Maino D, Schlange D. The Natural History of the Oculo-Visual Anomalies Associated with Traumatic Brain Injury (TBI): A Case Report. Poster presented at the 2013 College of Optometrists in Vision Development annual meeting, Orlando, FL.

1. 3241 South Michigan Avenue, Chicago, Illinois 60616
DISCUSSION
Research has noted that those adults with intellectual
disability and a psychiatric illness tend to offer few
complaints when taking a case history even though they
are often on numerous medications and exhibit frequent
visual and systemic anomalies. This acceptance of visual
disabilities was the case for this patient as well. The
longitudinal findings seen here suggest that those with
TBI may demonstrate variable findings over their lifetimes
and require close monitoring of these changes so that
appropriate and timely intervention can be provided.
It also appears that surgery for strabismus may be of
limited intermediate and long term value13
. Optometric
vision therapy appears to have moderate success at least
initially. Vision therapy may need to be re-instituted with
this now adult patient to help her regain the 2nd
degree
fusion and stereopsis that TB demonstrated after the
initial therapy program some years earlier14
.
INTRODUCTION
The Center for Disease Control and Prevention reports
that traumatic brain injury (TBI) occurs in 1.7 million
individuals in the United States each year. The vision
problems routinely reported for those with TBI include
binocular vision, accommodative and oculomotor
dysfunctions; reduced visual acuity, visual field loss and
vision information processing anomalies, as well as
oculo-vestibular, midline perceptual shift and attentional
issues1,2,3,4,5
. We know little, however, about the long-term
natural history or natural course of the oculo-visual-
neuro- anomalies associated with TBI. After an extensive
PubMed/Google Scholar search, this case report appears
to be the very first of its kind to appear in the literature.
CASE REPORT
CASE HISTORY
TB is now a 31 y/o W/F who has a history of TBI after
falling out of a window at age 2. She has been evaluated
26 times over the past 29 years primarily by the first
author. At 4 years of age, TB underwent a bilateral lateral
muscle resection for an exotropia (07-1986). After surgery
it was noted that she was an intermittent esotrope at
distance and had a “flick” exotropia at near. Between
1988 and 1993 she also participated in 19 vision therapy
sessions. TB’s compliance was variable but did exhibit 2nd
degree fusion and 3rd
degree fusion towards the end of
the therapy program. Visual acuities varied but stabilized
after a while at approximately 20/40 OD/OS until the
last visit where visual acuities appeared to decrease in
the right eye. The case history indicates that she had a
tendency to voice fewer complaints as she became an
adult. This trend towards adults with intellectual disability
and a psychiatric illness voicing fewer complaints has
been documented by recently published research6,7
. She
is currently living somewhat independently with her
mother and receives services during the day.
Dominick M Maino, OD, MEd, FAAO, FCOVD-A, Darrell G. Schlange, OD, DOS, FAAO
llinois College of Optometry, Chicago, IL
Diagnoses*
The Natural History of the Oculo-Visual Anomalies Associated
with Traumatic Brain Injury (TBI): A Case Report
CONTACT INFORMATION
Dominick M Maino, OD, MEd, FAAO, FCOVD-A
dmaino@ico.edu
www.ico.edu
The numbers of medications increased significantly as
additional diagnoses were added for various systemic
and psychiatric disorders. Visual acuities fluctuated
significantly, but usually were around 20/40 – 20/50.
As a child, her refractive error showed a small amount
of hyperopia and astigmatism which later developed
into myopia. She also had a tendency to exhibit
accommodative excess which could have played a role in
the myopia seen as she became older. The oculomotor
assessment post-surgical intervention for exotropia also
varied from orthophoria to a constant esotropia with a
mild upward gaze restriction and nystagmus. Stereopsis
and 2nd
degree fusion was seen after an active course
of optometric vision therapy, but then was lost over the
years. No major eye health problems were noted.
The longitudinal study of those with TBI and the
frequently encountered oculo-visual anomalies should
be studied to ascertain the natural history and long
term effects of various interventions over time. This case
study is the first to report such findings. A key element
of successful long-term care of patients with TBI must
include the comprehensive diagnostic and therapeutic
care provided by the behavioral/developmental/
functional optometrist.
Date 2013-2010 2009-2007 2006-2003 2011-1992 1991
Systemic Allergies HAs “ “ “ “
Neurological TBI, seizures
Mild MR, Emotional/Behavioral
Disorder, Speech/Lang Delays
“ “ “ “
Oculo-visual CRXT, Amblyopia, IXT, Amblyopia, CRXT IXT, Esophoria IET/IXT
CMA, Intermittent Nystagmus “ “ CMA CHA
Date 1991 1988 1986
Systemic Allergies HAs “ “
Neurological TBI, seizures
Mild MR, Emotional/Behavioral
Disorder, Speech/Lang Delays
“ TBI, seizures
Oculo-visual CAET/IAXT’ Ortho,
Esophoria, OMD
Exotropia
(bilateral lateral
rectus resection)
*This is a representative
sample of, but not necessarily
data from every visit.CMA CHA
Date 01-2013 09-2011 09-2009 05-2009 06-2007
Medications Ibuprofen, Potassium,
Fenofibrate, Singulair,
Pepcid, Sertraline,
DetrolLa, Loratadine,
Gabapentine,
`Carbamazepine ER,
Prilosec, Tilia FE
Potassium, Singulair,
Pepcid, Sertraline,
Gabapentine,
Carbamazepine,
Prilosec, Tilia FE,
Prochlorperazine,
Trilpix, Vesicare,
Pseudoephedrine,
Naproxen, Niacin,
Vitamins
Potassium,
Singulair,
Prilosec,
Vesicare,
Lipitor, Zoloft,
Loratadine, Tilia FE
Potassium, Singulair,
Gabapentine,
Tilia FE, Vesicare,
Pseudoephedrine,
Pepcid, Lipitor,
Ibuprofen, Zoloft,
Estrostep, Flonase,
DetrolLa
Date 11-2006 9-2004 8-2003 02-1987 07-1986
Medications Singulair, Gabapentine,
Tilia FE, Vesicare,
Pseudoephedrine, Pepcid,
Lipitor, Ibuprofen, Zoloft,
Flonase, DetrolLa
Risperdal, Zoloft,
Gabapentine, Zoloft,
Claritin, Flonase,
DetrolLa
Risperdal,
Zoloft,
Gabapentine,
Zoloft, Claritin,
Flonase,
DetrolLa
Dilantin Dilantin
*This is a representative sample of, but not necessarily complete data from every visit.
Date OD OS
01-10-2013 -1.75-.50X070 -1.25-1,00X180
09-29-2011 -1.75 -2.50
(Stable for 4 years)
11-30-2006 -1.50 -1.75
11-17-2005 -1.25 -1.25
09-23-2004 -1.25 -1.25-.50X180
07-03-1993 +.25-.25X180 +1.50-.75X180
# 10-20-1992 +1.25-1.00X020 +1.75-1.25X140
09-05-1991 +1.00-1.00X180 +1.75-1.75X180
03-10-1988 +2.25-1.25X175 +2.00-1.25X178
*This is a representative sample of, but not necessarily
complete data from every visit
# Exam at a children’s hospital.
THE EXAMINATION
The examination sequence varied and different tools were
used over the years as advances were made in developing
examination instrumentation and techniques. Visual
acuities were taken using Teller Cards, HOVT, Lea symbols,
Snellen and VEP.8
Objective examination procedures
were frequently utilized because of behaviors that
would interfere with the standard subjective assessment
techniques.
VISION THERAPY
Post-surgical strabismus vision therapy for remaining
binocular vision dysfunctions, oculomotor anomalies,
amblyopia and vision information processing (VIP)
anomalies was instituted. VIP problems diagnosed at 10
years 11 months of age included: visual discrimination,
memory, spatial relations, form constancy, sequential
memory, figure ground and closure. Vision therapy can be
an effective treatment for those with TBI.9,10,11,12
During vision
therapy, TB did achieve 2nd
and 3rd
degree fusion. Lenses
were prescribed to provide best VA and binocular vision.
Case History*
Refractive Error *Medications *
Date 01-10/13 09-29-11 05-27-10 05-07-09 12-20-07 11-30-06 11-17-05
Chief Complaint None None Concern for
vision
Ocular health
assessment
Hx of
amblyopia
Needs
Glasses
None
Date 09-23-04 08-21-03 10-23-93 11-18-92 10-20-92# 09-10-92 09-05-91
Chief Complaint None Itchy eyes FU OM
function
Problems
reading small
print
Strabismus
evaluation
Nystagmus None Post
strabismus
surgery
exam
Date 08-05-91# 09-15-88 03-10-88 01-07-88 08-16-87# 07-31-86
Chief Complaint Afraid of
the dark
VEP/Laser
interferometry
Rx Follow up Eye turns in
less with Rx
Exotropia BLRR
surgery
*Information from vision therapy sessions not noted.
# Exam at a children’s hospital. This is a representative sample of, but not necessarily data from every visit.
REFERENCES
1 Sands W, Taub M, Maino D. Limited research and education on special populations in
optometry and ophthalomology. Optom Vis Dev 2008;39(2):60-61
2 Available from http://c.ymcdn.com/sites/www.covd.org/resource/resmgr/position_papers/
acquired-brain-injury_-_aoa.pdf?hhSearchTerms=traumatic+and+brain+and+injury
accessed 9/2013
3 Taub M. TBI a major cause of disability. Optom Vis Dev 2009;40(1):12-13.
4 Maino D, Schlange D, Donati R. Bakouris C, Nikoniuk M. A Gun Shot to the Head: Oculo-
visual Perceptual Anomalies. International Congress of Behavioral Optometry/Neuro-
Optometric Rehabilitation Association 2010. Ontario, CA 4/10 (published abstract)
5 Schlange D, Maino D, Caden B. Executive functioning, attentional performance disorders
in adults with traumatic brain injury (TBI). Poster presented at the American Academy of
Optometry meeting, Phoenix, AR (10/12)
6 RJ Donati RJ, Maino DM, Bartell H, Kieffer M. Polypharmacy and the Lack of Oculo-Visual
Complaints from those with Mental Illness and Dual Diagnosis.Optometry 2009;80:249-254.
7 Schnell PH, Maino D, Jespersen R. Psychiatric Illness and Associated Oculo-visual Anomalies.
In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special
Needs; Lippincott Williams Wilkins. New York, NY;2012:111-124.
8 Mandese M. Oculo-visual evaluation of the patient with traumatic brain injury. Optom Vis
Dev. 2009;40(1):37-44.
9 Ciuffreda KJ, Ludlam DP, Kapoor N. Clinical oculomotor training in traumatic brain injury.
Optom Vis Dev 2009;40(1):16-23.
10 Tong D, Zink C. Vision dysfunctions secondary to motor vehicle accident: a case report.
Optom Vis Dev 2010;41(3)158-168
11 Maino D, Schlange D. Treating Functional Anomalies Associated with Organic Disease.
Poster poster presented at the College of Optometrists in Vision Development annual
meeting, Fort Worth, TX (10/12)
12 Maino D, Schlange D. Improving vision function in the patient with traumatic brain
injury. Published Abstract/Poster The International Brain Injury Association’s Ninth World
Congress on Brain Injury, Edinburgh, Scotland 3/12.
13 Maino D. The number of placebo controlled, double blind, prospective, and randomized
strabismus surgery outcome clinical trials: none!. Optom Vis Dev. 2011;42(3):135-138.