TBI and doctors of optometry

TBI: More can be done

AOA Focus-March 2019

Excerpted from page 30 of the March 2019 edition of AOA Focus.

Carl Garbus, O.D., chair of the AOA's Vision Rehabilitation Committee, works with a patient in his practice.
Photography by Joseph Escamilla


Last fall, two teams of doctors of optometry were busy planting the AOA’s position on the underrecognized role doctors of optometry play in the care of TBI patients. One of those teams consisted of Carl Garbus, O.D., and Gary Asano, O.D., who participated in the 13th annual Envision Conference in Wichita, Kansas. Each lectured to an audience of doctors, therapists and researchers. Dr. Garbus spoke on how to prescribe special lens systems for TBI patients, Dr. Asano on prescribing special filters for visually impaired patients.

"Injuries to the brain affect the transfer of visual information to different areas of the brain. Disruption of the visual information can have devastating effects"

Posted also at the highly trafficked entrance to the conference’s exhibit hall, the doctors emphasized to the health care professionals who stopped by the importance of referring patients to primary eye care providers and vision rehabilitation services. The AOA members talked about the treatment modalities at their disposal, including lenses, filters, prisms and occlusion. Vision rehabilitation interventions also were laid out.

Their message was well received, with some already familiar with the role of optometry and others wanting to know more about the training of doctors of optometry, Dr. Asano says.

“The physical therapists were very intrigued,” Dr. Asano says. “Some of them had never worked with an optometrist.”

Dr. Garbus, chair of the AOA Vision Rehabilitation Committee, adds, “We are trying to provide a framework for optometrists to look at and suggest what needs to be considered for special testing. Some of the tests are simple and others are more time-consuming. Optometrists can decide for themselves if they want to add the tests or refer to a colleague to manage the patient.”

Recognizing optometry’s role

The AOA has seen the writing on the wall.

In recent years, its Vision Rehabilitation and Sports and Performance Vision Committees have set their sights on outreach to doctors of optometry. Both have created networks and are sharing resources with hundreds of doctors. The AOA has even made it easier for patients to search for vision rehabilitation and sports performance vision providers in its doctor locator.

And in August 2018, the AOA’s Board of Trustees appointed a TBI task force, which includes vision rehabilitation and sports and performance vision providers. Lori L. Grover, O.D., Ph.D., member of the AOA Board of Trustees, provided the impetus for the measure.

It’s about patients and improving their health and quality of life, Dr. Grover says. TBIs can have devastating consequences. Daily functions taken for granted—such as reading, driving, shopping, dressing and even walking—can be disrupted and leave patients feeling socially isolated.

“A large part of my clinical practice in vision impairment and rehabilitation always involved patients with head injury, stroke and other neurological conditions and disease,” Dr. Grover says. “I’m passionate about the care doctors of optometry provide and advocating for optometry’s expertise on the patient’s health care team.

“Doctors of optometry play a key role throughout the continuum of TBI care, from prevention and primary care to tertiary rehabilitative care,” she adds. “Advocacy to minimize the negative impacts of TBI, from clinical care to policy, must include optometrists who, as physicians, coordinate and collaborate care in conjunction with other doctors and health professionals to manage and treat TBI and its sequelae.”

And the task force’s charge? Since last fall, the committee has been developing a document that will lay out the role of primary eye care in TBI, including regular comprehensive eye examinations, vision rehabilitation and sports and performance vision. Expected to be released in March, the document will also address issues of prevention and how managing vision health is crucial to helping patients safely return to work, to play or to learning. The document will serve to shape AOA’s advocacy, education and outreach on TBI.

Moreover, doctors of optometry are in a unique position to make a difference. Certainly because of their training but also because they serve 10,000 communities across the country. And in about a third of them, they are the only eye doctors and provide a critical path to reaching patients who may not even recognize they suffered a brain injury.

The AOA is committed to helping members reach and treat these patients.

“The purpose of the task force is to create a greater awareness among our members on how important it is to help the significant number of patients with post-trauma and brain injury,” says Dr. Garbus, who practices in California. “The realization that vision is affected along with many other associated areas has a great impact on the patient, and there are treatments that are optometrically based. Many optometrists do not realize what they can do in managing these patients.”

Amanda Nanasy, O.D., chair of the AOA’s Sports and Performance Vision Committee, who works with professional sports teams in Florida, says, “We should have a place on post-concussion teams.”

In a September 2018 article in JAMA Ophthalmology, researchers looked at vision and aging data from about 2,500 participants ranging in age from 65 to 84 and residing in the Salisbury, Maryland, area. Visual acuity was assessed using Early Treatment Diabetic Retinopathy Study charts and cognition using the Mini-Mental State Examination. Researchers at the University of Miami Miller School of Medicine, Johns Hopkins University School of Medicine, and Purdue University Department of Human Development and Family Studies confirmed not only that visual acuity and cognitive impairment were linked but also reported that vision is “likely the driving force” in the changes, not the reverse.

“The longitudinal association between vision and cognitive functioning suggests maintaining good vision may be an important interventional strategy for mitigating age-related cognitive changes,” the researchers say. “Our findings reinforce the importance of the primary prevention of visual impairment that could be achieved through the prevention of disabling ocular conditions and treatment of correctable visual impairment.”

Raising awareness

Last October, Dr. Nanasy and Andy Morgenstern, O.D., carried optometry’s message to the third annual Chronic Traumatic Encephalopathy (CTE) Continuing Medical Education Conference in Boston.

They attended the conference to learn more about CTE but also to reach out to leading CTE researcher Ann McKee, M.D., and her team. Dr. McKee is professor of neurology and pathology and director of the Boston University CTE Center, which is renowned for its research on CTE and repetitive brain injury, especially in professional athletes.

The doctors of optometry expounded on the role of vision dysfunction in people with CTE and TBI and how optometry can help detect, rehabilitate and refer when needed.

“Unfortunately, CTE and TBI are not limited to professional sports,” says Dr. Nanasy, who suffered a TBI in a car accident last summer. “We are seeing it in young athletes and military service members who are exposed to blast and repetitive concussion. These individuals present regularly to optometrists for clinical care. Optometry is a primary entry point into the multidisciplinary TBI care team.”

Adds Dr. Morgenstern: “As a result of that great conference and sidebar meetings, we will begin to expand optometry’s role and visibility in the CTE community through expanded collaborative work in accessibility to comprehensive eye exams and brain injury evaluations, sports-vision evaluations, access to vision rehabilitation and coordinated CTE/eyerelated research.”

The fallout

There will be plenty of opportunities for doctors of optometry to make a difference to patients, especially children and adults. The number of children with mild TBI prompted the CDC to issue its first-ever treatment guidance on the subject. And with America aging—more than 88 million Americans will be older than 65 in 2050–elderly adults also are at risk for falls. The most common causes of TBI among people 65 and older are trips and slips.

Carl Garbus, O.D.

Carl Garbus, O.D., chair of the AOA's Vision Rehabilitation Committee, works with a patient in his practice.

Photography by Joseph Escamilla

“The visual system is an extension of the brain,” Dr. Garbus says. “Injuries to the brain affect the transfer of visual information to different areas of the brain. Disruption of the visual information can have devastating effects.”

There’s a price to be paid physically and mentally for those who suffer from brain injuries. Medical costs for TBI in 2015 came to over $50 billion, according to the CDC.

William Monaco, O.D., has spent a lifetime studying the vision health of older adults, particularly in nursing homes. Dr. Monaco was a member of the team that revised the AOA’s Optometric Care of Nursing Home Residents manual in 2014.

Beyond the care that doctors can provide to help patients maintain their quality of life, there are steps that can be taken by patients and their families to prevent falls, he says. More research is needed, but some studies have suggested that balance therapy might be one option to keep older adults mobile. Dr. Monaco cites the CDC’s STEADI (Stopping Elderly Accidents, Deaths & Injuries).

Research also indicates that fewer than half of the elderly tell their doctors about falls, according to the CDC.

“What are the factors we can measure clinically, and in the environment, that will allow us to establish predictors of human performance and prevent falls?” Dr. Monaco asks. “I think we can do better.”

At birth, Dr. Monaco says, human growth is exponential. “We get stronger and stronger every day, and then we eventually plateau,” he says. A decline will follow, but that doesn’t mean that we can’t manage the decline, he adds, by identifying factors that will work against us. For instance, studies have linked declining vision with a decline in cognition.

It’s why it’s important to maintain your vision over a lifetime. Vision is key to a safer and longer life, Dr. Monaco says.

“Wouldn’t it be nice to manage the decline by keeping vision at the best possible level we can?” Dr. Monaco adds.

To join the AOA's Vision Rehabilitation committee and Sports and Performance Vision Committee to help discuss the future of TBI efforts, visit aoa.org/vision-rehabilitation and aoa.org/spv.

March 25, 2019

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