Eye and Vision Care Following Blast Exposure And/Or Possible Traumatic Brain Injury

CLINICAL RECOMMENDATION FOR THE EYE CARE PROVIDER EYE AND VISION CARE FOLLOWING BLAST EXPOSURE AND/OR POSSIBLE TRAUMATIC BRAIN INJURY

Introduction and Background The use of explosive devices is a common method of attack in Figure 1: Algorithm for Eye and Vision Care Following Blast Exposure and/or Possible Traumatic Brain Injury military conficts and can result in complex injuries to those involved. Blast waves, shrapnel and blunt force can result in Service member or Veteran structural damage to the eye itself and cause lesions or with history of blast exposure and/or possible TBI presents swelling in the brain that may interfere with vision.1,2,3,4 Over to eye care provider 307,283 new cases of traumatic brain injury (TBI) have been 5 reported in U.S. forces from 2000 through 2014 Q2. Data Conduct basic eye/vision exam suggest that as many as 75 percent of patients experiencing a (Table 1) TBI may also have associated visual dysfunctions, with additional cases of eye injuries caused by blast exposure.2 The Gather additional TBI-related resulting visual dysfunctions can have a signifcant functional history (Table 2) impact on the lives of Service members and Veterans.3,6,7 To Conduct supplemental testing improve patient outcomes, it is important to increase for oculomotor dysfunction awareness and establish recommendations for the (Table 3) management of eye injuries and visual dysfunctions associated with TBI and blast exposure. Urgent medical eye care Are urgent medical eye Y management (Table 4) care needs* present? Clinical Recommendation (Table 4) Consider referral for specialized care (Table 4) This clinical recommendation is designed to help guide eye N care providers (optometrists and ophthalmologists) treat patients with eye and vision problems following a possible TBI Non-urgent medical eye Are non-urgent medical eye Y care management (Table 5) or blast exposure. The recommendations include tests to help care needs** present? eye care providers screen and assess for the most common (Table 5) Consider referral for specialized care (Table 5) ocular injuries as well as visual dysfunctions caused by, or N associated with TBI. Management, rehabilitation and referral Non-urgent management or considerations are also provided for specifc medical Are TBI-related visual Y rehabilitation for TBI-related conditions and TBI-related visual dysfunctions. These dysfunctions present? visual dysfunction (Table 6) (Table 6) recommendations should not replace sound clinical judgment Consider referral for specialized care (Table 6) or standard practice when caring for a patient. N

Summary of Algorithm of Care Exit algorithm/ The “Algorithm for Eye and Vision Care Following Blast Exposure provide ongoing care and/or Possible TBI” (Figure 1) is intended to assist eye care providers evaluate, manage and refer patients presenting with *Urgent medical eye care needs: Conditions indicating possible ocular, eye or vision problems following a possible TBI or blast cranial nerve or structural brain injury, which may be sight- or life- threatening, that require immediate management by the eye care exposure. The process begins when a Service member or provider and/or referral to more specifc specialized care Veteran presents to an eye care provider as the result of a **Non-urgent medical eye care needs: Potentially chronic eye or visual self-referral or referral from another provider. The algorithm conditions for which management by the eye care provider or referral to includes recommended eye and vision tests for a basic exam as more specifc specialized care may be addressed over a course of time well as questions to obtain a TBI-related history. It also includes medical conditions that indicate the need for either urgent or non-urgent care management or referral to specialty care. This algorithm covers the recommended evaluation, management and rehabilitation procedures for the initial eye care assessment and is not intended to be used for long-term care.

Revised Date: 11 February 2015 Basic Eye Exam Table 2: TBI-Related Ocular History Questions† Table 1 includes eye/vision tests recommended as basic components of an exam by an eye care provider regardless of a TBI-Related Ocular History Questions specifc history of blast exposure, head injury, concussion or Did you have any neurological problems or symptoms before your TBI. It is recommended that these routine tests be augmented as TBI (multiple sclerosis, stroke, brain tumor, severe headaches, other)? needed, depending on provider specialty as well as the When did your TBI occur (on what date)? individual patient and environmental factors, particularly those related to possible blast exposure or TBI. Did you lose consciousness during or after your TBI incident? Table 1: Basic Eye/Vision Examination by an Eye Care Provider Were you disoriented or confused during or after your TBI incident? Do you bump into objects and walls more now than before your injury? Basic Eye/Vision Exam Were your eyes, eyelids or area around your eyes injured when your History* TBI event occurred?

Visual acuity Do you cover or close one eye at times since your injury?

Refractive error measurement Have you noticed a change in your vision since your injury?

External exam Are you more sensitive to light, either indoors or outdoors, since Pupillary testing your injury?

Extraocular muscle (EOM) testing/pursuits Have you had any double vision since your injury?

Cover test (distance and near) Have you noticed any changes in your peripheral vision since your injury? Confrontation visual feld testing Is your vision blurry at distance or near since your injury? Tonometry Have you noticed a change in your ability to read since your injury? Slit lamp biomicroscopy: Anterior segment, cornea, macula, lens and optic nerve Do you lose your place while reading more now than before your injury? Binocular indirect ophthalmoscopy (BIO) with scleral depression** How long can you read continuously before you need to stop? Gonioscopy** Do you get headaches during/after reading more now than before *It is recommended that assessment of medical history also include your injury? the question, “Have you been exposed to blast or sustained a head Do you have more diffculty remembering what you have read now injury, concussion or traumatic brain injury (TBI)?” A positive response than before your injury? to this question would be a suffcient rationale to ask TBI-related ocular history questions and conduct supplemental testing. †Goodrich G., Martinsen, G. (2013). Development of a mild traumatic **If patient history indicates exposure to blast, head injury, brain injury-specifc vision screening protocol: a Delphi study. Journal concussion and/or TBI of Rehabilitation Research & Development, 50(6), 757-768.

In-Depth TBI Evaluation Table 3: Supplemental Testing for Oculomotor Dysfunction Problems in the Basic Eye Examination by an Eye Care Provider† TBI-Related Ocular History and Additional Testing If the response regarding a possible TBI-associated event is Supplemental Testing for Oculomotor Dysfunction positive, it is recommended that additional questions be Distance cover test – unilateral and alternate (free space)†† asked during the basic eye exam to obtain a more complete history. Table 2 presents recommended questions used to Near cover test – unilateral and alternate (free space)†† obtain a detailed ocular history for a Service member or Versions (EOMs) and/or pursuits†† Veteran who has been exposed to a blast or sustained a head Accommodation injury or TBI.6 It is also recommended that gonioscopy and a dilated retinal exam with scleral depression be performed to Saccades 7 rule out occult ocular injury. Near point of convergence (NPC) Supplemental Testing for Oculomotor Dysfunction Repeated NPC (any method) Oculomotor dysfunctions are some of the most common forms of † vision problems associated with blast, head injury and TBI.7,8,9 Goodrich G., Martinsen, G. (2013). Development of a mild traumatic brain injury-specifc vision screening protocol: a Delphi study. Journal Using results from the basic eye exam and TBI-related history of Rehabilitation Research & Development, 50(6), 757-768. questions as a point of reference, an eye care provider may have ††If not already completed as part of basic eye/vision exam reason to suspect a possible TBI. To better evaluate TBI-related visual dysfunctions, it is recommended that the provider apply a targeted set of tests to detect the possible presence and type of oculomotor dysfunction. The specifc tests listed in Table 3 include those recommended for use during the exam to help guide additional management and care by the eye care provider.8

CLINICAL RECOMMENDATION FOR THE EYE CARE PROVIDER 2 Medical Eye Conditions Whether or not a provider has confrmed a possible TBI, a patient’s history and possible blast exposure may indicate the Urgent medical eye care needs: need for additional screening for various ocular injuries and Conditions indicating possible ocular, cranial nerve or vision problems. Due to the wide range of possible ocular structural brain injury, which may be sight- or life- injuries and TBI-related visual dysfunctions, it is threatening, that require immediate management by the recommended that the eye care provider evaluate the patient eye care provider and/or referral to more specifc to identify or rule out specifc conditions. Depending on the specialized care results from the exam as well as the possibility that a medical condition may present acutely, the patient may require urgent care management. Chronic medical conditions that require Non-urgent medical eye care needs: ongoing or follow-up care may also be present. Table 4 Potentially chronic eye or visual conditions for which includes a list of medical conditions that may require urgent management by the eye care provider and/or referral to management or immediate referral to specialized care. Table more specifc specialized care may be addressed over a 5 lists additional medical conditions considered to be non- course of time urgent that may be chronic or require medical management over a course of time. Both Tables 4 and 5 also include testing, evaluation and management procedures for the eye care provider to consider during treatment as well as options for referral to specialty care.

Table 4: Testing, Evaluation, Management and Referral Considerations for Conditions That May Require Urgent Medical Eye Care Additional Testing and Condition/Presentation Evaluation Considerations Management Considerations Referral Considerations Acute Proptosis • Imaging (CT, MRI) • Lateral canthotomy/cantholysis • Ophthalmic plastic and • Ultrasonography • IOP control reconstructive surgery care • Compartment syndrome • Axial length measurement • Antibiotics/steroids • Otorhinolaryngology care • Orbital cellulitis/abscess • Forced ductions • Orbital decompression • Retrobulbar hemorrhage • Fundus exam • Abscess/sinus drainage • Thyroid related orbitopathy • Exophthalmometry • Refraction (hyperopic shift) • Thyroid function testing (r/o)

Adnexal dysfunctions • Eyelid function • Tarsorrhaphy • Ophthalmic plastic and • Evaluate for eyelid and/or • Botulinum toxin injection(s) reconstructive surgery care • Eyelid retraction conjunctival scarring or wound • Correction of lid retraction • Neuro-ophthalmic care • Lagophthalmos repair issues • Gold eyelid weights • Neurology care • Orbicularis muscle weakness • Imaging (CT, MRI) • Lid spring • Trichiasis • Ice pack test or tensilon testing • Nerve transposition • Eyelid reconstruction/scar excision • Ocular lubrication • Eyelash epilation Afferent pupillary defect • Color vision testing • Refer if abnormal • Neuro-ophthalmic care • OCT testing/imaging • Neurology care • IOP check • Steroids • Neurosurgery care • Imaging (CT, MRI) • Observation (if not referred for • STS, FTA-ABS, VDRL neurological care) (r/o syphilis) • Platelet count, temporal artery biopsy Corneal abrasion • Fluorescein dye • Ocular lubrication • Cornea/external eye (no open globe) • NaCl eye eye drops (for disease care recurrent erosion post abrasion) • Bandage contact lens Corneal laceration (penetrating) • Seidel test • Rigid corneal shield • Cornea/external eye • Imaging (CT, MRI*) • Corneal laceration repair disease care *MRI contraindicated with suspected metallic intraocular foreign body

CLINICAL RECOMMENDATION FOR THE EYE CARE PROVIDER 3 Table 4: Testing, Evaluation, Management and Referral Considerations for Conditions That May Require Urgent Medical Eye Care (cont.) Additional Testing and Condition/Presentation Evaluation Considerations Management Considerations Referral Considerations Dislocated/displaced • Ophthalmic ultrasound • Lensectomy • Cornea/external eye crystalline lens or intraocular (contraindicated if open globe • IOL implantation disease care lens (IOL) implant injury or corneal laceration exist) • IOL removal/repositioning • Gonioscopy

Displaced LASIK fap • Slit lamp evaluation • Flap replacement • Cornea/external eye • Epithelial ingrowth removal disease care • Epithelial keratectomy • Refractive surgical care • Reposition fap/bandage contact lens

Endophthalmitis • Vitreous tap and/or anterior • Fortifed topical • Vitreo-retinal care chamber paracentesis with antibiotic eye drops • Cornea/external eye culture and sensitivity testing • Intravitreal/systemic antibiotics disease care • Vitrectomy

Facial nerve palsy • Eyelid function • Tarsorrhaphy • Ophthalmic plastic and • Evaluation of facial muscles • Botulinum toxin injection(s) reconstructive surgery care • Imaging (CT, MRI) • Correction of lid retraction • Neuro-ophthalmic care • Ice pack test or tensilon test • Gold eyelid weights • Neurology care • Lyme disease testing (r/o) • Lid spring • Nerve transposition • Ocular lubrication Headache (unremitting) • Imaging (CT, MRI) • Glaucoma treatment and/ • Emergency room care • Angiography or iridotomy • Neuro-ophthalmic care • IOP check or gonioscopy • Antibiotics • Neurology care • Blood pressure check • Treatment for high • Neurosurgery care • CBC, platelet count, temporal blood pressure • Glaucoma care artery biopsy • Filter evaluation • Otorhinolaryngology care • Lumbar puncture • Sinus evaluation

Hyphema (without evidence of • Determine extent of hyphema • Dilating drops • Cornea/external eye corneal laceration or and document daily changes • Topical corticosteroid drops disease care open globe) in size • IOP control • Glaucoma care • IOP check • Anterior chamber washout • Gonioscopy

Ocular surface foreign body • Seidel test • Rigid corneal shield • Cornea/external eye (possibly penetrating) • Eyelid eversion, fornix and • Foreign body removal disease care conjunctiva evaluation (defer if • Rust ring removal open globe injury) • Bandage contact lens • Imaging (CT, MRI*) *MRI contraindicated with suspected metallic intraocular foreign body

Ocular trauma • IOP check • Observation (unless obvious • Vitreo-retinal care (blunt, no open globe) • Imaging (CT, MRI) injury present) • Cornea/external eye • Ophthalmic ultrasound disease care (contraindicated if open globe • Glaucoma care injury or corneal laceration exist) • Neuro-ophthalmic care • Gonioscopy • Binocular indirect ophthalmoscopy • 90 or 78 diopter lens slit lamp exam • Palpate orbital/ periorbital area

Ocular trauma (penetrating) • Imaging (CT, MRI*) • Rigid corneal shield • Vitreo-retinal care • Foreign body removal • Cornea/external eye • Cornea/globe laceration *MRI contraindicated with • Repair open cornea/globe disease care • Intraocular foreign body suspected metallic intraocular foreign body • Glaucoma care

CLINICAL RECOMMENDATION FOR THE EYE CARE PROVIDER 4 Table 4: Testing, Evaluation, Management and Referral Considerations for Conditions That May Require Urgent Medical Eye Care (cont.) Additional Testing and Condition/Presentation Evaluation Considerations Management Considerations Referral Considerations Periocular trauma • Imaging (CT, MRI) • Facial laceration repair • Ophthalmic plastic and • Eyelid function • Eyelid/tear duct reconstructive surgery care • Facial laceration • Probe/irrigate lacrimal system laceration repair • Maxillofacial surgery care • Facial/orbital fracture • Palpate orbital/ • Probe/intubate tear system • Facial plastic surgery care • Lid laceration periorbital area • Fracture repair • Otorhinolaryngology care • Forced ductions • Orbital reconstruction • Plastic surgery care Ptosis or ocular • Eyelid function • Ptosis correction • Ophthalmic plastic and motility abnormality • Forced duction testing and • Myasthenia gravis treatment reconstructive surgery care active force generation testing • Fresnel prisms • Neuro-ophthalmic care • Ocular motility • Muscle surgery • Neurology care • Ice pack test or tensilon testing • Monocular occlusion to • Neurosurgery care • Imaging (CT, MRI) eliminate diplopia • Pediatric and adult strabismus • Parks 3-step test • Botulinum toxin injection(s) surgical care • Cover-testing in 9 positions • Ptosis crutch of gaze Retinal break, hole • Peripheral retina exam/ • Argon laser treatment • Vitreo-retinal care or detachment scleral depression • Retinal detachment repair • Low vision rehabilitation care (if • Pupillary responses test • Vitrectomy treatment is unsuccessful) • Fluorescein angiography • Long-term follow-up care • Ophthalmic ultrasound • Observation (if not referred to (contraindicated if open specialty care) globe injury or corneal laceration exists) Soft tissue necrosis • Culture workup • Bandage therapeutic • Burn and/or wound care • Blood work contact lens • Ophthalmic plastic and • Necrotizing fasciitis • Orbicularis function • Artifcial tear ointments/ reconstructive surgery care • Steven’s-Johnson syndrome • Lagophthalmos gels/drops • Cornea/external eye • Toxic epidermal necrolysis • Fluorescein dye • Suture tarsorrhaphy disease care • IOP check • Symblepharon ring • Custom therapeutic contact • Topical/systemic antibiotic lens care • Debridement • Symblepharon lysis • Probe/intubate tear system • Hyperbaric oxygen Traumatic optic neuropathy • Imaging (CT, MRI) • Observation • Neuro-ophthalmic care • Visual felds • Prescription lens flters/tints • Neurology care • Color vision testing • Neurosurgery care • Pupil evaluation • Filter evaluation Vision loss • Pupil evaluation • Anterior chamber paracentesis • Emergency room care (sudden, unexplained) • Dilated fundus exam/scleral • Hyperbaric oxygen therapy • Vitreo-retinal care depression • IV tissue plasminogen activator • Neuro-ophthalmic care • Visual felds • Selective intra-arterial • Neurology care • OCT thrombolytic therapy • Interventional radiology care • Carotid Doppler • Steroids • Echocardiogram • Retinal detachment repair • Angiography • Vitrectomy • CBC, platelet count, temporal artery biopsy • Imaging (CT, MRI) • IOP check Vitreous hemorrhage • Peripheral retina exam/scleral • Argon laser treatment • Vitreo-retinal care depression • Retinal detachment repair • Ophthalmic ultrasound • Vitrectomy (contraindicated if open globe injury or corneal laceration exists)

Abbreviations: CBC = complete blood count; CT = computed tomography; FTA-ABS = fuorescent treponemal antibody absorption test; IOL = intraocular lens; IOP = intraocular pressure; IV = intravenous; LASIK = Laser-Assisted In Situ Keratomileusis; MRI = magnetic resonance imaging; NaCl = sodium chloride; OCT = optical coherence tomography; r/o = rule out; STS = serologic test for syphilis; VDRL = venereal disease research laboratory test

CLINICAL RECOMMENDATION FOR THE EYE CARE PROVIDER 5 Table 5: Testing, Evaluation, Management and Referral Considerations for Conditions That May Require Non-Urgent Eye Medical Care and/or Rehabilitation Additional Testing and Condition/Presentation Evaluation Considerations Management Considerations Referral Considerations Cataract • Refraction • Prescription eyeglasses/ • Cataract surgery • Ocular biometry spectacles • Contact lenses • Lensectomy/IOL implantation Corneal abrasion • Foreign body exam • Antibiotic therapy • Cornea/external eye • Seidel sign • Bandage soft contact lens disease care • Fluorescein testing Corneal scarring • Corneal topography • Prescription eyeglasses/ • Cornea/external eye • Refraction spectacles disease care • Contact lenses • Custom therapeutic contact • Lamellar keratoplasty lens care • Penetrating keratoplasty Iridodialysis • Gonioscopy • Manage IOP • Glaucoma care • OCT • Manage dislocated lens • Cornea/external eye • IOP check • Surgical repair of iridodialysis disease care • Custom therapeutic contact lens care Loss of eye(s) • Socket evaluation • Clean and reft prosthesis • Ophthalmic plastic and • Condition and size of prosthesis • Socket reconstruction reconstructive surgery care • Evaluation of eyelid position • Patient education on prosthesis • Ocular prosthesis care and socket care • Blind rehabilitation care • Prescription eyeglasses with • Low vision rehabilitation care polycarbonate lenses • Prescription safety eye protection Nystagmus • Visual felds • Prescription eyeglasses • Neuro-ophthalmic care • Imaging (CT, MRI) with prism • Neurology care • Muscle surgery • Pediatric and adult strabismus • Botulinum toxin injection(s) surgical care • Low vision rehabilitation care • Vestibular audiology care (ENT and/or PT) • Custom therapeutic contact lens care Ocular surface disease • Fluorescein/rose bengal/ • Mucomimetic/artifcial tear • Cornea/external eye disease lissamine green testing therapy care • Trichiasis • Schirmer testing • Nutritional therapy • Custom therapeutic contact • Lid margin disease • Eyelash evaluation • Epilation lens care • Dry eye syndrome • Eyelid margin evaluation • Punctal plugs • Lid hygiene • Oral or topical antibiotics Ocular surface foreign body • Seidel sign • Foreign body removal • Cornea/external eye (non-penetrating) • Ophthalmic ultrasound • Topical antibiotic eye drops disease care • Imaging (X-ray, CT) • Bandage contact lens Optic nerve pallor • Color vision testing • Observation • Glaucoma care • OCT • Filter evaluation • Neuro-ophthalmic care • Visual felds • Neurology care • Imaging (CT, MRI) • FTA-ABS, STS, VDRL (r/o syphilis) • IOP check Proptosis • Imaging (CT, MRI) • Orbital reconstruction • Ophthalmic plastic and • Ultrasonography • Tumor removal reconstructive surgery care • Axial length measurement • Orbital decompression • Exophthalmometry • Consider pseudoproptosis • Forced ductions • Dilated fundus exam • Refraction (hyperopic shift) • Thyroid function testing (r/o)

Abbreviations: CT = computed tomography; ENT = ear, nose and throat; FTA-ABS = fuorescent treponemal antibody absorption test; IOL = intraocular lens; IOP = intraocular pressure; MRI = magnetic resonance imaging; OCT = optical coherence tomography; PT = physical therapy; STS = serologic test for syphilis; VDRL = venereal disease research laboratory test

CLINICAL RECOMMENDATION FOR THE EYE CARE PROVIDER 6 TBI-Related Visual Dysfunctions Following identifcation or rule out of urgent and non-urgent recommended testing, management and referral medical conditions, it is recommended that the eye care considerations for specifc TBI-related visual dysfunctions. provider conduct additional screening for specifc TBI-related These recommendations were established to help enable eye visual dysfunctions and conditions commonly seen following care providers to identify and manage visual dysfunctions blast exposure, head injury or TBI. In addition to the initial associated with TBI that affect the quality of life and testing for oculomotor dysfunctions and in consideration of functional outcomes of Service members and Veterans. These known medical eye care needs, it is recommended that the recommendations are provided under the assumption that all eye care provider screen for additional TBI-related visual existing medical conditions listed in Tables 4 and 5 continue dysfunctions including vision loss, visual feld loss and/or to be managed by the eye care provider and referrals are other conditions that affect vision. Table 6 includes the made as needed.

Table 6: Testing, Evaluation, Management and Referral Considerations for Conditions That May Require Non-Urgent Care and/or Rehabilitation for TBI-Related Oculomotor Problems and/or Visual Dysfunctions Additional Testing and Condition/Presentation Evaluation Considerations Management Considerations Referral Considerations Accommodative dysfunction • Accommodative amplitude • Prescription eyeglasses/ • Oculomotor rehabilitation care testing spectacles with or without prism • Accommodative excess • Accommodative facility testing • Accommodative • Accommodative infacility • Accommodative accuracy amplitude training • Accommodative insuffciency (monocular estimate • Accommodative spasm method) testing

Depth perception abnormalities • Stereopsis testing • Prescription eyeglasses/ • Oculomotor rehabilitation care • Unilateral cover and alternate spectacles with or without prism • Pediatric and adult strabismus • Impaired stereoscopic vision cover testing • Vergence training surgical care • Parks 3-step test • Strabismus surgery • Neuro-ophthalmic care • Vergence testing • Cyclophoria testing • Associated phoria/fxation disparity testing Eye movement disorders • Developmental eye • Prescription eyeglasses/ • Oculomotor rehabilitation care movement testing spectacles with or without prism • Neuro-ophthalmic care • Abnormal pursuits • Maddox rod testing • Prescription contact lenses • Custom therapeutic contact • Abnormal saccades • King-Devick testing • Oculomotor training lens care • Nystagmus • Eye movement recording study • Botulinum toxin injection(s) • Vestibular audiology care (ENT • Oscillopsia and/or PT)

Loss of visual function • Low vision assessment • Prescription eyeglasses/ • Blind rehabilitation care • Mobility assessment spectacles with or without prism • Low vision rehabilitation care • Blindness • Visual feld testing • Prescription optical low • Low vision • Visual neglect assessment vision devices • Visual feld loss • Foveal feld testing • Prescription optical and • Visual neglect • Imaging (CT, MRI) electronic visual feld expanders • Glare and contrast or enhancement devices sensitivity testing • Mobility aids and training • Low vision aids and training

Ocular alignment disorder • Parks 3-step test • Prescription eyeglasses/ • Oculomotor rehabilitation care • Unilateral cover and alternate spectacles with or without prism • Pediatric and adult strabismus • Convergence insuffciency cover testing • Vergence therapy surgical care • Convergence excess • Vergence testing • Occlusion • Neuro-ophthalmic care • Fusional vergence dysfunction • Cyclophoria testing • Strabismus surgery • Custom therapeutic contact • Other heterophoria • Vertical deviation testing • Botulinum toxin injection(s) lens care • Strabismus (paretic and • Saccades testing non-paretic) • Forced ductions testing and active force generation testing • Imaging (CT, MRI)

Photophobia/glare sensitivity • Glare assessment • Tinted prescription • Neuro-ophthalmic care • Corneal topography eyeglasses/spectacles • Neurology care • Tear flm evaluation • Tinted prescription • Psychology care • Cataract assessment contact lenses • Psychiatry care • Special prescription lens • Pain management care flters/tints • Pharmacotherapy

CLINICAL RECOMMENDATION FOR THE EYE CARE PROVIDER 7 Table 6: Testing, Evaluation, Management and Referral Considerations for Conditions That May Require Non-Urgent Care and/or Rehabilitation for TBI-Related Oculomotor Problems and/or Visual Dysfunctions (cont.) Additional Testing and Condition/Presentation Evaluation Considerations Management Considerations Referral Considerations Reading diffculties • Refractive analysis • Prescription eyeglasses/ • Oculomotor rehabilitation care • Accommodative testing spectacles with or without prism • Pediatric and adult strabismus • Eye strain • Unilateral cover and alternate • Convergence training surgical care • Diffculty with visual memory cover testing • Vergence therapy in reading • Phoria testing • Headache • Vergence testing • Loss of reading place • Developmental eye • Lack of sustained reading ability movement testing • Words appear to jump • King-Devick testing when reading • Eye movement recording study • Ocular motility testing

Abbreviations: CT = computed tomography; ENT = ear, nose and throat; MRI = magnetic resonance imaging; PT = physical therapy

Conclusion 5. Defense Medical Surveillance System and the Theater This clinical recommendation is based on a review of the Medical Data Store (DMSS-TMDS). (2014). Prepared by the literature and consensus of expert opinion. It is intended to Armed Forces Health Surveillance Center. http://dvbic. provide procedural recommendations for the eye care provider dcoe.mil/dod-worldwide-numbers-tbi. regarding assessment, management, rehabilitation and referral 6. Luu, S., Lee, A. W., Daly, A., & Chen, C. S. (2010). Visual for patients with medical eye care conditions and visual feld defects after stroke—a practical guide for GPs. dysfunctions associated with TBI. These recommendations are Australian Family Physician, 39(6), 499-503. not a substitute for existing guidance or clinical judgment. As with all clinical decisions, feld and operational circumstances 7. Warren, M. (2009). Pilot study on activities of daily living may require deviation from these recommendations. limitations in adults with hemianopsia. American Journal of Occupational Therapy, 63(5), 626-633. 8. Goodrich G., Martinsen, G. (2013). Development of a mild References traumatic brain injury-specifc vision screening protocol: a 1. Dougherty, A. L., MacGregor, A. J., Han, P. P., Heltemes, K. Delphi study. Journal of Rehabilitation Research & J., & Galarneau, M. R. (2011). Visual dysfunction following Development, 50(6), 757-768. blast-related traumatic brain injury from the battlefeld. 9. Cockerham, G. C., Goodrich, G. L., Weichel, E. D., Orcutt, Brain Injury, 25(1), 8-13. J. C., Rizzo, J. F., Bower, K. S., et al. (2009). Eye and visual 2. Stelmack, J. A., Frith, T., Van Koevering, D., Rinne, S., & function in traumatic brain injury. Journal of Rehabilitation Stelmack, T. R. (2009). Visual function in patients followed Research and Development, 46(6), 811-818. Veterans Affairs Polytrauma Network site: An electronic 10. Kapoor, N., & Ciuffreda K. J. (2011). Vision problems. In J. medical record review. Optometry, 80(8), 419-424. M. Silver, T. W. MacAllister, & S. C. Yudofsky (Eds.), 3. Barnett, B. P., & Singman, E. L. (2015). Vision concerns Textbook of traumatic brain injury (pp. 363-373). (2nd ed.). after mild traumatic brain injury. Current Treatment Options Arlington, VA: American Psychiatric Publishing. in Neurology, 17(2), 1-14. 11. Brahm, K. D., Wilgenburg, H. M., Kirby, J., Ingalla, S., 4. Magone, M. T., Kwon, E., & Shin, S. Y. (2014). Chronic Chang, C.Y., & Goodrich, G. L. (2009). Visual impairment visual dysfunction after blast-induced mild traumatic brain and dysfunction in combat-injured servicemembers with injury. Journal of Rehabilitation Research and traumatic brain injury. Optometry and Vision Science, Development, 51(1), 71-80. 86(7), 817-825.

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Revised Date: 11 February 2015