Certain vision problems may be linked to a past traumatic brain injury, but it’s not always obvious. Neuro-optometrist Mark Wu, OD, discusses how to diagnose such issues, with tips on what to ask about symptoms. He explains the complementary roles of primary care, optometry and ophthalmology for improving vision, and explains what “vision rehab” and other therapies can offer.
All right, so welcome to this week's webinar title is automatic. His role in the management of the choir brain injuries. Um, so just a quick introduction here we, I will be going over some kind of, some of the more common causes of brain injuries as well as the vision problems that are associated with them that that I see clinically and then I'll kind of finish up with some of how different pieces of medicine kind of fits into this overall multidisciplinary management approach and then we'll talk a little bit more about um also um something called cerebral visual impairments, which is something that pertains to like newborns and young Children. Okay, so so to kind of start us off here um, I like to use the word acquired brain injury more than traumatic brain injury because technically traumatic brain injury is only one branch under the choir brain injuries And as you can see on our list here and this is obviously not uh not an uh not an exhaustive list. Um, that acquired brain injury includes traumatic vascular, which are two of the most common types of these ideologies that I see in my clinic. Um, and then of course there is this space occupying lesions, infectious inflammatory and there's a lot of other ways to injure the brain unfortunately. Okay, but we're going to talk about traumatic brain injury a little bit more here since that's what most clinicians are more familiar with. This is very common in both in two different age groups. One is the older adolescent group between 15 and 19 years old and then the other age group Uh due to most likely falls and other types of kind of like HP later issues. We see them a lot also in the elderly population greater than 65 years old. Um the annual incidents in the US according to the CDC data is about 500 and uh in 100,000 this might seem kind of low but I believe there is a lot of people that there are quite a few people every year who may not kind of considered what they have gone through to be A T. B. I. Ah So this may be kind of representative of that under reporting most tbs. However also fortunately are considered to be mild TBI I. S. Which is usually when we kind of talked about like like the the award concussion. It's typically referring to mild TBI ice and we'll kind of go over like what are some of the diagnostic criteria for a mild TBI i is um traumatic brain injuries are twice as common in men versus women. And concussion as we just talked about is the most common form. Okay, so this is a nice graphic here from brain line dot org which is a very helpful website for uh all patients with traumatic brain injury they have they have a lot of like resources for patients and also for providers as well. So the leading causes as of 2013 in the us are false, which is why that elderly group kind of really stands out there in uh as one of the most like prominent groups that that that that tends to be more susceptible to T. B. I. S. Um followed by you know um like like like physical assaults. Traffic accidents is also something very common in my clinic at the at the U. C. Berkeley I. Center where we focus more on like vision rehab. A lot of my patients come through are actually from traffic accidents more than false. And I'm gonna be kind of explaining some potential reasons why that might be even though the prevalence were false. Is that much higher according to this data? Okay okay so this table illustrates what's called a Glasgow coma scale. Uh This is the main skill that we used to assess. Uh uh okay sorry this is a skill that we used to to determine the severity of any kind of brain injuries. Um So overall so this is something that they actually used in the er if they were to bring someone who has lost consciousness and you know they these are some of the things that they they kind of look at um to determine is just considered a severe TBI patient, a moderate TBI patient or or a mile uh quarter mile case. Um So you can see at the bottom here we have you know minor is considered 13 to 15 points which means that they're generally pretty responsive. Um and they're oriented their eyes and people's all work normally. Um And then on the other end is where you have these lower point totals, like they're unable to open their eyes. There's no response that's generally when when when there's likely very significant brain damage. All right. So one of the one of the mechanisms, there's plenty of different mechanisms depending on the etiology of the brain injury, but one of them that that that is that has definitely gained quite a bit of traction over the years is something called uh Exxon o or like or like uh diffuse external injury. Um And this graphic is kind of illustrating how this particular injury mechanism works. So a lot of times, especially in kind of like traffic accidents, you will have the whiplash effect on the neck where you have initially. You have a cool action where the head gets dragged backwards and you and you and you can see that based on momentum here, the frontal part of the brain will kind of strike the frontal part of the skull and then followed by the whiplash effect or which is a contre coup where now you have the fast side of the brain hitting the back side of the skull. Um Something that this this illness face really well is that um a lot of our tv i patients. Um they don't have just one or two symptoms whether it be uh whether it's visual or non visual. Okay. Okay. Um and so a lot of the these patients come into my clinic with a multitude of different signs and symptoms. Some are visuals, some are emotional, some are um like language based beach you know and why is that? Well because with these kind of of of impacts to different parts of the brain every point of impact sends out a wave like a shockwave throughout the entire brain. And these shock wave causes these diffuse uh kind of sharing types of injuries. Okay so a little bit more about diffuse axonal injury. Uh It is caused by the sudden angular and rotational acceleration and deceleration forces uh that you get from kind of the brain impacting certain portions of uh of the skull. Mhm. Um It is present in all levels of T. B. I. S. And we and what the studies have seen is that which makes sense that as the impact for increases the types the diffuse injuries will definitely spread throughout. Like um like the deeper parts of the brain. So once again the mechanism is via these shock waves that emanates from the point of impact during the proof and the contract through parts of the the of the of the T. B. I. Okay. Um there's not gonna be a lot of like I didn't want to focus just um this presentation too much on the literature because I kind of wanted to focus more on kind of like what we can do as neuro optometrist, how we can work together with the, with PCP community, but I will mention that there are definitely a lot of studies out there, like this one where they have looked at kind of um like kind of the correlation between how how much impact for us and how it correlates with how much injury it causes the brain. So um so diffuse axonal injury is seen in most types of what what the study is called, like high energy impacts, such as low as that happens during like car accidents or just traffic accidents um compared to false, which are actually considered by literature to have a lower energy impact level. So, so remember kind of like from a few slides back, I was talking about how most of my very symptomatic patients tend to be patients who either had a pedestrian uh a a pedestrian versus car incident, harvest this car, harvest this truck or um or at least in this neck of the woods. We have a lot of like um a lot of people who who writes bicycles and kind of like, so it's like bike vs. Part. So a lot of these kind of power accidents, these are high impact. There's a lot of energy people get thrown out of the windows, people land on their heads on the gravel. There's just a lot of energy involved in these in these types of injuries and I suspect this is why the most of my very symptomatic patients are coming from these types of injuries compared to false. Okay okay so we're gonna talk a little bit about kind of like some of the, so these are some of the more common vision complaints that your patients might suffer from if they have a history of T. B. I. Or stroke. Um Some of the more common ones are ice cream or headache while reading. Um So you know we all deal with headaches from from a day to day basis. I specifically asked patients where their headaches are and whether or not their headaches are are more associated with during near work or right after near work. Um Because again like we deal with migraine patients tension type headache patients like all the time. But those headaches tend to be ah tend to occur in different locations. So so what I consider to be visual headaches are generally right around the eyebrows and also must be linked to kind of uh to um to some any kind of like near works like looking on the computer during work, reading for homework those kind of things. So we want to ask for where and and also the timing to see if it's a visually trigger headache or is there something else? Um Near blurts are very common complaint. Uh uh adults and kids alike can also complain about eye tracking challenges where they may know like prior to whatever injury they have sustained, they're able to read, you know, really like really quickly, like two, words a minute or faster and for whatever reason now they can only read um you know, like half of that speed or there or or if they tell, you know, like if I were to just pick up a book nowadays um a lot of times I had to you I had to use my finger to kind of like help me make sure that I'm not skipping any awards or lines on the book. Those are all very typical visual symptoms that could indicate there is some some types of acquired brain injuries. Um distance, blur, double vision is something that I also deal with very frequently in the eye, in both the in both the Berkeley clinic as well as the usually Berkeley clinics license activity. This one may be kind of harder to kind of understand, but lie sensitivity and technically any heightened sensitivity to any of the patients senses could be a symptom of some type of uh some type of brain injury. Um So licensing li in particular like they might come in with sunglasses, they might come in with a happy usually low um be like even though it's a cloudy day or even if your office lighting isn't that bright so that no, that should kind of triggered you guys to kind of think about, Okay, well hello, like are you know, like, do you find a room light? Really tough to kind of to tolerate? Have you had any kind of like, like head trauma or any kind of, you know, stroke um those kind of things? Okay, so then we'll talk a little bit about kind of what are some of the non visual symptoms that you guys will also likely see for these patients? A lot of patients will complain about poor memories. So it can either be in the form of unable to remember what they just read, even though they just read a whole paragraph or a whole chapter. Um It could also be poor memory of kind of like what they have to do during the daytime or or at least something that pertains to all doctors, like they might be missing or being laid to your appointments because they're unable to remember what exact time was the actual appointed um F Asia's or the inability to illicit like speech or just very choppy speech or or if it takes the patients who used to be like a, you know, like a public presenter and now suddenly, for whatever reason, they take forever to think about what they had to say or how or more how to say certain things. Um So the third bullet point here this, so this is actually very, very common to um vestibular symptoms. A lot of patients will come in with like, nausea dizziness, which again, can be can come from a whole slew of different uh like uh systemic diseases. But again, um, like history of trauma history of any kind of brain trauma, brain in brain brain injuries, you will definitely need to kind of like asked for these because they can alone cost acquired uh dizziness, vertigo, not or or any kind of other types of vestibular symptoms. Um, slower processing speed. So again, like going back to our reading rate example, someone who was a vivid reader who is a lawyer who used to read, you know, like papers and papers within the same night. Now they're unable to make it through even half of one. Um this may also be seen uh in kind of um, you know, uh TB patients who are driving on a, you know, on the streets or on the freeways there, their ability to kind of like process their surroundings or the oncoming traffic or how quickly are the cars ahead of them striving or are the cars stopping ahead of them? These all have to deal with at least partly had to deal with their uh like visual processing speed. So, again, these are kind of where some of the more like daily life examples where you can see challenges uh mm hmm. The last So, um so the whole emotional side of things, I mean, this is actually something that can really limit their ability to form new relationships. Um patients who suffer from like depression, pTSD anxiety. Uh, some patients tend to will become way more irritable compared to prior to the brain in brain injury. So we have to try to kind of be patient with with them. Like sometimes so tim it um I guess typically as doctors are not going to be the main recipients to some of these issues is actually going to be our front desk um um our front desk staff. So a lot of times, you know, they come in late and then the further service, oh you're late, we had to reschedule you and then like basically like a verbal fight can sometimes form, but sometimes it's kind of important to also educate staff that sometimes we have to remain calm, remain patient. Maybe this is maybe the patient doesn't realize that they are kind of being abusive uh definitely need to address that with the patients directly. But yes, I see a hand. Okay, uh Michelle, did you have a comment or or I or I can keep going. Okay, I'll keep going for now. Okay, so some of the challenges that I face when I see these patients um is that a lot of patients won't really associate, they're like vision issues or even their non vision issues with their actual brain trauma. Um They won't think that oh, I can't track as well after my my my tv I because this is a vision problem um or oh I am like sensitive way more after trauma because it's a vision problems. So, so this is something that I always had to kind of like spend time to educate the patients themselves and and a lot of times just validating a lot of these patients concerns and symptoms uh in the exam room can really make them feel like feel a lot better because you know, likely most of their family members and and friends, you know, we can't expect them to understand why they have changed their behavior, why there's so much more irritable, Why can't they read well anymore like that? Like let's say if this is a like a great school uh like an elementary school student. So we had to make sure like, hey, we need to educate the public about how actually a lot of their symptoms are all connected and attributable to their actual brain injury. So, this is something that I always work on in the examination to to educate not only the patients the whole uh as well as their family members who, who are coming with them to these visits. Um ah Autumn a tree is uh you know, for those of you who has never heard of vision therapy before. Um even in this presentation, we'll know like there is not a lot of recognition as of this time for neuro optometry is role in kind of like how we can actually perform vision rehab for patients with vision issues. So obviously if most of the patients issues are are more related to some of the non visual concerns that was on the previous slide then you know, then we may not be much of help but if they do complain about like like headaches after reading double vision blurred vision that fluctuates um licenses all of those things. We can definitely help you guys out in trying to help them regain some of their functions that they have lost. Uh And one of the main challenges that we also face is uh is that there is not allowed of like evidence based or like randomized control trials yet for all of the all of the the visual diagnoses and how vision therapy can actually help with some of these diagnoses. I'm gonna go over some of the bigger uh like the bigger literature studies up to the state but we're definitely just hitting the tip of the iceberg. Like there's a lot of work more to be done that me and my other colleagues are definitely working towards. Okay so most of the current evidence based studies that pertain to post T. B. I. Vision rehab has to deal with these three types of vision diagnoses, convergence insufficiency is something that's really well known by at this time and it is definitely one of the most well studied diagnosis in just in terms of how vision therapy can can actually help with the diagnosis um patients with what we call accommodative dysfunction or focusing muscle dysfunction which which accounts for a lot of the near blur or and or distance for issues that you know, that's something that has definitely been in uh in previous in prior uh literature studies as well. As long as the some of the various kind of like I like um like your uh your uh your uh sorry, neurologic eye movements Dysfunctions. So these three vision therapy can definitely make uh make a difference. Some of the more kind of like processing types of deficits from from brain trauma. Those are a little bit trickier to to kind of rehab. Uh and those are where kind of a lot of the pushback that I have seen from different types of providers have been kind of center on which I actually agree with them in the sense that like yeah there isn't a like like a set drool or or a set type of therapy that can help patients who want to update reading speed or want to be able to um to to to like uh to process things faster again, like things that have more to deal with their cognitive deficits post T. B. I. These are some of the skills that there are not a lot of uh kind of literature support yet. So that area I will also educate patients accordingly that hey You have convergence. You know you have convergence insufficiency. That is something that I can definitely help you with over the next like 3-4 months. However, some of the more cognitively based challenges I have like games and things like that that can potentially help improve those areas but I'm not gonna make you any kind of guarantees because like I just said there isn't a lot of evidence based research out there on that front yet. Okay. Um So I've looked into a couple of different uh little of literature studies. One of them was a retrospective review of 95 patients again with kind of like what I call ocular motor deficits which are the which have to do with the the previous three diagnosis list of above here and you know very small pool which is another kind of like downside to some of the studies out there so far but within the patients who actually qualify for this study the majority of them did improve you know significantly in terms of clinical testing as well as their symptoms at home. One of the bigger studies on convergence insufficiency is the convergence insufficiency treatment trials or C. I. T. T. For short. This was conducted in 2000 and eight. This looks specifically at four different possible treatment arms for treating convergence insufficiency. Uh They are pencil push ups, home based therapy which are based on like different computer programs, office based therapy and then placebo. So one thing you know here is that in the in their placebo group they actually still did do some kind of vision training in this group. it's not like they just give them like a pill or something. Um but it wasn't training that's directed towards convergence issues. Um So the highest percentage of uh successful outcome was seen in the in office treatment group, which is kind of not surprising because they have, you are kind of basically making sure you're keeping the patients more accountable because they're actually seeing you face to face. Uh and the earth and the other groups have basically just lower rates. So again, not a lot of like large scale studies yet, but that's hopefully something that optometry and and as well as ophthalmology can continue to um to collaborate towards. Okay, so towards the last part here, I do want to go over kind of how different specialty fields fits in to this grant. Um Grand scale of like man of management of acquired brain injuries. So, first, just a quick chart on the difference between autumn a tree like kind of what we can offer as optometrist versus what ophthalmology can offer you uh can offer The the primary primary care uh physicians. So for optometry, we specialize in vision. We have as I have been talking about for the last 10 minutes. Um so we can so we are in charge of kind of like I of identifying some of the like the eye or the vision weaknesses and we can come up with treatment plans or therapy plans to to rehabilitate these skills that have been lost or or have been reduced by whatever injury that they have sustained. Ophthalmology is really good at identifying and as well as managing like author diseases. So like a good example here would be a patient who came in with like blunt ocular trauma or blunt head trauma towards the eye. He has a lot of hemorrhages in the eye. So ophthalmologist will take care of these patients first by making sure that the hemorrhages are controlled and they will they will administer whatever treatment that's necessary and once they have restored the biological function of the eyeball these patients because they also have sustained a head trauma, they may experience things. I lie sensitivity, blur vision. Then my ophthalmology colleagues will then we will then refer these patients to us where we now look at, okay, do you need special glasses? Uh do you need vision therapy and those kind of things? Okay. We perform all the comprehensive eye exams. Ophthalmology performs really like problem based exams. We take care of pre imposed surgical care. So for like cataracts or glaucoma surgery. And then ophthalmology uh of course per they perform the actual surgical procedures. Um And last but not least we our goal as automotriz just in general or to try to make it to kind of manage the functional side of like uh like vision loss where ophthalmology is really good at diagnosing and and feeding anything that's more or that's more organic or more like diseases that you can see visibly in the eyeball. So that's kind of how we can complement one another. Um You guys may have heard of fizz i itri um This is a field that is actually really key in helping coordinate care for these TB patients. So these are Mds or um or deals who specialize in uh in physical medicine as well as rehab. They tend to serve the role of of like care coordinator uh four T for stroke or TBI patients. Um They communicate with all the other sub specialists that the patients may see or may need. They will identify like potential sub specialists who the whom the patients will will likely benefit from uh uh from scene. So these are kind of our main coordinators here, immigrant uh in uh in the grand scheme of things, these are just some of the neighborhood uh kind of listed for psychiatrists on this society website that I found. Um So obviously there is people at all different institutions here um within the UCSF system, we do have the physical medicine and rehab. A clinic where a lot of the physical therapists, occupational therapists, physiotherapists where that that's kind of where they reside. So neurologist. I think most of your prime most familiar with this particular group of specialists they diagnose and treat any types of neurological disease. They manage structural damage from trauma and stroke. Um and you know, they order a neuro imaging they identify and then they treat and then they think that is that has been picked up with by neuro imaging. Um So so they also a lot of times these are the specialists that the patients will see potentially first after primary care. Um And then once they have been worked up with Nero then narrow may send them directly to other specialists that they know. Or if they work with with with a psychiatrist they will then connect the patients with with with a set of uh the psychiatrist um within the neuro realm like uh those of you who are more familiar with the U. C. S. F. System will probably probably have heard at least. Um So there is a U. C. S. F. Uh clinic which they specialize in management of all types of headaches. Um However they do require you. So if you were to ever send a referral to that clinic you will first see like this I think it's like an automated message that will pop up on the epic system that will kind of that kind of goes through some of the minimum criteria before you can send someone directly to them. Uh The balance and fall center is a really good resource for patients with any types of vestibular symptoms. So definitely kind of keep them in mind if your patients have a lot of complaints about dizziness, nausea and you know the and uh and those kind of symptoms. Physical therapist obviously help train kind of to kind of help the patients regain some of their physical function, help them re learn some of the daily tasks that require like more normal uh physical function. Um you know, and and actually I didn't know this, but through my research I've learned that there's actually also different specialties within physical therapy, which I have listed here, which I found to be very very, very interesting. So both pt and OT s uh they both worked together to basically read like uh reorient patients to kind of how to live life again, basically. So, occupational therapist uh kind of, they tend to focus more on how to restore uh you know, things at home things in the workplace by recommending certain types of adaptive technology for patients. So that's kind of where they fit into the whole picture here. They also can help train someone like um train patient's ability to like write again. So like fine motor or or even like gross motor skills. So that's where I kind of uh where Otis fit into the to to the big picture here. So, these are a little more controversial, I must say. Um but I have a lot of patients who have gone through various kind of what we call adjunctive therapies. These don't have as much kind of once again, like at like large scale evidence based trials yet, but from a patient perspective, most of the patients that have gone through one or multiple of these types of therapies they have read, they have definitely told me that they felt better. But again whether that being like a placebo effect bird or an actual like physical restoration um that's kind of we're still trying to figure out like um if there's actually biological changes that's been that that these types of therapies can actually regain. Okay so for the for the last five minutes here before we get to some of your some of your questions here, I want to talk about something that that is kind of that's relatively under recognized how cerebral visual impairment or or C. V. I. For short. So as alluded to from the beginning part of my presentation, this particular term applies to uh infants and collars or just Children in just in general um some of the common causes. So once again these fall under the acquired brain injury um uh umbrella basically. So. But the main difference here is that these are basically brain injuries that occur perry Natalie uh that affects Children. And what's key here is that these injuries are supposed to adult brain injuries, they will actually have potential per like permanent life impacts on kids because this is typically during their critical period where all of their all of their normal brain functions developed. So if there's any kind of interruptions here, these could have potential life implications. Which is even why I'm even um kind of even see addressing this more so common causes perinatal huh? Like any source of para NATO uh hypoxia hydro step list. Some of you are most uh pretty familiar with that. Any kind of perinatal infection, trauma, you know, like things like shaken baby syndrome, pray ventricular white matter damage and any kind of like of like genetic deletion or just genetic mutation syndrome during birth can potentially have brain, brain can cause brain abnormalities. So these patients just like the adult version, they can also cause similar visual symptoms. Um but once again, any kind of eye misalignment in the form of such a business, any kind of like vision loss due to lazy eye or amblyopia. These if left untreated, these will have more permanent impact on these individuals. That's why it's really important to not forget that just because they're young just because they may look like they can walk and talk, okay, doesn't always mean that they are definitely, you know, there's no history of any kind of like any type of brain uh injury to them. So these are some of the things from an eye perspective for those of you who who who may perform like vision screenings, this is kind of what you want to look for you want to look for. Obviously if there's any kind of central business, if there's any kind of missed Agnes um if there's any um no uh I think downstairs at GOP see the the infant screening protocol now is to use a basically a camera and then to kind of use the flash to determine the likelihood of someone with my obeah or hybrid phobia or any kind of like prescription difference. So that's something that that would definitely uh that need to be that would definitely need to be uh followed. So so here's a quick kind of pop quiz here um You know like which little girl here has C. V. I. And it's kind of a trick question because both of them can actually have C. B. I. The girl on the right obviously have more like physical uh features but again they don't have to have physical deficits to have cerebral deficits. So that's something that I really try to emphasize for most providers is that if a little girls telling you she can't read, she's really behind on her reading level at school, she she seems very clumsy, she's always running into things like just because she can walk and talk okay doesn't mean that that she needs that she can be ignored. Okay. Um Yeah so this is kind of basically what I have just talked about. I wanted to take the last minute here to go over a quick kind of quickly go over the difference between legal blindness and low vision. So legal blindness is 2200 or or worse in the better eye. Low vision actually is more like it actually doesn't have a clinical definition. Okay. Low vision is more of a functional term where whatever vision the patient has, they're unable to make use of it for whatever they need to use in life. The legal blindness is the actual like definition that social Security looks at in terms of when they determine like disability and and um and and those types of needs. Okay, so just real to them, just really quickly here, um we can take care of all of the the kind of functional vision assessments we can give them classes. We can recommend these patients for like vision therapy. Uh We can try to connect them with the other professionals that's within our network that you are. No um like physical therapist or occupational therapists. So that's the kind of where tautology can fit in and where we can help you guys. And once again, brain injuries does not have a preference for an age group, even though the the the the elderly population as well as the uh the adolescent population is more it's more it's more uh more prevalent. Um They don't just cause one problem. They cost multiple problems due to the nature of the shockwave mechanism. So it's not that. Okay, well you only have vision problems. No. Typically patients complain about vision problems from brain injuries oftentimes have other issues going on as well. Okay, so definitely consider optometry if you guys have patients with that kind of medical history who is asking for help with their vision, with their reading, with with any kind of visually visually related tasks. Um and we can definitely kind of work together with all of you. Thank you so much for listening.