Hjernerystelse og syn
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Transcript of Hjernerystelse og syn
Om langvarige foslashlgevirkninger efter hjernerystelse
- med saeligrlig fokus paring synsforstyrrelser
Torben Helstrup neurooptometrist FCOVD (Slideshare Download)
Den der ler sidst - taelignker langsomst
1 Hjernerystelse og syn Helstrup 2014
Perspektiv og udvalgte pointer bull Indkredsning og paradokser bull Al tings ophav og rumtiden bull Optometrien i landskabet bull Synshjernens virke bull Fiksation og binokulaeligre lidelser bull Undersoslashgelser bull Sammenfatning
Aftenens program
Hjernerystelse og syn Helstrup 2014 2
Resten maring i selv Goggle
Hjerneskade Akut og laeliggelig fase Fokal skade og specifikke symptomer Mild hjerneskade mild traumatisk hjerneskade let hovedtraume mTBI) Ingen synlige skader men alligevel bestaringr udtalt mistrivsel og alvorlige symptomer hos en mindre gruppe (maringneder aringr) PostCommotionelle Syndrom (PCS) Global skade og staeligrkt aeligndret sensivitet
Hjernerystelse og syn Helstrup 2014 3
Snarligt kommende rdquoFysioterapeutenrdquo Behandling af en patient med dobbeltsyn og balancebesvaeligr i akut og subakut fase efter en apopleksi - et samarbejde mellem fysioterapeut og neurooptometrist ndash en case rapport Eriksen K udviklingsfysioterapeut1 Helstrup T neurooptometrist fcovd2 Meden P overlaeligge 3 1 Fysio- og ergoterapiafdelingen Bispebjerg Hospital opg 10 Bispebjerg Bakke 23 2400 Koslashbenhavn NV 2 Koslashbenhavns Private Synsplejeklinik Roslashdovre Centrum 247 2610 Roslashdovre 3 Apopleksiklinikken Bispebjerg Hospital Bispebjerg Hospital opg 1 Bispebjerg Bakke 23 2400 Koslashbenhavn NV
Hjernerystelse og syn Helstrup 2014 4
De usynlige skader
PCS Helstrup 2014 5
Konsensusrapport om Commotio cerebri (hjernerystelse) og det Postcommotionelle syndrom (langvarige foslashlgevirkninger)
httpshopsocialstyrelsendkproductscommotio-rapport
Langvarige symptomer efter hjernerystelse udstiller sundhedsvaeligsenets kollektive
uforstand
Tilgangen og raringdgivningen burde vaeligre meget ydmyg ndash men alligevel fremhaeligves ofte
bull Ro og hvile ndash i det uendelige (afmagtsraringdgivning) bull Psykologiske lidelser (ondt i livet) bull OK til det alternative (som garingr i selvsving)
Paradoks 1
Hjernerystelse og syn Helstrup 2014 6
httpwwwprivatsyndkklinikkenklinikkens-medarbejderecv-torbensprogforbistring-synslidelser
Hjernerystelse og syn Helstrup 2014 7
Cirka 15000 hjernerystelser aringrligt Beskue helingsproces for langt flertallet ndash dage uger
Men for cirka 1500 kikser det helt (PCS) Skolebarn kan sortere rdquoDuer ikkerdquo
Paradoks 2
Ingen systematisk tilgang til diagnose og behandling i Danmark httpwwwhjernerystelsedkavisartikel_jan2008pdf
Paradoks 3 Sygdom versus lidelse
bull En uheldig virkning af sygdomsbegrebet er at naringr der ikke stilles en medicinsk diagnose (og behandling) - saring opfattes tilstanden ikke som saring alvorlig
bull Det er helt forkert
bull Funktionsforstyrrelser kan afstedkomme meget alvorlige symptomer Personer kan vaeligre meget forpinte og uarbejdsdygtige
Hjernerystelse og syn Helstrup 2014 8
Optometrien i
landskabet
Hjernerystelse og syn Helstrup 2014 9
Daghoslashjskolen i centrum (neuropsyk)
NEUROLOGISK Nakkesmerter Hovedpine Svimmelhed Taringge eller dobbeltsyn Lysfoslashlsomhed Lydfoslashlsomhed Soslashvnproblemer Traeligthed
KOGNITIVT Daringrlig koncentrationsevne Opmaeligrksomhedsproblemer Hukommelsesvanskeligheder Generel forvirring Overbliksvanskeligheder Strukturproblemer Nedsat laeligseevne Ordfindingsvanskeligheder
ADFAEligRD Irritabilitet AEligngstelser Depression Aggression Indlaeligringsvanskeligheder Stressfoslashlsomhed Impulsivitet Humoslashrsvingninger Personlighedsforandringer
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Langtidsfoslashlger efter mild traumatisk hjerneskade
Hjernerystelse og syn Helstrup 2014 10
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Perspektiv og udvalgte pointer bull Indkredsning og paradokser bull Al tings ophav og rumtiden bull Optometrien i landskabet bull Synshjernens virke bull Fiksation og binokulaeligre lidelser bull Undersoslashgelser bull Sammenfatning
Aftenens program
Hjernerystelse og syn Helstrup 2014 2
Resten maring i selv Goggle
Hjerneskade Akut og laeliggelig fase Fokal skade og specifikke symptomer Mild hjerneskade mild traumatisk hjerneskade let hovedtraume mTBI) Ingen synlige skader men alligevel bestaringr udtalt mistrivsel og alvorlige symptomer hos en mindre gruppe (maringneder aringr) PostCommotionelle Syndrom (PCS) Global skade og staeligrkt aeligndret sensivitet
Hjernerystelse og syn Helstrup 2014 3
Snarligt kommende rdquoFysioterapeutenrdquo Behandling af en patient med dobbeltsyn og balancebesvaeligr i akut og subakut fase efter en apopleksi - et samarbejde mellem fysioterapeut og neurooptometrist ndash en case rapport Eriksen K udviklingsfysioterapeut1 Helstrup T neurooptometrist fcovd2 Meden P overlaeligge 3 1 Fysio- og ergoterapiafdelingen Bispebjerg Hospital opg 10 Bispebjerg Bakke 23 2400 Koslashbenhavn NV 2 Koslashbenhavns Private Synsplejeklinik Roslashdovre Centrum 247 2610 Roslashdovre 3 Apopleksiklinikken Bispebjerg Hospital Bispebjerg Hospital opg 1 Bispebjerg Bakke 23 2400 Koslashbenhavn NV
Hjernerystelse og syn Helstrup 2014 4
De usynlige skader
PCS Helstrup 2014 5
Konsensusrapport om Commotio cerebri (hjernerystelse) og det Postcommotionelle syndrom (langvarige foslashlgevirkninger)
httpshopsocialstyrelsendkproductscommotio-rapport
Langvarige symptomer efter hjernerystelse udstiller sundhedsvaeligsenets kollektive
uforstand
Tilgangen og raringdgivningen burde vaeligre meget ydmyg ndash men alligevel fremhaeligves ofte
bull Ro og hvile ndash i det uendelige (afmagtsraringdgivning) bull Psykologiske lidelser (ondt i livet) bull OK til det alternative (som garingr i selvsving)
Paradoks 1
Hjernerystelse og syn Helstrup 2014 6
httpwwwprivatsyndkklinikkenklinikkens-medarbejderecv-torbensprogforbistring-synslidelser
Hjernerystelse og syn Helstrup 2014 7
Cirka 15000 hjernerystelser aringrligt Beskue helingsproces for langt flertallet ndash dage uger
Men for cirka 1500 kikser det helt (PCS) Skolebarn kan sortere rdquoDuer ikkerdquo
Paradoks 2
Ingen systematisk tilgang til diagnose og behandling i Danmark httpwwwhjernerystelsedkavisartikel_jan2008pdf
Paradoks 3 Sygdom versus lidelse
bull En uheldig virkning af sygdomsbegrebet er at naringr der ikke stilles en medicinsk diagnose (og behandling) - saring opfattes tilstanden ikke som saring alvorlig
bull Det er helt forkert
bull Funktionsforstyrrelser kan afstedkomme meget alvorlige symptomer Personer kan vaeligre meget forpinte og uarbejdsdygtige
Hjernerystelse og syn Helstrup 2014 8
Optometrien i
landskabet
Hjernerystelse og syn Helstrup 2014 9
Daghoslashjskolen i centrum (neuropsyk)
NEUROLOGISK Nakkesmerter Hovedpine Svimmelhed Taringge eller dobbeltsyn Lysfoslashlsomhed Lydfoslashlsomhed Soslashvnproblemer Traeligthed
KOGNITIVT Daringrlig koncentrationsevne Opmaeligrksomhedsproblemer Hukommelsesvanskeligheder Generel forvirring Overbliksvanskeligheder Strukturproblemer Nedsat laeligseevne Ordfindingsvanskeligheder
ADFAEligRD Irritabilitet AEligngstelser Depression Aggression Indlaeligringsvanskeligheder Stressfoslashlsomhed Impulsivitet Humoslashrsvingninger Personlighedsforandringer
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Langtidsfoslashlger efter mild traumatisk hjerneskade
Hjernerystelse og syn Helstrup 2014 10
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Hjerneskade Akut og laeliggelig fase Fokal skade og specifikke symptomer Mild hjerneskade mild traumatisk hjerneskade let hovedtraume mTBI) Ingen synlige skader men alligevel bestaringr udtalt mistrivsel og alvorlige symptomer hos en mindre gruppe (maringneder aringr) PostCommotionelle Syndrom (PCS) Global skade og staeligrkt aeligndret sensivitet
Hjernerystelse og syn Helstrup 2014 3
Snarligt kommende rdquoFysioterapeutenrdquo Behandling af en patient med dobbeltsyn og balancebesvaeligr i akut og subakut fase efter en apopleksi - et samarbejde mellem fysioterapeut og neurooptometrist ndash en case rapport Eriksen K udviklingsfysioterapeut1 Helstrup T neurooptometrist fcovd2 Meden P overlaeligge 3 1 Fysio- og ergoterapiafdelingen Bispebjerg Hospital opg 10 Bispebjerg Bakke 23 2400 Koslashbenhavn NV 2 Koslashbenhavns Private Synsplejeklinik Roslashdovre Centrum 247 2610 Roslashdovre 3 Apopleksiklinikken Bispebjerg Hospital Bispebjerg Hospital opg 1 Bispebjerg Bakke 23 2400 Koslashbenhavn NV
Hjernerystelse og syn Helstrup 2014 4
De usynlige skader
PCS Helstrup 2014 5
Konsensusrapport om Commotio cerebri (hjernerystelse) og det Postcommotionelle syndrom (langvarige foslashlgevirkninger)
httpshopsocialstyrelsendkproductscommotio-rapport
Langvarige symptomer efter hjernerystelse udstiller sundhedsvaeligsenets kollektive
uforstand
Tilgangen og raringdgivningen burde vaeligre meget ydmyg ndash men alligevel fremhaeligves ofte
bull Ro og hvile ndash i det uendelige (afmagtsraringdgivning) bull Psykologiske lidelser (ondt i livet) bull OK til det alternative (som garingr i selvsving)
Paradoks 1
Hjernerystelse og syn Helstrup 2014 6
httpwwwprivatsyndkklinikkenklinikkens-medarbejderecv-torbensprogforbistring-synslidelser
Hjernerystelse og syn Helstrup 2014 7
Cirka 15000 hjernerystelser aringrligt Beskue helingsproces for langt flertallet ndash dage uger
Men for cirka 1500 kikser det helt (PCS) Skolebarn kan sortere rdquoDuer ikkerdquo
Paradoks 2
Ingen systematisk tilgang til diagnose og behandling i Danmark httpwwwhjernerystelsedkavisartikel_jan2008pdf
Paradoks 3 Sygdom versus lidelse
bull En uheldig virkning af sygdomsbegrebet er at naringr der ikke stilles en medicinsk diagnose (og behandling) - saring opfattes tilstanden ikke som saring alvorlig
bull Det er helt forkert
bull Funktionsforstyrrelser kan afstedkomme meget alvorlige symptomer Personer kan vaeligre meget forpinte og uarbejdsdygtige
Hjernerystelse og syn Helstrup 2014 8
Optometrien i
landskabet
Hjernerystelse og syn Helstrup 2014 9
Daghoslashjskolen i centrum (neuropsyk)
NEUROLOGISK Nakkesmerter Hovedpine Svimmelhed Taringge eller dobbeltsyn Lysfoslashlsomhed Lydfoslashlsomhed Soslashvnproblemer Traeligthed
KOGNITIVT Daringrlig koncentrationsevne Opmaeligrksomhedsproblemer Hukommelsesvanskeligheder Generel forvirring Overbliksvanskeligheder Strukturproblemer Nedsat laeligseevne Ordfindingsvanskeligheder
ADFAEligRD Irritabilitet AEligngstelser Depression Aggression Indlaeligringsvanskeligheder Stressfoslashlsomhed Impulsivitet Humoslashrsvingninger Personlighedsforandringer
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Langtidsfoslashlger efter mild traumatisk hjerneskade
Hjernerystelse og syn Helstrup 2014 10
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Snarligt kommende rdquoFysioterapeutenrdquo Behandling af en patient med dobbeltsyn og balancebesvaeligr i akut og subakut fase efter en apopleksi - et samarbejde mellem fysioterapeut og neurooptometrist ndash en case rapport Eriksen K udviklingsfysioterapeut1 Helstrup T neurooptometrist fcovd2 Meden P overlaeligge 3 1 Fysio- og ergoterapiafdelingen Bispebjerg Hospital opg 10 Bispebjerg Bakke 23 2400 Koslashbenhavn NV 2 Koslashbenhavns Private Synsplejeklinik Roslashdovre Centrum 247 2610 Roslashdovre 3 Apopleksiklinikken Bispebjerg Hospital Bispebjerg Hospital opg 1 Bispebjerg Bakke 23 2400 Koslashbenhavn NV
Hjernerystelse og syn Helstrup 2014 4
De usynlige skader
PCS Helstrup 2014 5
Konsensusrapport om Commotio cerebri (hjernerystelse) og det Postcommotionelle syndrom (langvarige foslashlgevirkninger)
httpshopsocialstyrelsendkproductscommotio-rapport
Langvarige symptomer efter hjernerystelse udstiller sundhedsvaeligsenets kollektive
uforstand
Tilgangen og raringdgivningen burde vaeligre meget ydmyg ndash men alligevel fremhaeligves ofte
bull Ro og hvile ndash i det uendelige (afmagtsraringdgivning) bull Psykologiske lidelser (ondt i livet) bull OK til det alternative (som garingr i selvsving)
Paradoks 1
Hjernerystelse og syn Helstrup 2014 6
httpwwwprivatsyndkklinikkenklinikkens-medarbejderecv-torbensprogforbistring-synslidelser
Hjernerystelse og syn Helstrup 2014 7
Cirka 15000 hjernerystelser aringrligt Beskue helingsproces for langt flertallet ndash dage uger
Men for cirka 1500 kikser det helt (PCS) Skolebarn kan sortere rdquoDuer ikkerdquo
Paradoks 2
Ingen systematisk tilgang til diagnose og behandling i Danmark httpwwwhjernerystelsedkavisartikel_jan2008pdf
Paradoks 3 Sygdom versus lidelse
bull En uheldig virkning af sygdomsbegrebet er at naringr der ikke stilles en medicinsk diagnose (og behandling) - saring opfattes tilstanden ikke som saring alvorlig
bull Det er helt forkert
bull Funktionsforstyrrelser kan afstedkomme meget alvorlige symptomer Personer kan vaeligre meget forpinte og uarbejdsdygtige
Hjernerystelse og syn Helstrup 2014 8
Optometrien i
landskabet
Hjernerystelse og syn Helstrup 2014 9
Daghoslashjskolen i centrum (neuropsyk)
NEUROLOGISK Nakkesmerter Hovedpine Svimmelhed Taringge eller dobbeltsyn Lysfoslashlsomhed Lydfoslashlsomhed Soslashvnproblemer Traeligthed
KOGNITIVT Daringrlig koncentrationsevne Opmaeligrksomhedsproblemer Hukommelsesvanskeligheder Generel forvirring Overbliksvanskeligheder Strukturproblemer Nedsat laeligseevne Ordfindingsvanskeligheder
ADFAEligRD Irritabilitet AEligngstelser Depression Aggression Indlaeligringsvanskeligheder Stressfoslashlsomhed Impulsivitet Humoslashrsvingninger Personlighedsforandringer
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Langtidsfoslashlger efter mild traumatisk hjerneskade
Hjernerystelse og syn Helstrup 2014 10
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
De usynlige skader
PCS Helstrup 2014 5
Konsensusrapport om Commotio cerebri (hjernerystelse) og det Postcommotionelle syndrom (langvarige foslashlgevirkninger)
httpshopsocialstyrelsendkproductscommotio-rapport
Langvarige symptomer efter hjernerystelse udstiller sundhedsvaeligsenets kollektive
uforstand
Tilgangen og raringdgivningen burde vaeligre meget ydmyg ndash men alligevel fremhaeligves ofte
bull Ro og hvile ndash i det uendelige (afmagtsraringdgivning) bull Psykologiske lidelser (ondt i livet) bull OK til det alternative (som garingr i selvsving)
Paradoks 1
Hjernerystelse og syn Helstrup 2014 6
httpwwwprivatsyndkklinikkenklinikkens-medarbejderecv-torbensprogforbistring-synslidelser
Hjernerystelse og syn Helstrup 2014 7
Cirka 15000 hjernerystelser aringrligt Beskue helingsproces for langt flertallet ndash dage uger
Men for cirka 1500 kikser det helt (PCS) Skolebarn kan sortere rdquoDuer ikkerdquo
Paradoks 2
Ingen systematisk tilgang til diagnose og behandling i Danmark httpwwwhjernerystelsedkavisartikel_jan2008pdf
Paradoks 3 Sygdom versus lidelse
bull En uheldig virkning af sygdomsbegrebet er at naringr der ikke stilles en medicinsk diagnose (og behandling) - saring opfattes tilstanden ikke som saring alvorlig
bull Det er helt forkert
bull Funktionsforstyrrelser kan afstedkomme meget alvorlige symptomer Personer kan vaeligre meget forpinte og uarbejdsdygtige
Hjernerystelse og syn Helstrup 2014 8
Optometrien i
landskabet
Hjernerystelse og syn Helstrup 2014 9
Daghoslashjskolen i centrum (neuropsyk)
NEUROLOGISK Nakkesmerter Hovedpine Svimmelhed Taringge eller dobbeltsyn Lysfoslashlsomhed Lydfoslashlsomhed Soslashvnproblemer Traeligthed
KOGNITIVT Daringrlig koncentrationsevne Opmaeligrksomhedsproblemer Hukommelsesvanskeligheder Generel forvirring Overbliksvanskeligheder Strukturproblemer Nedsat laeligseevne Ordfindingsvanskeligheder
ADFAEligRD Irritabilitet AEligngstelser Depression Aggression Indlaeligringsvanskeligheder Stressfoslashlsomhed Impulsivitet Humoslashrsvingninger Personlighedsforandringer
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Langtidsfoslashlger efter mild traumatisk hjerneskade
Hjernerystelse og syn Helstrup 2014 10
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Langvarige symptomer efter hjernerystelse udstiller sundhedsvaeligsenets kollektive
uforstand
Tilgangen og raringdgivningen burde vaeligre meget ydmyg ndash men alligevel fremhaeligves ofte
bull Ro og hvile ndash i det uendelige (afmagtsraringdgivning) bull Psykologiske lidelser (ondt i livet) bull OK til det alternative (som garingr i selvsving)
Paradoks 1
Hjernerystelse og syn Helstrup 2014 6
httpwwwprivatsyndkklinikkenklinikkens-medarbejderecv-torbensprogforbistring-synslidelser
Hjernerystelse og syn Helstrup 2014 7
Cirka 15000 hjernerystelser aringrligt Beskue helingsproces for langt flertallet ndash dage uger
Men for cirka 1500 kikser det helt (PCS) Skolebarn kan sortere rdquoDuer ikkerdquo
Paradoks 2
Ingen systematisk tilgang til diagnose og behandling i Danmark httpwwwhjernerystelsedkavisartikel_jan2008pdf
Paradoks 3 Sygdom versus lidelse
bull En uheldig virkning af sygdomsbegrebet er at naringr der ikke stilles en medicinsk diagnose (og behandling) - saring opfattes tilstanden ikke som saring alvorlig
bull Det er helt forkert
bull Funktionsforstyrrelser kan afstedkomme meget alvorlige symptomer Personer kan vaeligre meget forpinte og uarbejdsdygtige
Hjernerystelse og syn Helstrup 2014 8
Optometrien i
landskabet
Hjernerystelse og syn Helstrup 2014 9
Daghoslashjskolen i centrum (neuropsyk)
NEUROLOGISK Nakkesmerter Hovedpine Svimmelhed Taringge eller dobbeltsyn Lysfoslashlsomhed Lydfoslashlsomhed Soslashvnproblemer Traeligthed
KOGNITIVT Daringrlig koncentrationsevne Opmaeligrksomhedsproblemer Hukommelsesvanskeligheder Generel forvirring Overbliksvanskeligheder Strukturproblemer Nedsat laeligseevne Ordfindingsvanskeligheder
ADFAEligRD Irritabilitet AEligngstelser Depression Aggression Indlaeligringsvanskeligheder Stressfoslashlsomhed Impulsivitet Humoslashrsvingninger Personlighedsforandringer
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Langtidsfoslashlger efter mild traumatisk hjerneskade
Hjernerystelse og syn Helstrup 2014 10
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Hjernerystelse og syn Helstrup 2014 7
Cirka 15000 hjernerystelser aringrligt Beskue helingsproces for langt flertallet ndash dage uger
Men for cirka 1500 kikser det helt (PCS) Skolebarn kan sortere rdquoDuer ikkerdquo
Paradoks 2
Ingen systematisk tilgang til diagnose og behandling i Danmark httpwwwhjernerystelsedkavisartikel_jan2008pdf
Paradoks 3 Sygdom versus lidelse
bull En uheldig virkning af sygdomsbegrebet er at naringr der ikke stilles en medicinsk diagnose (og behandling) - saring opfattes tilstanden ikke som saring alvorlig
bull Det er helt forkert
bull Funktionsforstyrrelser kan afstedkomme meget alvorlige symptomer Personer kan vaeligre meget forpinte og uarbejdsdygtige
Hjernerystelse og syn Helstrup 2014 8
Optometrien i
landskabet
Hjernerystelse og syn Helstrup 2014 9
Daghoslashjskolen i centrum (neuropsyk)
NEUROLOGISK Nakkesmerter Hovedpine Svimmelhed Taringge eller dobbeltsyn Lysfoslashlsomhed Lydfoslashlsomhed Soslashvnproblemer Traeligthed
KOGNITIVT Daringrlig koncentrationsevne Opmaeligrksomhedsproblemer Hukommelsesvanskeligheder Generel forvirring Overbliksvanskeligheder Strukturproblemer Nedsat laeligseevne Ordfindingsvanskeligheder
ADFAEligRD Irritabilitet AEligngstelser Depression Aggression Indlaeligringsvanskeligheder Stressfoslashlsomhed Impulsivitet Humoslashrsvingninger Personlighedsforandringer
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Langtidsfoslashlger efter mild traumatisk hjerneskade
Hjernerystelse og syn Helstrup 2014 10
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Paradoks 3 Sygdom versus lidelse
bull En uheldig virkning af sygdomsbegrebet er at naringr der ikke stilles en medicinsk diagnose (og behandling) - saring opfattes tilstanden ikke som saring alvorlig
bull Det er helt forkert
bull Funktionsforstyrrelser kan afstedkomme meget alvorlige symptomer Personer kan vaeligre meget forpinte og uarbejdsdygtige
Hjernerystelse og syn Helstrup 2014 8
Optometrien i
landskabet
Hjernerystelse og syn Helstrup 2014 9
Daghoslashjskolen i centrum (neuropsyk)
NEUROLOGISK Nakkesmerter Hovedpine Svimmelhed Taringge eller dobbeltsyn Lysfoslashlsomhed Lydfoslashlsomhed Soslashvnproblemer Traeligthed
KOGNITIVT Daringrlig koncentrationsevne Opmaeligrksomhedsproblemer Hukommelsesvanskeligheder Generel forvirring Overbliksvanskeligheder Strukturproblemer Nedsat laeligseevne Ordfindingsvanskeligheder
ADFAEligRD Irritabilitet AEligngstelser Depression Aggression Indlaeligringsvanskeligheder Stressfoslashlsomhed Impulsivitet Humoslashrsvingninger Personlighedsforandringer
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Langtidsfoslashlger efter mild traumatisk hjerneskade
Hjernerystelse og syn Helstrup 2014 10
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Optometrien i
landskabet
Hjernerystelse og syn Helstrup 2014 9
Daghoslashjskolen i centrum (neuropsyk)
NEUROLOGISK Nakkesmerter Hovedpine Svimmelhed Taringge eller dobbeltsyn Lysfoslashlsomhed Lydfoslashlsomhed Soslashvnproblemer Traeligthed
KOGNITIVT Daringrlig koncentrationsevne Opmaeligrksomhedsproblemer Hukommelsesvanskeligheder Generel forvirring Overbliksvanskeligheder Strukturproblemer Nedsat laeligseevne Ordfindingsvanskeligheder
ADFAEligRD Irritabilitet AEligngstelser Depression Aggression Indlaeligringsvanskeligheder Stressfoslashlsomhed Impulsivitet Humoslashrsvingninger Personlighedsforandringer
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Langtidsfoslashlger efter mild traumatisk hjerneskade
Hjernerystelse og syn Helstrup 2014 10
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Daghoslashjskolen i centrum (neuropsyk)
NEUROLOGISK Nakkesmerter Hovedpine Svimmelhed Taringge eller dobbeltsyn Lysfoslashlsomhed Lydfoslashlsomhed Soslashvnproblemer Traeligthed
KOGNITIVT Daringrlig koncentrationsevne Opmaeligrksomhedsproblemer Hukommelsesvanskeligheder Generel forvirring Overbliksvanskeligheder Strukturproblemer Nedsat laeligseevne Ordfindingsvanskeligheder
ADFAEligRD Irritabilitet AEligngstelser Depression Aggression Indlaeligringsvanskeligheder Stressfoslashlsomhed Impulsivitet Humoslashrsvingninger Personlighedsforandringer
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Langtidsfoslashlger efter mild traumatisk hjerneskade
Hjernerystelse og syn Helstrup 2014 10
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Daghoslashjskolen i centrum (neuropsyk)
Sanseindtryk Hyppigt forekommende langtidsfoslashlger er nedsat evne til at integrere sanseindtryk Personen bliver lyd- og lysfoslashlsom Endvidere ses en hoslashj frekvens af synsforstyrrelser dobbeltsyn flimren taringgesyn samsynsproblemer og fokuseringsvanskeligheder samt cerebral astenopi (3) Synsproblemerne vil fremkalde mental udtraeligtning og kan forstaeligrke hovedpine og svimmelhed
L a n g t i d s f oslash l g e r e f t e r m i l d t r a u m a t i s k h j e r n e s k a d e
httpwwwdhicdkyderligereLangtidsfoelger_efter_mild_traumatisk_hjerneskadehtm
Hjernerystelse og syn Helstrup 2014 11
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Center for hjerneskade
Hvad er hjernerystelse Ved hjernerystelse kan der opstaring skader paring nervebanerne og i stoslashttevaeligvet hvilket paringvirker de kemiske systemer og blodgennemstroslashmningen i hjernen Forandringerne er ofte ikke synlige ved scanning eller neurologisk undersoslashgelse
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 12
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Center for hjerneskade
Commotio-enheden paring Center for Hjerneskade tilbyder ------- Ofte er den ramtes intellektuelle funktioner kun lettere paringvirket men foslashlgerne af hjernerystelsen betyder at de kun kan arbejde i kort tid ad gangen ------
Center for Hjerneskade samarbejder med en raeligkke eksterne fagpersoner (neurologer psykiatere optometrister mv) for at sikre at borgeren faringr det optimale udbytte af forloslashbet
httpcfhkudkGenoptraening-_voksnehjernerystelse
Hjernerystelse og syn Helstrup 2014 13
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014 14
Big Bang Elektromagnetisk straringling tyngdekraft og tiden frisaeligttes
4 D verden Rumlig afstand betyder tidslaeligngde - og vice versa (ikke abstrakt - volumen omkring os)
137 milliarder aringr Vaeligsen med sanseapparat til afkodning ---
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Rumtiden (spacetime)
Fakta Rumtid I Einsteins relativitetsteori er tid og det tredimensionale rum slaringet sammen til en enkel firedimensional rumtid (4D)
Et punkt i rumtiden bliver benaeligvnt en haeligndelse
Enhver haeligndelse har 4 koordinater (t x y z) ndash en for hver dimension
Hjernerystelse og syn Helstrup 2014
Tid- hoslashjre-venstre- op-ned og naeligr-fjern dimensionerne
15
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Rumtiden (spacetime)
Hjernerystelse og syn Helstrup 2014
16
Al erkendelse af eget staringsted og al tings indbyrdes relationer - samt alt handling og faeligrden er baseret paring rumtidsanalyse og fremtidsfortolkning
4 D
Volumen
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Synshjernens virke
PCS Helstrup 2014 17
Interface 1 Kontaktflade
mellem ydre og indre
verden (fiksationsfelt) Interface 2 Lysenergi til elektrisk impuls og
foslashrste processering
Signalmix og foslashlsomhedsregulering af interface 2 Opsplitning af egenskaber analyse og bevidsthed Samme aktivitet
fysisk elektrisk
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Hjernerystelse og syn Helstrup 2014 18
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
De visuelle motorveje
Hvad
Hvor hvordan
Hjernerystelse og syn Helstrup 2014 19
X Orkestermodellen
80- 90 fra retikulaeligre formation og V1
Max 40 af retinale signaler transportes videre fra LGN
Interface
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
The binding problem - eller hvordan sammenflettes
og adskilles hjernecelleaktivitet
Hjernerystelse og syn Helstrup 2014
X Som et orkester ndash men uden dirigent
1 Signalforstaeligrkning (synkronitet) 2 Signal-stoslashj forhold optimalt (baggrundsaktivitet svag) 3 Forgrund ndash baggrund (filtrering af vaeligsentlighed)
20
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Faeligrden og navigation
Hjernerystelse og syn Helstrup 2014 21
Online justering (transportstativ)
Minds eye Fremtidsfortolkning af rumtiden (txyz) - og masterplan for bevaeliggelse
Sanser til at afkode ydre og indre verden
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Kumulerede hastighedsfordelinger for fritgaringende yngre (17-64 aringr) aeligldre (65 aringr+) og handikappede fodgaeligngere (med rollator stok) i signalregulerede kryds
Normal ganghastighed
Fremtidsfortolkning rdquoLaeligserdquo og handle
Hjernerystelse og syn Helstrup 2014 22
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Fremtidsfortolkning rdquoLaeligserdquo og handle
Faeligrden kraeligver at rumtiden fortolkes gt Kollisionskurs- og tid gt timing (ogsaring i rullestol)
Syn styrer bevaeliggelse og hastighed gt Masterplan
Hjernerystelse og syn Helstrup 2014 23
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
PCS Helstrup 2014 24
Scanning af information i rumtiden (txyz) - via saccader
Spe
cial Issue
Saccade
Search
and
Orie
nt
Jun
e 2
01
1
Vo
lum
e 33
Issue 1
1 Pages 1
94
5ndash2
16
7
Saccademotoren Fiksation Lokalisation Identifikation Ny saccade
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Vis
ible
Ma
n B
rain
as
in F
ig 2
Corbetta M PNAS 199895831-838
copy1998 by National Academy of Sciences
htt
p
ww
wp
nas
org
co
nte
nt
95
38
31
F5
exp
ansi
on
htm
l Frontoparietal cortical networks for directing attention and the eye to visual locations Identical independent or overlapping neuralthinspsystems
Hjernerystelse og syn Helstrup 2014 25
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
4-D fiksation sammenfatning og formaringl
bull Fiksation Visuelle
ankerpunkt i rumtiden
bull HVOR er det
(perifere syn) Global analyse
(M system) bull HVAD er det
(centrale syn) Lokal analyse
(P system)
X
Y
Z
bull Rumtidsanalyse analyse for beregning af kollisionskurs- og tid
bull Timing af bevaeliggelser
Trin 1
Hjernerystelse og syn Helstrup 2014 26
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Figure 1 Eye movement scanpath (in red) of a person viewing a painting by Rein note the tendency to fixate on the faces Adapted from Yarbus (Eye Movements and Vision Plenum New York 1967)
Saccader i aktion
Afkodning af billede (scanningsmoslashnster)
Hjernerystelse og syn Helstrup 2014 27
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Scanningsmoslashnstre er opgave relaterede
Hjernerystelse og syn Helstrup 2014 28
httpentirelysubjectivecomsaccades-we-see-what-we-are-looking-for
Godt bud paring efferente ruter fra V1 til LGN Hjernen opsoslashger og leder efter saeligrlige interessepunkter (POI) ndash afhaeligngig af opgaven (indefra gt ud)
Saccader i aktion
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Kontaktsport og hjernerystelse
J Neurol Sci 2013 May 15328(1-2)28-31 doi 101016jjns201302008 Epub 2013 Saccades and memory baseline associations of the King-Devick and SCAT2 SAC tests in professional ice hockey players
Neurology 2011 Apr 2676(17)1456-62 doi 101212WNL0b013e31821184c9 Epub 2011 Feb 2
The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters
Hjernerystelse og syn Helstrup 2014 29
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
King-Devick Test httpenwikipediaorgwikiKing-Devick Test
bull The King-Devick Test (K-D Test) is
defined by Mosbyrsquos Medical Dictionary as a tool for evaluation of saccade consisting of a series of test cards of numbers The test cards become progressively more difficult to read due to variability of spacing between the numbers Both errors in reading and speed of reading are included in deriving a score[1] Saccades are quick simultaneous movements of both eyes
bull In 2011 researchers discovered a link between King-Devick Test and sideline remove-from-play concussion screening
J Neurol Sci 2011 Oct 15309(1-2)34-9 doi 101016jjns201107039 Epub 2011 Aug 16 The King-Devick test and sports-related concussion study of a rapid visual screening tool in a collegiate cohort Hjernerystelse og syn Helstrup 2014 30
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Saccade-neurologien saringret
J Sports Med Phys Fitness 2014 Feb54(1)70-7
The King-Devick test as a concussion screening tool administered by sports parents
High levels of test-retest reliability were observed (intraclass correlation coefficient 090 [95 CI 084-097]) Additionally 6 boxers who participated in multiple bouts showed no worsening of their K-D times further supporting that scores are not affected by the fatigue associated with sparring Conclusion The K-D test is a rapid sideline screening tool for concussion that can be effectively administered by non-medically trained laypersons
Hjernerystelse og syn Helstrup 2014 31
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Kommerciel hjemmeside httpkingdevicktestcom
Test af scanningsmoslashnster
Hjernerystelse og syn Helstrup 2014 32
httpswwwyoutubecomwatchv=hGcz0dQUZnw
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Signalproblemer ved saringret saccade neurologi
Hjernerystelse og syn Helstrup 2014 33
Kan ikke saccadere normalt gt og kan ikke afkode txyz meningsfyldt gt kommer ud af synkronitet med rumtiden
Al bevaeliggelse baringde egen og i omgivelser bliver en trussel gt og kraeligver enorm mental anstrengelse at haringndtere (kognitivt load maksimalt) Afledte subjektive klager er ofte bull Konfusion Kan ikke se Tv film eller faeligrdes i centre ( for
mange bevaeliggelser og ligebyrdighed i signaler) bull Bliver let usikker paring eget staringsted og kan ikke bevaeligge hoved
eller krop hurtigt (svimler) Orientering tager tid bull Visuel aktivitet generelt meget kraeligvende og traeligttende og
har ofte opgivet laeligsning (isaeligr computer) bull Hvis man rdquosynderrdquo faringr man rdquotaeligskrdquo (let op til et doslashgn efter)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Det hele starter med Okulaeligr fiksation
Hjernerystelse og syn Helstrup 2014
Sigtemekanik til traringdloslashs online rumlig sansning
34
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Spotlight = Fiksationsomraringde = Perceptionsfelt
Hjernerystelse og syn Helstrup 2014 35
Ankerpunkt og traringdloslashse perceptuelle kontakt i fysiske verden
Macula ca 1 grad Paramaculaeligre omraringde ca 10 grader (tommel i strakt arm ca 2 grader)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
bullFiksation bullSmooth Pursuit bullSaccader bullOptokinetiske refleks bullVestibulaeligre-okulaeligre refleks
Fastholde eller skifte fiksationsfelt - mhp at opsoslashge og tolke rumlig information Fiksationsstabiliserende ved bevaeliggelse (hoved og krop)
Biomekanik til fiksation (et oslashje)
rdquoJaeliggerenrdquo Saccader og VOR gt OPSOslashGE information i omgivelser rdquoForfoslashlgerenrdquo Smooth pursuit og OKR gt FOslashLGE objekt ndash og stimulus kommer fra oslashjet selv (input-out drevet)
Sansekonflikt Transportsyge
Hjernerystelse og syn Helstrup 2014 36
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Binokulaeligre ankerpunkt (fiksationsfelt) rdquoPoint of interestrdquo
Stereopsis (synsvinkelforskel)
Motorisk triangulation
(proprioception)
Hjernerystelse og syn Helstrup 2014 37
2
Signalforstaeligrkning
Rumtidsfortolkere af i signaler i t- og z dimensionerne
POI
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
POI Fiksationsfelt (Mindrsquos eye) Input-output drevet
Naeligrtriade Selvstaeligndige og gensidigt modulerende reaktioner bull Vergens version bull Akkommodation bull Pupil
Biomekanik til fiksation (to oslashjne) Binokulaeligre syn
Hjernerystelse og syn Helstrup 2014 38
Mindrsquos eye Paramaculaeligre omraringde daeligkker ca 10 grader af synsfeltet Oslashjenbevaeliggelser er klart hurtigere og mere praeligcise en hovedbevaeliggelser Saccader scanner synsfeltet
Ballistisk saccade til nyt objekt Bi-fiksation Smooth pursuitndash og
vergensfunktionen samarbejder (bi-fiksation indenfor Panums omraringde)
Vergens vinkel
POI
POI
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Hjernerystelse og syn Helstrup 2014
Version subsystem
Vergence subsystem
Conjugate movements
Disconjugate movements
Fast eye movements
Slow eye movements
Vestibular
Proprioceptive
Vergence eye movements
39
Ocular motor system in 3D space
XY Z(T)
Fiksations- og scanningsfelt
POI
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Kredsloslashb
Sensoriske og motoriske systemer i samspil Input og output samtidigt
Hjernerystelse og syn Helstrup 2014 40
Signal sortering
Direktoslashren
Maskinrummet
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Binokulaeligre synslidelser
Hjernerystelse og syn Helstrup 2014 41
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
General approach to diplopia
Danchaivijitr C Kennard C J Neurol Neurosurg Psychiatry
200475iv24-iv31 copy2004 by BMJ Publishing Group Ltd
42 Hjernerystelse og syn Helstrup 2014
Blikafhaeligngig skelevinkel
Dobbelt konturering
Posttraumatisk dekompenseret phorie PTDF
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
World Health Organisation ICD 2007
bull Diseases of the eye and adnexa (H00-H59)
bull H00-H06Disorders of eyelid lacrimal system and orbit
bull H10-H13Disorders of conjunctiva
bull H15-H22Disorders of sclera cornea iris and ciliary body
bull H25-H28Disorders of lens
bull H30-H36Disorders of choroid and retina
bull H40-H42Glaucoma
bull H43-H45Disorders of vitreous body and globe
bull H46-H48Disorders of optic nerve and visual pathways
bull H49-H52Disorders of ocular muscles binocular movement accommodation and refraction
bull H53-H54Visual disturbances and blindness
bull H55-H59Other disorders of eye and adnexa
Lidelser som afhjaeliglpes med optisk behandling ndash ogeller terapi
Medicin eller kirurgi har ingen eller begraelignset virkning
Portvagt problematik
Hjernerystelse og syn Helstrup 2014 43
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Ortho
Basic eso (37841)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens insufficiens
(37885) AFgtNF ACA lav
(WHO H 518) Afst problem
Konvergens insufficiens
(37883) NFgtAF ACA lav
(WHO H 511) Naeligrproblem
Basic exo (37842)
AF=NF ACA norm
(WHO H 503) Afst + naeligr problem
Divergens Excess (37885)
AFgtNF ACA hoslashj (WHO H 518) Afst problem
Konvergens excess (37884)
NFgtAF ACA hoslashj (WHO H 511) Naeligrproblem
Udvidet Duane klassifikation
Eso
Exo
ICD 9 og 10 koder
Hjernerystelse og syn Helstrup 2014
Se konsensus testprotokoller AOA og AAO
44
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Asthenopia (aesthenopia) or eye strain is an condition that manifests itself through nonspecific symptoms such as fatigue pain in or around the eyes blurred vision headache and occasional double vision Symptoms often occur after reading computer work or other close activities that involve tedious visual tasks
httpenwikipediaorgwikiAsthenopia
Asthenopia (WHO ICD 10 H 531)
Hjernerystelse og syn Helstrup 2014
Hovedpine og traeligtte oslashjne
45
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Toslashrt oslashje
Asthenopi
Ergonomi refraktion Binokularitet
Ametropi Astigmatisme Akkomodation Presbyopi
Heterofori Fusion ACA Suppression
ICHD 1132 ICHD 1133
Indretning Synsafstand Blikvinkel Belysning
Aringrsagssammenhaelignge
Hjernerystelse og syn Helstrup 2014
httpjournalslwwcomoptvissciFulltext200311000Is_all_Asthenopia_the_Same_8aspx 46
httpwwwncbinlmnihgovpubmed14627938
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
The International Classification of Headache Disorders 2nd Edition (ICHD-II)
IHS WHO Diagnosis
ICHD-II Code ICD-10NA Code
1132 G 44843 Headache attributed to refractive errors (H 520 ndash H 527)
1133 G 44843 Headache attributed to heterophoria or heterotropia (latent or manifest squint) (H 503 ndash H 505)
Hjernerystelse og syn Helstrup 2014 47
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Kompensationsbetinget hovedpine (11325)
bull Aringrsagen er meget kraftig anvendelse af akkommodationskonvergens ndash som kompensation for utilstraeligkkelig fusionskonververgens
bull Resultatet er en binokulaeligr hysterisk reaktion i akkommodationsfunktionen (Smertefremkaldende Mild - svaeligr)
Hjernerystelse og syn Helstrup 2014 48
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Kompensationsbetinget hovedpine (11325)
Objektivt
bull Ofte paringfaldende lille pupil ved naeligrcovertest samt konvergensnaeligrpunktsmaringling
Subjektivt (stereopsis + visus normal)
bull Exoforie kombineret med lavt ACA forhold
bull Positive fusionsevne markant reduceret (tydeligst ved 6 m test)
bull Negative relative akkommodation beskeden (monokulaeligr visus bedst fra ca 125)
Hjernerystelse og syn Helstrup 2014 49
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Gensidig Modulation ACA CAC
(Bi) fiksation Version Vergens (sigte)
Akkommodation Refraktion
(fokus)
Pursuit Fastholde Fiksation
(rdquoforfoslashlgerenrdquo)
Saccade Opsoslashge ny Fiksation
(rdquojaeliggerenrdquo)
Trin 1 Fiksation lokalisation og identifikation
Biomekaniske enheder for visuel perception
PCS Helstrup 2014 50
Offentlige sundhedsvaeligsen iagttager IKKE naeligrtriaden (anvender 1966 modellen) Optometristelever dumper med samme praksis UDLOslashBSDATO
Naeligrtriaden
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Undersoslashgelser
Hjernerystelse og syn Helstrup 2014 51
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Occurrence of oculomotor dysfunctions in acquired brain injury A retrospective analysis
Kenneth J Ciuffreda OD PhD Optometry (2007) 78 155-161
Table 3 Summary of the percentage of individuals in each subgroup (where for TBI n= 160 and for CVA n= 60) within a given category of ocular motor dysfunction and the most common anomaly present
Ocular motor dysfunction TBI () Most common anomaly CVA () Most common anomaly
Accommodation 411 Accommodative insufficiency 125 Accommodative infacility Versional 513 Deficits of saccades 567 Deficits of saccades Vergence 563 Convergence insufficiency 367 Convergence insufficiency Strabismus 256 Strabismus at near 367 Strabismus at far CN palsy 69 CN III 10 CN III
Note The ldquonrdquo represents the number of persons tested for accommodation which only included those under the age of 40 years (ie prepresbyopic) TBI = 51 and CVA= 8
Hjernerystelse og syn Helstrup 2014 52
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
httpwwwncbinlmnihgovpubmed19617197
1
Brain 2009 Oct132(Pt 10)2850-70 doi 101093brainawp181 Epub 2009 Jul 16 Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression malingering or intellectual ability Heitger MH Jones RD Macleod AD Snell DL Frampton CM Anderson TJ Author information Abstract Post-concussion syndrome (PCS) can affect up to 20-30 of patients with mild closed head injury (mCHI) comprising incomplete recovery and debilitating persistence of post-concussional symptoms Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI Here we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (ie mCHI patients of similar injury severity but good recovery) on reflexive anti- and self-paced saccades memory-guided sequences and smooth pursuit All completed neuropsychological testing and health status questionnaires
Hjernerystelse Synsforstyrrelser og ingen psykiske vanskeligheder
Hjernerystelse og syn Helstrup 2014 53
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Mean time post-injury was 140 days in the PCS group and 163 days in the control group The PCS group performed worse on anti-saccades self-paced saccades memory-guided sequences and smooth pursuit suggesting problems in response inhibition short-term spatial memory motor-sequence programming visuospatial processing and visual attention This poorer oculomotor performance included several measures beyond conscious control indicating that subcortical functionality in the PCS group was poorer than expected after mCHI The PCS group had poorer neuropsychological function (memory complex attention and executive function) Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability Compared with neuropsychological tests eye movements were more likely to be markedly impaired in PCS cases with high symptom load Poorer eye movement function and particularly poorer subcortical oculomotor function correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment eye movements showed additional dysfunction in motorvisuospatial areas response inhibition visual attention and subcortical function Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity but also has a biological substrate Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile Routine oculomotor testing should be feasible in centres with existing access to this technology
2
54 Hjernerystelse og syn Helstrup 2014
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
httpwwwncbinlmnihgovpubmed23341281
httpwwwrehabresearchvagovjour2012497szymanowicz497html
J Rehabil Res Dev 201249(7)1083-100 Vergence in mild traumatic brain injury a pilot study Szymanowicz D Ciuffreda KJ Thiagarajan P Ludlam DP Green W Kapoor N Author information Abstract Vergence dysfunction in individuals with mild traumatic brain injury (mTBI) may have a negative effect on quality of life functional abilities and rehabilitative progress In this study we used a range of dynamic and static objective and subjective measures of vergence to assess 21 adult patients with mTBI and nearwork symptoms The results were compared with 10 control adult subjects With respect to dynamic parameters responses in those with mTBI were slowed variable and delayed With respect to static parameters reduced near point of convergence and restricted near vergence ranges were found in those with mTBI The present results provide evidence for the substantial adverse effect of mTBI on vergence function
Hjernerystelse og nedbrud i vergensfunktion
Hjernerystelse og syn Helstrup 2014 55
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Optom Vis Sci 2012 Dec89(12)1740-51 doi 101097OPX0b013e3182772dce Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury Alvarez TL Kim EH Vicci VR Dhar SK Biswal BB Barrett AM Author information Abstract PURPOSE This study assessed the prevalence of convergence insufficiency (CI) with and without simultaneous vision dysfunctions within the traumatic brain injury (TBI) sample population because although CI is commonly reported with TBI the prevalence of concurrent visual dysfunctions with CI in TBI is unknown METHODS A retrospective analysis of 557 medical records from TBI civilian patients was conducted Patients were all evaluated by a single optometrist Visual acuity oculomotor function binocular vision function accommodation visual fields ocular health and vestibular function were assessed Statistical comparisons between the CI and non-CI as well as inpatient and outpatient subgroups were conducted using χ and Z tests
1
httpwwwncbinlmnihgovpubmed23190716
Samtidige synsproblemer
Hjernerystelse og syn Helstrup 2014 56
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
RESULTS 1 Approximately 9 of the TBI sample had CI without the following simultaneous diagnoses saccade or pursuit dysfunction third fourth or sixth cranial nerve palsy visual field deficit visual spatial inattentionneglect vestibular dysfunction or nystagmus 2 Photophobia with CI was observed in 163 (21 of 130) 3 and vestibular dysfunction with CI was observed in 185 (24 of 130) of the CI subgroup 4 Convergence insufficiency and cranial nerve palsies were common and yielded prevalence rates of 233 (130 of 557) and 269 (150 of 557) respectively within the TBI sample 5 Accommodative dysfunction was common within the nonpresbyopic TBI sample with a prevalence of 244 (76 of 314) 6 Visual field deficits or unilateral visual spatial inattentionneglect was observed within 296 (80 of 270) of the TBI inpatient subgroup and was significantly more prevalent compared with that of the outpatient subgroup (p lt 0001) 7 Most TBI patients had visual acuities of 2060 or better in the TBI sample (85 473 of 557) CONCLUSIONS Convergence insufficiency without simultaneous visual or vestibular dysfunctions was observed in about 9 of the visually symptomatic TBI civilian population studied A thorough visual and vestibular examination is recommended for all TBI patients
2
httpwwwncbinlmnihgovpubmed23190716 Hjernerystelse og syn Helstrup 2014
57
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
NeuroRehabilitation 2014 Jan 134(1)129-46 doi 103233NRE-131025 Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI) An integrative approach Thiagarajan P1 Ciuffreda KJ1 Capo-Aponte JE2 Ludlam DP1 Kapoor N3 Author information Abstract BACKGROUND Considering the extensive neural network of the oculomotor subsystems traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction OBJECTIVE To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI METHODS Twelve subjects with mTBI participated in a cross-over interventional study involving oculomotor training (OMT) and sham training (ST) Each training was performed for 6 weeks 2 sessions a week During each training session all three oculomotor subsystems (vergenceaccommodationversion) were trained in a randomized order across sessions All laboratory and clinical parameters were determined before and after OMT and ST In addition nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed
httpwwwncbinlmnihgovpubmed24284470
1 Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 58
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
httpwwwncbinlmnihgovpubmed24284470
2
RESULTS Following the OMT over 80 of the abnormal parameters significantly improved Reading rate along with the amplitudes of vergence and accommodation improved markedly Saccadic eye movements demonstrated enhanced rhythmicity and accuracy The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention None of the parameters changed with ST CONCLUSIONS OBVR had a strong positive effect on oculomotor control reading rate and overall reading ability This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI
Okulomotorisk rehabilitering
Hjernerystelse og syn Helstrup 2014 59
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Sammenfatning af undersoslashgelser med god belaeligg
Hjernerystelse og syn Helstrup 2014 60
bull Synsforstyrrelser er hyppige efter hjernerystelse bull Saccade neurologien saringres ndash og kan ret simpelt testes bull Synsskader er klart uafhaeligngige af psykologiske lidelser bull Det binokulaeligre syn kan skades (bifiksation) og
vergenslidelser blottes (mu kompensationadfaeligrd)
bull Reparation og genoptraeligning af vergenslidelser mhb normal (bi)fiksationsevne gt Laeligsefunktion (stabilt afkodningsfelt)
bull Goslashremaringlsbestemte aktiviteter dirigeret af masterplan mhb normal saccade funktion gt Faeligrden (strategisk afkodningsfelt)
En andel af PCS lidende kan ikke rehabiliteres fuldstaeligndigt hvis det optomotoriske apparat ikke inddrages Behandlingsplanen skal iagttage
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
PCS Helstrup 2014 61
Vores placering i
tvaeligrfaglig opgave
Haeligvde forstaringelse for synshjerne og
biomekanik
Perspektiv
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)
Formaringl og budskaber
Hjernerystelse og syn Helstrup 2014 62
bull Oplysning til borgere Stort og smaringt bull Laeligngerevarende synsproblemer kan maringske lindres eller
afhjaeliglpes
bull Behandling er ikke for nybegyndere Der er mange faldgrupper
bull Henvis til en kollega med erfaring (foresposlashrg evt DO Saust) bull Hvis terapi bull Lokale svigt i det optomotoriske apparat og afledte
kompensationer skal adresseres foslashrst bull Genoptraeligning skal foslashrst og fremmest indeholde
goslashremaringlsbestemte aktiviteter i rumtiden (saringkaldt top-down aktivitet modsat bottom-up aktivitet)