Low Vision Rehabilitation/James Roddy

James Roddy is a 32 year old personal trainer. One evening, after feeling unusually tired he went to bed early. The next morning when he tried to get up he couldn't. His wife, Rebecca, called an ambulance after being rushed to hospital, James was diagnosed with an Acquired Brain Injury (ABI) in the form of a stroke. James' case will help you to analyse patient information and determine the likely site of brain injury and describe the functional implications associated with different areas of the brain. You will be able to modify a standard vision consultation to facilitate assessment of a brain injured patient and discuss strategies that might assist visual processing for patients with brain injury.

Question

Describe the functional implications of James' stroke and how you can assess him and assist him?
Use the scenario and resources below to formulate your own response to this question. You are looking for reasons as well as proposed solutions.

Activities

Task 1

ABI refers to any brain damage that occurs after birth, including damage caused by infection, disease, lack of oxygen or a blow to the head. Two thirds of all people with an ABI who have their activity limited or restricted are over the age of 45. One third of those are over the age of 65 and the largest age group is between 40 and 49. However it can affect people of working age, teenagers and even children.
Start by familiarising yourself with the concept of ABI. Visit The Better Health Channel Acquired Brain Injury page.

Watch the lectorial Introduction to Brain Function.
You can find the accompanying Power Points here.

Referral letter to orthoptist for low vision rehabilitation.

Task 2

Upon admission to hospital, James had a Glasgow Coma Scale (GCS) score of 10 (E4 V3 M3). What does this mean?
Find out by watching the Student's guide to the Glasgow Coma Scale

Task 3

James has been at a rehabilitation centre for 4 weeks. This is particularly hard on his family as he was the sole provider for his wife, Rebecca, and their 18 month old baby, Amy. James has been very angry since the stroke. He was previously a very active and sporty person. He was also building up his personal training business and attracting more clients. His anger has been upsetting Rebecca and she is not looking forward to James returning to the family home in a couple of weeks.

You receive a referral letter from the Occupational Therapist at the rehabilitation centre to see James before he returns home. Please read the contents of the letter and highlight the issues James is having, as reported by the Occupational Therapist.

Questions - task 3:

Describe the likely psycho-social impact the stroke has had on James (and his family) at this stage in his life.
Consider what you know about James so far in order to determine the likely lesion site of his stroke.

Orthoptist's role in ABI assessment and advice

Low Vision orthoptic assessment of a patient with ABI is very similar to any other patient assessment but there are some other aspects to consider:

Use the medical history to identify the likely lesion site & therefore the possible impairment
Perform the assessment in a quiet and comfortable surrounding for the patient
Use simple instructions and where appropriate, yes/no questions
Be prepared to repeat your instruction in a different way if the patient didn't understand you
Reassure the patient - don't shout(!)
Consider the person as a "whole" not just a pair of eyes
Look for functional solutions, be creative, adapt conventional tests and treatments

The orthoptist's role includes assisting the patient to adapt to their impairment. First you should perform a thorough examination to determine visual function. This includes visual acuity and contrast testing (particular affected in parietal lesions), visual field assessment (eg: optic neuropathy is common in closed head injury, hemianopia is common in occipital lesions) and also consider issues such as neglect. A small proportion of head injuries also result in ocular motility defects, so don't forget your cover test, ocular movements, convergence etc.

Task 4

Watch this Vision Rehabilitation for patients with Acquired Brain Injury playlist which will give you an understanding of potential rehabilitation strategies.

Read the article by:
Koons P, Johnson S, Kingston J & Goodrich GL. Scanning training in neurological vision loss: case studies. Eye and Brain. 2010.
This is an open access article. The link takes you to a web-page where you can download the PDF.

Once you have read the article, answer the following questions:

According to Koons et. al. why does hemianopia go undetected in brain injured patients?
What reasons to the authors give for lack of acceptance of a single rehabilitation strategy for patients with acquired brain injury?
Summarise the underlying principle for rehabilitation using prisms, vision restoration therapy (VRT) and scanning therapy (ST).
Consider the case study about AS a 22 year old female. What injuries to her brain did she sustain as a result of her accident?
Does AS have any significant past ocular history? Do you think this will affect the rehabilitation program designed for her? Explain.
What does AS want to achieve from rehabilitation? How do you think her cognitive and functional problems will impact on her achieving this goal?
For how long did AS receive rehabilitation?
What positive functional gains did she make post rehabilitation? Do you think as a result of rehabilitation that she was able to meet her original goal? Explain.

Task 5

Case studies.
For each case consider the signs and symptoms and try to determine where the brain injury might have occurred. What might you as an Orthoptist do to assist in each case?
Deeper discussion of these cases will take place face to face in week 8 of semester.

Case 1
A 30 year old following an MCA in which he sustained head injuries. There are no obvious signs of brain damage. His wife complains he is not able to do even simple tasks such as making a cup of coffee. He becomes obsessed with a single idea and will not move onto other things. You notice he does not initiate interaction - and seems “ flat” in his communication. It is difficult to get him to concentrate on the testing procedures.

Case 2
Brian a 45 year old businessman suffered a CVA 12/ 12 ago. No detectable loss of VA however he is unable to identify simple objects placed in front of him such as a cup. You ask Brian to do some written tasks and he cannot write words, he has difficulty drawing and fails your eye/ hand coordination tasks. You also notice he has difficulty maintaining visual attention. He has right quadrantanopia. He complains he can no longer read and whilst he used to be good at math he now has a lot of trouble doing the accounts for his company.

Case 3
You are asked to assess Janine, an intelligent 12 year old who was hit by a motor car some 6/ 12 ago. M says Janine often bumps into things and her class teacher notices she has great difficulty reading and writing, she has difficulty finding objects in pictures and often says the wrong word when reading aloud or does not recognise a word she had previously known. Janine confides in you that she is quite scared because she sometimes sees things that are not really there. She has an homonymous hemianopia with macular sparing.

Case 4
Joe is a 19 year old apprentice who has been involved in a fight. He was hit across the head with an iron bar. Now he persists in talking a lot and never remembers anything the guys tell him. He seems to have become even more aggressive. He cannot recognise faces and has difficulty concentrating when he meets with his mates at the pub or at the footy. He has a right homonymous hemianopia.

Case 5
You are asked to assess a young girl in a SDS Kylie is a quiet young girl who has constant tremors and dizziness. She is in a wheelchair. You notice she is unable to touch objects when you ask her to and has great difficulty using the matching card when doing the vision test. You used the matching card because her speech is quite slurred and you thought it would be easier. You also note she has nystagmus.

Additional resources

The Guide Dogs ABI referral service also has a lot of useful information.