ABSTRACTBACKGROUND: Traumatic brain injury (TBI) results from mild, moderate or severe trauma to the head. The use of firearms, motor vehicles and falls causing the most deaths from TBI with firearms being the leading cause of death among persons aged 20 to 74 years. The CDC estimates that 5.3 million Americans (2% of the US population) have suffered a TBI. More than 1.4 million people a year sustain a TBI with 50,000 of these individuals dying and 235,000 being hospitalized.

CASE REPORT: A 25 y/o H M (AO) with a history of a gunshot to the right side of the head presented with left side spastic-ity, hemianopsia, diplopia, problems tracking a moving object and reading difficulty. AO had completed a post TBI rehabilitation program (OT, PT, Speech/Lang), but still has PT 2X a week. His current medications include Phenytoin, Sertra-line, Kepra and Baclofen. AO had no known allergies. He had a small amount of myopia and astigmatism. An exotropia with left hyper was noted at far/near. Other functional vision and vision information processing problems were noted as well. The fundus was remarkable for temporal ON pallor. His final diagnosis was exotropia, hypertropia, diplopia, suppres-sion, oculomotor dysfunction, accommodative instability, dry eye, optic nerve pallor, left hemianopsia, visual attention dis-order and multiple vision information processing anomalies. A multifocal prescription was given with both ground in and Fresnel prisms. Artificial tears and Omega-3s with appropri-ate hydration were suggested for the dry eye. In/out of office optometric vision therapy program was started.

CONCLUSIONS: AO showed many of the oculo-visual anoma-lies associated with Post Trauma Vision Syndrome. We have decreased his dry eye symptoms, eliminated his diplopia and significantly improved his oculomotor abilities. Because of this, his reading and quality of life has already improved. Un-fortunately after several visits he decided not to continue therapy primarily because of transportation issues and possi-ble non-acceptance of his limitations. All individuals with TBI should be assessed and treated by an optometrist who may be able to provide additional rehabilitative services beyond

those routinely offered by the medical community.

BACKGROUNDEach year 1.4 million people in the U.S. suffer a traumatic

brain injury with 50,000 dying and 235,000 being hos-

pitalized. More than a million are evaluated in but then

released from an emergency room. For children 14 years

of age and younger, traumatic brain injury accounts for

almost 2700 deaths, 37,000 hospital admissions, and

435,000 emergency room visits. For children birth to 4yrs

and adults older than 75 falls are the most frequently en-

counter cause of TBI, while children birth to 4yrs and teens

15-19 yrs are most at risk for having traumatic brain injury.

Violence remains the second leading cause of fatalities in

the US with violence related deaths exceeding auto ac-

cidents as a major cause of TBI related fatality. Gun inci-

dents account for 40% of TBI associated deaths.

CASE SUMMARY

AO was originally seen in the Illinois Eye Institute Disabili-

ties Service on 01-21-09. He was a former Chicago gang

member who was shot in the head 1.5 years earlier suffer-

ing a traumatic brain injury. He had completed all of his

acute rehabilitative therapy programs, but was still partici-

pating in physical therapy. AO noted a left side weakness;

eye irritation, tearing, itching OS, and occasional double

vision both horizontally and vertically. His medications in-

cluded Phenytoin, Sertraline, Kepra, and Baclofen. A com-

prehensive medical history was not possible since he ap-

peared to be reluctant to share this information with us.

Several of the medical sources that he gave us were not

valid and, therefore no further information could be ob-

tained. (See examination findings in table 1) (Vision thera-

py information in Table 2)

AO returned to the Peds/BV/Disability Service for a strabis-

mus evaluation and visual field. It was noted that he dem-

onstrated an intermittent left hypertropia and exotropia,

a dry eye and a left hemianopic visual field loss. We also

conducted a vision information process assessment that

demonstrated several areas of visual perceptual/vision in-

formation processing dysfunction (Table 3).

The Visagraph was performed at the beginning of treat-

ment on 04/2009 and again during the recent follow-up

assessment (Table 4.) Significant improvement was noted

during this year as a result of multidisciplinary treatment

including prism glasses, office/home vision therapy and

other components of his TBI rehabilitation program (OT,

PT, Speech/Language, psychological counseling, family

support, etc.) (See Table 4)

The TOVA (Test of Variables of Attention) was completed

on 03/2010 because of concern with AO’s attentional is-

sues and difficulty staying on task. The results for atten-

tion, impulsivity, response time, variability of response

time, d’ deterioration score and ADHD score (subject’s

comparison with an ADHD age-matched norms) are sum-

marized in Table 5.

Treatment recommendations included a prescription with

vertical and horizontal prism, artificial tears, and optometric

vision therapy. Vision therapy sessions included the use of

various hand-eye/oculomotor therapy, Vision Builder com-

puter software, Brock String, Major Amblyoscope, and ac-

commodative techniques. The patient discontinued vision

therapy after a few sessions to concentrate on his physical

therapy program.

AO returned for a comprehensive evaluation on 3-2-10 that

showed a decreased incidence of strabismus, but other-

wise only moderate changes from the initial evaluation.

He did not wish to start vision therapy again and only

wanted glasses. He was informed to return to us when

he was ready to fully participate in an active therapy pro-

gram. We will conduct a follow-up vision information

processing assessment at that time as well.

CONCLUSIONSAlthough AO had multiple symptoms, he was not ready to accept the new

person he had become versus the macho gang member he was. His ability

to accept help and to take an active part in his vision rehabilitation program

was limited by this. There were also other issues that included transporta-

tion and fiscal concerns. He was informed that we would be available to

continue his care when he was able to participate fully and that he should

return to us at least once a year for a comprehensive evaluation. Even with

this limited involvement in therapy, positive and significant changes were

made that helped to improve his quality of life.

CONTACTDominick M. Maino, OD, MEd, FAAO, FCOVD-A dmaino@ico.eduwww.ico.edu

A Gun Shot to the Head: Oculo-Visual & Perceptual Anomalies

D. Maino, D. Schlange, R. Donati, C. Bakouris, M. Nikoniuk • Illinois College of Optometry

Table 1: Examination/Follow-up Findings

Date RefractiveError BestVisualAcuity Strabismus Function ExternalEyeHealth InternalEyeHealth VisualField01/21/09 OD-.50-.25X090 20/20- 8PDLHdist lagophthalmus ONTempPallor Lhemianopic OSPl 20/20- 6PDXT Dryeye VFdefect 8PDLHnear 18PDXT01/28/09 Nochange NoRDSforms LIROR? DiplopiaW4D Accinsufficiency02/11/09 ODPl-.50X090 20/20 4BI/3BU NoChange NoChange NoChangeFollow-upEvaluationRx OS-.50sph 20/20- 4BI/3BD04/21/09Follow-upEvaluation Diplopiastillpresent,notasfrequentlynoted,added6BUODand6BIOSusingFresnelprismlenses

03/02/10 ODPl 20/15 6BI/5BU 10XP10LHTdistIntermittentDiplopia NoChange NoChange NoChangeComprehensiveEvaluation OS-.25SPH 20/20 6BI/5BD 15XP4LHTnear +.75MEM (Dryeyeimproving) DiplopiasignificantlylessPatientdidnotwanttocontinueanytherapyexceptforthewearingoftheglasses.Theprescriptiongivenwiththeprismeliminatedthediplopiamostofthetime.

Table 2: Optometric Vision Therapy

04/28/09 Startedin-officeoptometricvisiontherapy(OVT)program(VisionBuilderactivities)05-26-09to09/14/09 ContinuedOVT (VisionBuilder,RotatingPegboard,WayneSaccadicFixator,Brockstring,Vectograms)8VTsessions09/14/09 PatientdiscontinuedOVT

Table 3: Vision Information Processing Assessment findings below expected performance02/04/09

DEM Reversals Frequency Fine Motor Visual-Motor Integration Test of Visual Perceptual SkillsOMDysfunction Recognitionsubtest WoldSentenceCopyTest DTVMI VisualDiscrimination VisualSequential-Memory VisualFormConstancy VisualFigure-Ground VisualClosure

Table 5: The TOVA (Test of Variables of Attention) was completed on 03/2010 because of concern with AO’s attentional issues and difficulty staying on task. The results for attention, impulsivity, response time,

variability of response time, d’ deterioration score are summarized below. His ADHD score (subject’s comparison with ADHD age-matched norms) was not normal at -5.59 (normal = ≤ -1.80) is suggestive of ADHA.

Table 4: The Visagraph was first completed 4/2009 and one year later on 3/2010. Significant improvement was achieved during this year as a result of his TBI

and vision rehabilitation program.

Visagraph Results: PreVT & 1-Year In-progress VT

VisagraphParameters Pre-VT4/09 In-Progress3/10

Change(+=improved)

Fixations/100words 250 182 68+

Regressions/100words 59 33 26+

Span(words)/fixation 0.40 0.55 0.15+

Readingrate(words/min) 98 135 37+

RelativeEfficiency(grade) 0.32(1.1) 0.63(2.5) 0.31(1.4)+

Crosscorrelation 0.61 0.89 0.28+

Anomalies 1/1/23 2/4/10 1/3/13+

Multipleregressions 2 1 1+

Saccadicstartdifferences 43 29 14+

FixationDurationS.D. 118ms 97ms 21+

ImprovementinALLparameters

0

20

40

60

80

100

120

Inattention Impusivity

Stan

dard

Sco

re

TOVA - Inattention and Impulsivity

1st half (12 min) of test

2nd half (12 min) of test

Patient's Attention control deteriorates during the last 15 min. of 24 min. test.

Impulsivity is normal

0

20

40

60

80

100

120

Response Variability

Stan

dard

Sco

re

TOVA - Response Time & Variability

1st half (12 min) of test

2nd half (12 min) of test

Response Time and the Variability of Response Time deteriorate rapidlyduring last 12-15 min. of this 24 min. test. Normal is standard score ≥ 80.

0

20

40

60

80

100

120

Inattention Impusivity

Stan

dard

Sco

re

TOVA - Inattention and Impulsivity

1st half (12 min) of test

2nd half (12 min) of test

Patient's Attention control deteriorates during the last 15 min. of 24 min. test.

Impulsivity is normal

0

20

40

60

80

100

120

Response Variability

Stan

dard

Sco

re

TOVA - Response Time & Variability

1st half (12 min) of test

2nd half (12 min) of test

Response Time and the Variability of Response Time deteriorate rapidlyduring last 12-15 min. of this 24 min. test. Normal is standard score ≥ 80.

Practicinghandeyeandpursuitswitharotator

AOLEVF AOREVF

TBIpatientpostrehab

TBIPatientusingtheWayneSaccadicFixator

TBIpatientusingPaddleBallcomputertherapy

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Maino D (ed). Diagnosis and Management of Special Populations. Mosby-Yearbook Inc St. Louis, MO. 1995. Reprinted Optometric Education Program Foundation, Santa Anna, CA. 2001.

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A PDF of this poster is available at http://www.slideshare.net/DMAINO

Many of the OVD references available at http://www.covd.org/Home/OVDJournal/OVD401/tabid/263/Default.aspx

Contact: Dominick M. Maino, OD, MEd, FAAO, FCOVD-A; dmaino@ico.edu; http://www.ico.edu, http://www.MainosMemos.blogspot.com