective integration of visual information processing and visual motor performance, the BI patient is frequently handicapped as a consequence of disruption in the visual system.

A significant number of patients with BI will present with signs and symptoms which indicate a vision problem. These include, but are not limited to, the following:

Symptoms
Signs
Double vision Eye turn
Blurred vision Closing or covering one eye
Reduced ability to sustain Head tilts or turns attention on visual tasks
Dizziness Bumping into objects
Headaches Abnormal posture
Eye strain Balance and coordination problems
Confusion related to visual tasks Poor judgement of depth
Difficulty reading Reduced ability to accurately localize objects

OPTOMETRIC EVALUATION AND MANAGEMENT

The patient with BI should be evaluated by an optometrist who has training and clinical experience in the care of eye and vision problems related to brain injury. As a member of, or consultant to, the patient's rehabilitation team, the optometrist is able to relate specific visual dysfunctions to patient's symptoms and performance in order to provide remediation and guidance. This will increase the effectiveness of the overall rehabilitation program, which is often highly dependent upon vision. The evaluation of the patient with brain injury may include, but is not limited to, the following:

  • Comprehensive eye and vision examination
  • Extended sensorimotor evaluation
  • Higher cerebral function assessment of visual
  • information processing
  • Low vision evaluation
  • Extended visual field evaluation
  • Electrodiagnostic testing

Optometric management of the patient with brain injury may incorporate any of the following:

  • Treatment of ocular disease or injury either directly or by comanagement with other health care professionals
  • Treatment of the visual dysfunction utilizing lenses, prisms, occlusion, low vision devices, and/or optometric vision therapy
  • Counseling and education of patient, family, or caregiver about the patient's visual problems, functional implications, goals, prognosis, and management options
  • Consultation with other professionals involved in the rehabilitation and health care of the patient.

CONCLUSION

Optometrists provide essential vision services in the rehabilitation process of the patient with brain injury, including diagnosis, treatment and consultation in order to maximize the patient's outcome. The ultimate goal of these services is to improve the patient's quality of life.

REFERENCES

  1. Aksionoff EB, Falk NS. The differential diagnosis of perceptual deficits in traumatic brain injury patients. J Am Optom Assoc 1992; 63:554-558.
  2. Aksionoff EB, Falk NS. Optometric therapy for the left brain injured patient. J Am Optom Assoc 1992; 63:564-568.
  3. Cohen AH. Optometric management of binocular dysfunctions secondary to head trauma: case reports. J Am Optom Assoc 1992; 63:569-575.
  4. Cohen AH, Rein LD. The effect of head trauma on the visual system: the doctor of optometry as a member of the rehabilitation team. J Am Optom Assoc 1992; 63:530-536.
  5. Gianutsos R, Ramsy G. Enabling rehabilitative optometrists to help survivors of acquired brain injury. J Vis Rehabil 1988; 2(1):37-58.
  6. Harrison RJ. Loss of fusional vergence with partial loss of accommodative convergence and accommodation following head injury. Binoc Vis 1987; 2(2):93-100.
  7. Hellerstein LF, Freed S. Rehabilitative optometric management of a traumatic brain injury patient. J Behav Opt 1994; 5(6):143-148.
  8. Hellerstein LF, Freed S, Maples WC. Vision profile of patients with mild brain injury. J Am Optom Assoc 1995; 66:634-639.
  9. Ludlam WM. Rehabilitation of traumatic brain injury with associated visual dysfunction - a case report. Neuro Rehabilitation 1996; 6:183-192.
  10. Padula W. Visual evoked potentials (VEP) evaluating treatment for post-trauma vision syndrome (PTVS) in patients with traumatic brain injuries (TBI). Br Inj 1994; 8:125-133.
  11. Roberts S. Visual disorders of higher cortical function. J Am Optom Assoc 1992; 63:723-732.
  12. Rosenthal M, Griffith ER, Bond MR, et al, eds. Rehabilitation of the adult and child with traumatic brain injury. Philadelphia: F.A. Davis Company, 1990; 351-365.
  13. Stanworth A. Defects of ocular movement and fusion after head injury. Br J Ophthalmol 1974; 58:266-271.
  14. Streff JW. Visual rehabilitation of hemianoptic head trauma patients emphasizing ambient pathways. Neuro Rehabilitation 1996; 6:173-181.
  15. Tierney DW. Visual dysfunction in closed head injury. J Am Optom Assoc 1988; 59:614-622.
  16. Vogel MS. An overview of head trauma for the primary care practitioner: part II-ocular damage associated with head trauma. J Am Optom Assoc 1992; 63:542-546.
  17. Waiss B, Soden R. Head trauma and low vision: clinical modifications for diagnosis and prescription. J Am Optom Assoc 1992; 63:559-563.
  18. Zost M. Diagnosis and mangement of visual dysfunction in cerebral injury. In: Maino D., ed. Diagnosis and management of special populations, St. Louis: CV Mosby, 1995.

Resources available from the American Optometric Association:

  1. Extended sensorimotor evaluation. American Optometric Association. St. Louis, MO, June 1992.
  2. Assessment of higher cerebral function. American Optometric Association. St. Louis, MO, May 1994.
  3. Definition of optometric vision therapy. American Optometric Association. St. Louis, MO, November 1996.