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ACCCOS More Than Meets the TB-EYE 09APR2017 AM

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ACCCOS More Than Meets the TB-EYE 09APR2017 AM 5/9/17 DISCLOSURE MORE THAN MEETS THE All information in this presentation is my opinion only based on peer reviewed information and was gained through the public domain and google searches TB-EYE I am an employee consultant/contractor of Booz Allen Hamilton Current assignment is Optometric Subject Matter Expert at the Department of Defense/Veterans Affairs Vision Center of Excellence located at the Walter ANDREW S. MORGENSTERN, OD FAAO Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland DIPLOMATE, AMERICAN BOARD OF OPTOMETRY All information presented is the opinion of Andrew Morgenstern, OD FAAO and NOT the opinion of the US Government, Department of Defense, BETHESDA, MARYLAND Department of Veterans Affairs, Army, Navy, Air Force, Vision Center of Excellence or any other US Government organization, US Government Contractor or Booz Allen Hamilton DISCLOSURE: VOLUNTEER POSITIONS ADVISORY BOARDS AND CONSULTANT • Alcon • Allergan • American Optometric Association • American Optometric Association • Bruder Healthcare • President, Optometric Cornea Cataract and Refractive Society (OCCRS) • Bryn Mawr Communcations • International Keratoconus Academy • Founding Executive Board Member, International Keratoconus Academy • Oasis • Past-President Maryland Optometric Association • Oculus • Red Cross Volunteer Optometrist WRNMMC • Science Based Health • TLC Laser Eye Centers • ARBO/COPE Reviewer I have no financial interests regarding anything discussed in this presentation 1 5/9/17 Free Subscription Mailed to Your Home or Office www.bit.ly/AOCaccess AMERICAN OPTOMETRIC ASSOCIATION EVIDENCE BASED GUIDELINE COMPREHENSIVE PEDIATRIC AND VISION GUIDELINE JESSUP CELLARS VANCE THOMPSON, MD JUSTIN SCHWEITZER, OD SYRIAN SARIN GAS ATTACK PURITY OF INFORMATION 2 5/9/17 TBI AND OPTOMETRY OBJECTIVES • Statistics on mTBI (Concussion) and TBI • High Yield Vision Testing • Special Vision Testing • Rehabilitative Options • Impact of Vision Deficits on Return to Play/Work • Military and mTBI/TBI • NFL and NFL Concussion Protocol LOBES OF THE BRAIN FRONTAL PARIETAL TEMPORAL OVERVIEW OF OCCIPITAL TRAUMATIC BRAIN INJURY CEREBELLUM BRAIN STEM WHAT IS A TBI? TYPES OF TBI According to the Centers for Disease Control (CDC) “A TBI is caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. The severity of a TBI may range from “mild” (i.e., a brief change in mental status or consciousness) to “severe” (i.e., an extended period of unconsciousness or memory loss after the injury). Most TBIs that occur each year are mild, commonly called concussions. 3 5/9/17 OTHER TYPES OF BRAIN INJURIES BRAIN INJURY TYPES AND TERMS (TRAUMATIC AND ACQUIRED) • Aneurysm • Anoxic Brain Injury • Closed Head Injury • Concussion • Brain Contusions • Hypoxic-Ischemic Injury • Hematoma • Diffuse Axonal Injury • Infarction • Intra-Cranial Pressure • Chronic Traumatic Encephalopathy • Open Head Injury • Organic Brain Injury • Subarachnoid Hemorrhage CONCUSSION WHAT IS DIFFUSE AXONAL INJURY (DAI)? • Occurs in about half of all severe head traumas • Another name for Mild Traumatic Brain Injury (mTBI) • Can also occur in moderate and mild brain injury • Most common form of TBI • Typically diffuse and not focal • Effects are usually temporary but can include headaches and problems with concentration, memory, balance and coordination • Severe DAI is one of the leading causes of death in people with traumatic brain injury • Can easily affect vision NORMAL AXON DIFFUSE AXONAL INJURY 4 5/9/17 DIFFUSE AXONAL INJURY WHAT IS CHRONIC TRAUMATIC ENCEPHALOPATHY? • White Matter Injury • Results from the brain moving back and forth in the skull as a result of acceleration or deceleration • As tissue slides over tissue, shearing injury occurs • Responsible for unconsciousness, as well as the vegetative state that occurs after a severe head injury BOSTON UNIVERSITY ALUMNI CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE) • Chronic Traumatic Encephalopathy (CTE) is a progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic subconcussive hits to the head. CTE FACTS BOSTON UNIVERSITY CTE • CTE was originally reported in 1928 by a pathologist, who described the clinical • Top left: Whole brain section from a 65 year old control subject showing no tau protein deposition aspects of a progressive neurological deterioration (‘punch drunk’) that occurred • Bottom left: Microscopic section from 65 year old after repetitive brain trauma in boxers. control subject also shows no tau protein deposition • Originally termed dementia pugilistica’ (pugilistica comes from the Latin root pugil, • Top middle: Whole brain section from John Grimsley showing abundant tau protein deposition in the for boxer) amygdala and adjacent temporal cortex • • Bottom middle: Microscopic section showing The trauma triggers progressive degeneration of the brain tissue, including the numerous tau positive neurofibrillary tangles and build-up of an abnormal protein called TAU. neurites in the amygdala • Top right: Whole brain section from a 73 year old • Changes in the brain can begin months, years, or even decades after the last brain world champion boxer with severe dementia showing trauma or end of active athletic involvement. very severe tau protein deposition in the amygdala and thalamus • The brain degeneration is associated with memory loss, confusion, impaired • Bottom right: Microscopic section from a 73 year old world champion boxer with severe dementia showing judgment, impulse control problems, aggression, depression, and, eventually, extremely dense tau positive neurofibrillary tangles progressive dementia. and neurites in the amygdala 5 5/9/17 CTE HISTORY CTE HISTORY CTE HISTORY CTE STAGE 1 CTE STAGE 2 CTE STAGE 3 6 5/9/17 CTE STAGE 4 ADVANCED CTE TOP TEN OF TBI WHAT IS THE INCIDENCE OF TBI? ACCORDING TO THE CDC • According to the CDC data recovered from the VA/DOD CPG on Management Number 1 of Concussion/mTBI • 1.7 Million Americans per year survive a TBI A traumatic brain injury is a blow or jolt to the head or a penetrating head injury • 230,000 are hospitalized that disrupts the function of the brain. You do not need to lose consciousness • 50,000 die which is ~30% of all injury related deaths to sustain a concussion. TOP TEN OF TBI TOP TEN OF TBI Number 3 Number 2 The three groups at highest risk for traumatic brain injury are children (0-4 year olds), teenagers (15-19 year olds), and adults (65 and older). (2) 1.7 million people sustain a TBI each year in the United States. By the numbers, every American has more than a 1:300 chance of sustaining a traumatic brain injury each year. Males aged 0 to 4 years have the highest rates of TBI- related emergency department visits, hospitalizations, and deaths combined. 7 5/9/17 TOP TEN OF TBI TOP TEN OF TBI Number 4 Number 5 Estimates peg the number of sports-related traumatic brain injuries as high as 3.8 Wearing a seatbelt and a helmet are the best ways to prevent a TBI million per year. TOP TEN OF TBI TOP TEN OF TBI Number 7 Number 6 A concussion is a mild brain injury. The consequences of multiple concussions can Males are almost twice as likely to have a TBI than females be far more dangerous than those of the first TBI TOP TEN OF TBI TOP TEN OF TBI Number 8 Number 9 The area most often injured are the frontal lobes that control thinking and A blow to one part of the brain can cause damage throughout. emotional regulation 8 5/9/17 GLASGOW COMA SCALE TOP TEN OF TBI Psychopharmacological Treatment for Cognitive Impairment in Survivors of Traumatic Brain Injury: A Critical ReviewBrian W. Writer, D.O.; Jason E. Schillerstrom, M.D.The Journal of Neuropsychiatry and Clinical Neurosciences 2009;21:362-370. Number 10 Most people that have a TBI can recover relatively well HOW MANY PEOPLE HERE FEEL COMFORTABLE MANAGING A TBI PATIENT? DIAGNOSIS OF TRAUMATIC BRAIN INJURY WHAT DOES A TBI EYE EXAM LOOK LIKE? WHAT TESTS DO WE PERFORM? • Full Dilated Eye Exam? www.veteranstoday..com • Cycloplegic Refraction? • Accommodative Testing? • Vergence Testing? • What Else??????? 9 5/9/17 CAN HAVE SIGNIFICANT DIFFERENCES IN VISUAL CONSIDERATIONS DE NEAR AND DE DISTANCE VISUAL ACUITY IN A TBI PATIENT • Photophobia • Loss or decrease • Visual Acuity • Color Discrimination • Brightness Detection • Contrast Sensitivity • Visual Field Defects • Visual Midline Shift Syndrome AOA BRAIN INJURY MOST COMMON VISUAL COMPLAINTS AFTER MTBI ELECTRONIC RESOURCE MANUAL (BIERM) PART A AND B Oculomotor • Diplopia Binocular • Convergence Insufficiency Vision Field Losses • The BIERM serves as a • With Neglect comprehensive resource to aid • Without Neglect optometrists in evaluating patients Accomodative with brain injury. http://www.brainline.org/content/2010/02/vision-issues-after-brain-injury-brainline-talks-with-dr- gregory-goodrich_pageall.html INJURY TO THE VISUAL PATHWAY INJURY TO VISUAL PATHWAY 10 5/9/17 EXAMINATION OF AFFERENT PATHWAYS EXAMINATION OF EFFERENT PATHWAYS • Acuity • Lids • Contrast Sensitivity • CN VII (Supra and Infra Nuclear) • Color • CN V-1 • Amsler Grid • Ocular Stability an Binocular Alignment • Confrontation Visual Fields • Accommodation in Free Space • Photo Stress Test • Sensory Status • Pupils and Near Vision Testing HIGH YIELD VISION TESTING VISION TESTING FOR MTBI • History Distance Cover test Near Cover Test • Qualify the mTBI with Injury
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