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RRP 11-008 – HSR&D Study

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RRP 11-008
Developing a Consensus Vision Screen for Patients with Mild Traumatic Brain Injury
Gregory L Goodrich PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: July 2011 - September 2012

BACKGROUND/RATIONALE:
Over 180,000 troops serving in Afghanistan and Iraq have sustained a mild traumatic brain injury (mTBI). Prior research has shown that mTBI may cause disorders of the binocular and oculomotor visual systems. Such disorders present with clinical symptoms including blurred or double vision (diplopia), convergence and/or accommodative deficits, and pursuit and saccade deficiencies among others. Patients suffering these symptoms may experience difficulty in performing daily living activities that rely upon vision. A particularly severe problem is difficulty or inability to read. While these deficits are visual patients may not recognize the visual nature of the problem and attribute the visual difficulty to other factors including inability to concentrate, memory issues, lack of interest/motivation, or other symptoms commonly associated with mTBI. Diagnosis of binocular/oculomotor deficits requires examination techniques which are not routinely provided in optometry settings and no tool for effective screening currently exists aside from time-consuming, comprehensive examinations. Such comprehensive examinations would exceed the capacity of VA eye care personnel to provide.

Optometrists in the VA are responsible for over 1.5 million patient visits annually. A survey of some 600 VA optometrists serving active duty personnel and veterans with mTBI was conducted in 2011 and found that over 70% of respondents served mTBI patients. The settings in which these optometrists worked spanned the range of VA medical centers, clinics, and outpatient settings. However, there is no standard of care for binocular/oculomotor examinations. Thus, there is a need for an examination protocol, amenable to VA and other (e.g. Department of Defense) settings, which would allow eye care providers to efficiently screen mTBI patients so that referrals for appropriate care can be made. Such referrals would correct or ameliorate the visual problems experience by these patients and contribute to an improved quality of life.

OBJECTIVE(S):
The study developed a collaborative group of 16 VA optometrists who are experienced in providing binocular/occulomotor examinations to form an expert panel. The panel will define a) what patient history elements need to be included in an optometric screen for visual dysfunctions? and b) what examination elements should be used in the screen. The end product of the study will be a binocular/occulomotor dysfunction screen useable within VA optometry. It will also form the basis for further research to validate the screen and to ultimately assist in estimating the prevalence of binocular/occulomotor dysfunctions in veterans with mTBI.

METHODS:
A modified Delphi method was employed to elicit opinions from a team of expert participants regarding vision evaluation of the mTBI patient, including case history questions and exam procedures. Sixteen optometrists from nine states and a wide variety of optometry settings served as the expert panel. Two Delphi rounds were conducted for the patient history and two rounds were conducted for the examination portion. The original items for the Delphi rounds were selected from VHA Directive 2008-065, current literature sources, and history and examination items submitted by participating experts. The initial history survey had 40 questions and the examination survey contained 43 items. Routine eye examination procedures (e.g. visual acuity) were not included as these are routinely done in all eye care settings. Participants rated each item on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree). Participants were encouraged to make comments about any item and were provided feedback on the prior round results before the second round. Items were rejected if less than 50% of responses were marked "agree" or "strongly agree". Agreement (consensus) was defined as 80% (e.g. rated "agree" or "strongly agree") for item inclusion. Items not rejected or accepted in the first round were resubmitted during the second round. Items not accepted following the second round were rejected.

FINDINGS/RESULTS:
The Delphi methodology resulted in a patient history consisting of 17 items covering a range of issues including pre-post mTBI-causing event, neurological history, specifics of the TBI-inducing event and ocular injuries. The methodology resulted in seven items to measure oculomotor, accommodative, and binocular vision function. The resulting history and examination mTBI screen provides an expert-driven protocol which can be used to screen mTBI patients for binocular/oculomotor deficits in VA and other eye care settings.

IMPACT:
Binocular vision and oculomotor dysfunctions affect a very high percentage of veterans incurring mild traumatic brain injury. These dysfunctions negatively impact educational, vocational, and social activities and may adversely affect treatment for other disorders associate with mTBI. At present there is no recognized clinical screen to detect these dysfunctions. Additionally, VA optometrists already serve a large number of VA patients and the resources available to address visual consequences of mTBI are severely constrained. The current project utilized a modified Delphi technique to provide an evidence based screen which potentially addresses a known need within VA healthcare.

Concurrently the Department of Defense and Department of Veterans Affairs Vision Center of Excellence created an initiative to develop clinical practice guidelines related to vision loss and dysfunction in troops incurring traumatic brain injury. The current study provided an evidence-based binocular/oculomotor screen that has been incorporated into the draft clinical practice guidelines. Thus the current project has shown an impact beyond the VA.

PUBLICATIONS:

Journal Articles

  1. Goodrich GL, Flyg HM, Kirby JE, Chang CY, Martinsen GL. Mechanisms of TBI and visual consequences in military and veteran populations. Optometry and vision science : official publication of the American Academy of Optometry. 2013 Feb 1; 90(2):105-12.
Journal Other

  1. Borden P, Klein M, Goodrich GL. Considerations for prescribing portable LED lights for low vision. Visibility. 2013 Feb 1; 7(1):1-8.
Book Chapters

  1. Cockerham G, Goodrich GL, Ciuffreda K, Cockerham K, Saunders G. The nature of the injury. In: Tyler CW, editor. Visual Function and Its Management in mTBI. San Francisco, CA: Smith-Kettlewell Eye Research Institute Press; 2013. 176 p.
  2. Kardon R, Gorin M, Goodrich GL, Wickum S, Tyler C, Mucha A. Tests, Evaluation and Assessment. In: Tyler CW, editor. Visual Function and Its Management in mTBI. San Francisco, CA: Smith-Kettlewell Eye Research Institute Press; 2013. 176 p.
Conference Presentations

  1. Goodrich GL. What brain injury and history teach us about how we use visual acuity. Presented at: Visual Disability and Rehabilitation Scientific Symposium (Symposium Scientifique sur L’Incapacité Visuelle et la Réadaptation); 2014 Feb 11; Longueuil, Canada.
  2. Goodrich GL. An American Approach: Vision Rehabilitation Following Acquired Brain Injury - Lessons from US Veterans and Troops. Paper presented at: Syn Med Stroke Annual Skandinavisk Symposium; 2013 Dec 5; Copenhagen, Denmark.
  3. Goodrich GL. Traumatic Brain Injury: a Visual Perspective. Paper presented at: Veterans Resource Coordinating Group South Plains Veterans Annual Summit; 2013 Nov 5; Lubbock, TX.
  4. Goodrich GL. Vision Loss and Dysfunction Following Traumatic Brain Injury: An Overview. Veterans Health Administration Employee Education System & VA/DOD Vision Center of Excellence: Managing Vision Disorders Following Traumatic Brain Injury. Paper presented at: Blinded Veterans Association Annual Meeting; 2013 Aug 19; Spokane, WA.
  5. Goodrich GL, Flyg H, Kirby J, Martinsen G. Visual function, traumatic brain injury, and PTSD. Poster session presented at: Stanford University School of Medicine Neuroscience Forum; 2013 May 13; Stanford, CA.
  6. Goodrich GL. I didn't see that coming: Vision after brain injury. Paper presented at: Defense Medical Rehabilitation Centre Headley Court Meeting; 2013 Apr 26; Epsom, United Kingdom.
  7. Goodrich GL. I didn't see that coming: Vision after brain injury. Paper presented at: West of England School and College Neurological Vision Impairment Conference; 2013 Apr 24; Exeter, United Kingdom.
  8. Goodrich GL. Vision Rehabilitation Following Acquired Brain Injury - Lessons from US Veterans and Troops. Paper presented at: Santa Clara Valley Brain Injury Annual Conference; 2013 Feb 28; San Jose, CA.
  9. Goodrich GL. Evolution or Revolution and New Opportunities: a Discussion on Low Vision and Stroke Rehabilitation Today and Tomorrow. Presented at: Syn Med Stroke Annual Skandinavisk Symposium; 2012 Dec 5; Copenhagen, Denmark.
  10. Goodrich GL, Flyg H, Kirby J, Martinsen G. Visual function, traumatic brain injury, and PTSD. Poster session presented at: American Academy of Optometry Annual Meeting; 2012 Oct 24; Phoenix, AZ.
  11. Goodrich GL, Flyg H, Kirby J, Martinsen G. Comparison of visual loss and dysfunction by mechanism of TBI. Poster session presented at: Stanford University School of Medicine Neuroscience Forum; 2012 Jun 8; Stanford, CA.
  12. Goodrich GL, Flyg H, Kirby J, Martinsen G. Vision loss and dysfunction following brain injury: Blast vs other trauma mechanisms. Poster session presented at: Traumatic Brain Injury Annual Conference; 2012 Jan 1; Alexandria, VA.
  13. Goodrich GL, Arditi A, Rubin G, Keeffe J, Legge G. The low vision timeline: An interactive history. Poster session presented at: New York State Association for the Education and Rehabilitation of the Blind and Visually Impaired Fall Conference; 2011 Nov 5; Rochester, NY.
  14. Goodrich GL, Flyg H, Kirby J, Martinsen G. Vision loss and dysfunction following brain injury: Blast vs other trauma mechanisms. Poster session presented at: American Academy of Optometry Annual Meeting; 2011 Oct 12; Boston, MA.
  15. Tyler C, Likova L, Goodrich GL. Oculomotor dysfunction in mild traumatic brain injury. Poster session presented at: Federal Interagency Conference on Traumatic Brain Injury; 2011 Jun 12; Washington, DC.
  16. Tyler C, Likova L, Goodrich GL. Brainstem/midbrain imaging for oculomotor dysfunction in mild traumatic brain injury. Presented at: Society for Brain Mapping and Therapeutics Brain, Spinal Cord Mapping & Image Guided Therapy Annual World Congress; 2011 Jun 8; San Francisco, CA.


DRA: Brain and Spinal Cord Injuries and Disorders
DRE: none
Keywords: QUERI Implementation
MeSH Terms: none