An American Approach: Vision Rehabilitation Following Acquired Brain Injury and Stroke – Lessons from US Veterans and

1. Gregory L. Goodrich, Ph.D. Western Blind Rehabilitation Center & Psychology Service Supervisory Research Psychologist VA Palo Alto Health Care System An American Approach: Vision Rehabilitation Following Acquired Brain Injury and Stroke – Lessons from US Veterans and Troops

2. It’s a pleasure to be here! The top ten best places to be born in 2013:1. Switzerland 2. Australia 3. Norway 4. Sweden 5. Denmark 6. Singapore 7. New Zealand 8. Netherlands 9. Canada 10. Hong Kong god morgen

3. I have no financial interest in any product discussed • The views expressed are my own and do not necessarily reflect those of the Department of Veterans Affairs or the Palo Alto Health Care System • My research colleagues • Jennine Kirby, O.D. • Heidi Flyg, O.D. • Karen Brahm, O.D. • Gary Martinsen, O.D. • Glenn Cockerham, O.D. Disclaimers & Acknowledgments

4. The Department of Veterans Affairs (VA) is a federal program serving veterans • 22.2 million veterans (Denmark ~5.5 million) • Serves36% of all veterans • 55% of 1.5 million Iraq and Afghanistan veterans receive VA services; 94% outpatient & 6% hospitalized) • Total US population ~ 313 million (EU ~ 503,679,730) • 152 medical centers, over 1100 clinics • 13 Blind Rehabilitation Centers, 54 Low Vision Clinics • Currently serve veterans from WWII, Korea, Vietnam, Gulf War, and wars in Afghanistan and Iraq as well as peacetime intervals Background

5. Brief history of how I got here • What do traumatic brain injury and stroke have in common (and differences)? • Review of our research on TBI and vision loss • Studies of vision loss/dysfunction • Inpatient • Outpatient • Mechanism of injury • Rehabilitation • What we know and don’t know • Summary Outline

6. Most of my career in low vision research (reading, mobility, technology, etc.) • 2003 WBRC admitted first military patient with TBI-related vision loss • Not a happy story • We learned that individuals with TBI-related vision loss didn’t fit well into “traditional” low vision rehabilitation • This led to research to characterize the vision injury and co-existing conditions • Which, in turn, led to clinical rehabilitation programs How I got here

7. Vision loss – Stroke & Trauma • Stroke • Binocular/oculomotor problems • Visual field loss • Visual acuity loss (rare) • Visual processing • Light sensitivity • Co-morbid loss (paresis, paralysis, cognitive, emotional, etc.) • Trauma • Binocular/oculomotor problems • Visual field loss • Visual acuity loss (rare) • Visual processing • Light sensitivity • Co-morbid loss (paresis, paralysis, cognitive, emotional, etc.)

8. In brain injury from both stroke and trauma vision loss/dysfunction are frequently undiagnosed Vision rehabilitation is usually only one of numerous types of rehabilitation needed by the patient Vision loss/dysfunction degrades education, vocation and quality of life Caregivers play an important role in recovery We know much less than we would like! Similarities aside “the devil may be in the details” Danish Other commonalities English

9. Stroke often occurs to specific brain areas • Traumatic brain injury may lack this specificity • Some differences in co-morbidities • Post traumatic stress disorder (PTSD) • May reflect that PTSD is not assessed in civilian settings • Dual sensory impairment (DSI): hearing & vision (blast) • Severity may be assessed on different scales • Glasgow Coma Scale vs NIH Stroke Severity • Commonalities and differences in visual loss/dysfunction between stroke- and trauma-related injury have not been well studied Some differences

10. ~85% of TBIs are mild • ~15% of TBIs are moderate/severe/penetrating • In our studies severity of TBI does not correlate with severity of vision loss/dysfunction, but • mTBI generally associated with binocular/occulomotor dysfunction in outpatients • Inpatients exhibit vision loss and binocular/ occulomotor dysfunction • In TBI vision loss may relate to severity of injury, damage to eye, orbit, optic tract, etc. Severity of brain injury

11. Traumatic Brain Injury http://www.cdc.gov/traumaticbraininjury/statistics.html • Incidence = 1.7 million/yr. (not treated hence not reported = ???) • 1.365 million treated; 275,000 hospitalized • Cost = $76.5 billion/yr. • Causes • Falls ~ 523,000 • Stuck by/against (sports, accidents, etc.) ~ 271,000 • Motor Vehicle Accident ~ 218,000 • Assault ~ 148,000 • Other/Unknown ~202,000 • Aquired brain injury: stroke/anoxia/tumor/etc. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5619a2.htm • Stroke ~ 795,000/yr. • Cost ~ $62.7 Billion/yr. Epidemiology: UNITED StaTES

12. Traumatic Brain Injury • Incidence = 1.6 million/yr. Ribbers, G.M. Int Encyl Rehab (http://cirrie.buffalo.edu/encyclopedia/en/) • 18% of US incidence (reporting or just less accident prone?) • Cost = € 2.9 billion/yr. • Causes similar to US data • Aquired brain injury: stroke/anoxia/tumor/etc. (http://www.escardio.org/communities/EHRA/publications/papers-interest/Documents/ehra-stroke-report-recommend-document.pdf) • Stroke ~ 2 million/yr. • Cost ~ € 38 Billion/yr. Epidemiology: Europe

13. Visual Acuity • Interestingly, visual acuity is not often impacted (~3% - 14% in inpatients; ~1% – 2% in outpatients) • may be most affected by non-blast injury or more severe level of injury • Blast events result in enucleation (18%) or blindness (6%) in polytrauma patients • Visual acuity often considered “gold standard” of visual function – “status”may hinder identification of patients with visual abnormalities Visual changes following tbi

14. Visual Field • 14% - 33% found in our studies of polytrauma patients • Hemianopia most common field loss usually homonimous but may be bitemporal • Monocular or binocular • Quadrant loss or field constriction Visual changes following tbi

15. Binocular/Oculomotor Dysfunctions • Accommodation • Vergence • Strabismus • Pursuits • Fixation Visual changes following tbi

16. Very good documentation that dysfunctions negatively affect quality of life, for example, • Reading • Schuett, S. Neuropsychologia, 2008 • Mobility & Driving • Hatt, S. J Ophthal, 2007; Chen, S. Top Stroke Rehab, 2009; DVBIC, July 2, 2009 • Communication and social interaction • Babbage, D., Neuropsych, 2009 • Visual Processing • Mckenna, K. et al, 2005, Brain Inj • Recovery and reintegration • Saunders, et al, JRRD, 2012 • Quality of life • Cockerham, NEJM, 2009 Binocular/oculomotor dysfunction

17. Goodrich, et al. JRRD, 2007 • Lew, et al. JRRD, 2007 • Stelmack, et al. Optom, 2009 • Cockerham, et al. JRRD, 2010 • Lew, et al. (DSI) NeuroRehab, 2010 • Cockerham, et al. NEJM, 2011 (occult eye injury) • Dougherty, et al. Brain Inj, 2011 • Capo’-Aponte, et al. Mil Med, 2012 • Goodrich, et al. Opt Vis Sci 2013, (in press) • Goodrich, et al. JRRD, 2013 (in press) VA/DoD TBI & Vision literature

18. The following slides summarize our studies on VA outpatients • Majority diagnosed with mTBI • Majority male ~95% • Mean age ~ 29 years • Served in Afghanistan and/or Iraq • The data presented will address mechanism of injury (blast vs other trauma such as motor vehicle accidents, falls, assault, etc.) Outpatient studies (Brahm, et al.OVS 2009; Goodrich, et al. OVS (in press))

19. Polytrauma Networks Site (outpatient clinic) • Referred to clinic if answered yes to any one question • 1. Have you ever been in a blast/explosion (or close proximity), • vehicular crash, or fall? (79% blast, 21% other) • 2. Have you ever been rendered unconscious? (50%) • 3. Have you ever had head trauma (98%) • Visual status pre-injury unknown outpatient Population

20. Patient Self-reported visual and reading problems

21. Example of effects of dysfunction • Alphabet Pencils • Read 1st letter on left pencil then first on left pencil • second on first pencil then second on left pencil, etc.

22. Spontaneous Recovery? • Findings from studies of military/veteran and civilian populations following TBI suggests spontaneous recovery may occur in accommodation, strabismus and pursuits/saccades, to a lesser degree in convergence. Self-reported and measured reading difficulties may persist • Limitations of these conclusions is that we don’t know the visual status of patients prior to injury and that the comparison study (Capo-Aponte) was a controlled study with small N *includes both symptoms and measured deficits 1. Goodrich GL et al. JRRD. 2007;44:929-36. 2. Brahm KD et al. Optom Vis Sci 2009;86:817-25. 3. Stelmack JA et al. Optometry 2009;80:419-24. 4. Ciuffreda KJ et al. Optometry 2007;78:155-61. 5. Capo-Aponte JE et al. Mil Med 2012;177:804-13.

23. The question of mechanism of injury is an over-arching one for us since blast significantly differs from other mechanisms of injury primarily from the primary blast wave (over-pressure wave) and likelihood of injury due to burns and injury from projectiles/shrapnel (including infection risk) Mechanism of injury

24. In civilians: motor vehicle accidents, falls, assaults, struck by/against, other most frequent causes In military personnel: blast event, motor vehicle accident, falls, assaults, gunshot, struck by/against, other There is some evidence that traumatic brain injury due to a blast event differs from other causes. Blast events are also associated with higher rates of eye injury and loss of one or both eyes which is consistent with our findings. Svetlov, S, et al. (2009) J Neurotrauma; Hurley, R. et al (2006), NEJM Mechanism of Injury

25. Polytrauma ~ multiple, simultaneously occurring injuries usually involving TBI • Populations studied were • inpatients of a polytrauma rehabilitation center • outpatients with diagnosed mild traumatic brain injury (mTBI) or • Most common injury: blast-related (~50%) • Median age ~ 29 years (range 19 to 59) • ~95% male Vision loss/dysfunction in polytrauma

26. Comprehensive Eye/Vision Examination (now mandated by VA for all Polytrauma Rehabilitation Center patients) • Patient history • Visual acuity (ETDRS, Feinbloom Number Chart)* • Visual field (Goldman, Arc Perimeter, Tangent Screen, Confrontation)* • Binocular/occulomotor • Fixation, accommodation, vergence, saccades, etc. • Reading ability assessed * Test selection determined by pt. capacity (i.e., mobile, bed-ridden, etc.) Vision Examination

27. 75% self-reported visual symptoms • 84% self-reported reading difficulties • 59% Light sensitivity • Optometric findings - Dysfunctions • Over-all 70% presented with one or more findings • 46% Convergence • 25% Pursuit and/or saccadic • 21% Accommodation • 11% strabismus • 5% fixation or nystagmus inpatient symptoms and findings

28. Reported by 59% of patients • More common in mTBI • Most commonly reported by patients with PTSD • Statistical analysis concludes that “light sensitivity” is due to PTSD not visual condition • Important in that it suggests that not all visual symptoms generated by vision change • Need to ensure we “sort out” visual from non-visual symptoms More about “light sensitivity”

29. inpatient Population By Mechanism of Injury – Visual Dysfunctions • Rates of visual acuity and field loss <3%

30. Inpatient – Vision Loss

31. Numbers and cost • 244,217 TBIs as of May 16, 2012 http://www.health.mil/Libraries/TBI-Numbers-Current-Reports/dod-tbi-worldwide-2000-2012Q1-as-of-120516.pdf • 187,539 mild; 56,678 moderate, severe, penetrating • Causes: blast, MVA, fall, assault, gunshot, etc. • Cost from 2000 to 2010 yearly cost = $2.3 billion for military eye injuries including TBI NAEVR Report, K.Frick, PhD Professor, Johns Hopkins Bloomberg School of Public Health, May 2012 • 54,291 service members had some degree of visual impairment • Total cost to military, VA, & society over remainder of service members lifetime = $24.3 Billion Vision & War – Numbers and Costfrom Afghanistan & Iraq

32. Area contains a good deal of controversy regarding effectiveness of interventions • Prisms • Vision Restoration Therapy • Vision Rehabilitation Therapy • Scanning Training • NVT Scanning Therapy Rehabilitation – Field Loss

33. Prisms relocate image from affected field to intact field • Training requirements extensive • Fixation spot (minimize eye movement) and presentation of image in intact field • Training in office/outdoors (weekly visits up to a period of weeks) • Patient “success” – 27% to 81% (Bowers, et al, Arch Ophthal, 2008) • Patient “discontinuance” a concern Prisms

34. Nova Vision Therapy (NVT) • Based on concept of brain plasticity • Initial office visit with computer assessment • Home training • In home computer • Two 30 minute sessions per week for 3 to 6 months • Weekly “results” uploaded to NVT computer and a new training program download to patient computer based upon prior week’s performance • Some literature suggests a small 3 to 5 degree improvement while other reports little improvement Vision Restoration Therapy

35. NVT Systems • Computer assessment on scanning bar • Computer suggests initial training program • Additional training components include paper and pencil tests, indoor/outdoor mobility lessons • Assessment of both static (NVT scanning bar) and dynamic training (Mobility Assessment Course) • Little formal study of effectiveness NVT Scanning Therapy

36. Review articles • Riggs, et al. Am J Phys Med Rehabil, 2007 • Pelak, et al. Curr Treat Options Neurol. 2007 • Conclude that scanning training is currently the most promising option for rehabilitation of field losses such as hemianopia • Both reviews highlight the need for controlled trials to determine rehabilitation potential What does the literature tell us?

37. Casualties for the wars in Afghanistan and Iraq have highlighted vision loss/dysfunction following TBI and the need for: • Better access to care, and • Additional research to understand the loss/dysfunction and to improve rehabilitation • In TBI the mechanism of injury does not change the resulting visual loss/dysfunction Summary - 1

38. All forms of brain injury (e.g. trauma, stroke) may involve visual loss or dysfunction • Estimates of the number of people affected represent a “best guess” • Vision not routinely assessed in most settings dealing with brain injury thus it is likely that current estimates under-report • Cost estimates based on incidence suggest that society pays a very heavy price Summary - 2

39. Additional research is needed to understand the effects of trauma to the brain on the visual system and how these interactions affect the “whole” individual And, we lack “gold standards” for rehabilitation therapies for the visual deficits caused by brain injury Other than that we’re good Summary - 3

40. I look forward to learning more at this conference My contact address: Gregory.Goodrich@va.gov Thank you

41. The 11th International Conference on Low Vision 31 March – 3 April 2014 Advancing research • Upgrading practice • Improving participation www.vision2014.org