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Introduction

Following a neurological event such as a traumatic brain injury, cerebrovascular event, multiple sclerosis, etc., the medical needs of the person are of primary importance initially, for purposes of survival. As medical treatment proceeds and the survival needs of the person are met, the team of rehabilitation professionals will be established in an attempt to improve upon function performance in order to sustain quality of life. The rehabilitation team may be composed of a physician, physical therapist, occupational therapist, speech therapist, recreational therapist, vocational specialist, case manager, the psychologist, social worker, and nurse, to name several. It is often during this tim e that additional medical and rehabilitative needs are identified through diagnosis or observation by member s of the rehabilitation team. The case manager is an integral member of the rehabilitation team. It is im perative that the case manager understand the implications of a vision dysfunction and the potential ramifications a ffecting the outcome of rehabilitation if the visual problem is not diagnosed or treated appropriately. If the case manager can detect a visual dysfunction, then their recommended rehabilitation program will be facilitated if the visual problem can be corrected. However, visual problems resulting from the acquired brain injury are often overlooked during treatment of the injury. Frequently the problems are hidden and neglected which, in turn, can impair rehabilitation progress. Very few health care rehabilitation professionals are aware of vi sual problems resulting from brain injury. This can create a gap in rehabilitation resulting in incomplete treatme nt. It is the intent of this presentation to give the case manager tools to identify and define visual pr oblems caused by neurological events. In addition, emphasis will be placed on what results can be expect ed from neuro-optometric rehabilitation as part of the overall rehabilitation team.

Visual problems are not usually identified in early stages of medical treatment unless trauma, disease, or some overt symptom is reported by the person. If there is trauma or disease, an ophthalmologist will usually be called into the hospital in order to develop a treatment protocol. During the rehabilitation process, observations of motor dysfunction by the team or symptoms by the patient may be directed more toward function and performance. This may cause the team memb er to recommend the vision examination. In most cases, the person will be referred to an ophthalmologist or optometrist to have a thorough eye examination, the results of which are rarely directed toward th e reason for referral. The examining doctor will usually determine the state of health of the eyes and possible refractive needs (whether the person needs glasses to see clearly at distance). Upon returning to the rehabilitati on program, the person will continue to demonstrate the same performance or express the same symptoms prior to referral.

Vision problems are among the most common dysfunctions to occur following a neurological event. In most cases, they are secondary to the neurological event but they can become a primary interference to performance and directly affect outcome of rehabilita tion. Gianutsos and Matheson (1986) have emphasized that visual problems can not only occur following brain injury but interfere with information processing. Hellerstein, Freed, and Maples (1995) have documented commonality of vision problems following traumatic brain injury affecting accommodation, binocularity , oculomotor function, and visual field.

Two visual syndromes have been documented in th e literature and are common following a neurological event. Post Trauma Vision Syndrome (Padula and Argyris-1994) and Visual Midline Shift Syndromes (Padula and Shapiro-1992) are two conditions that freque ntly occur following a neurological event and often are undiagnosed from routine eye examinations.

Vision problems can often be misinterpreted as related to psychological issues, perceptual problems, vestibular dysfunction, and / or other neurological problems that may or may not be treatable. The symptoms can vary but frequently fall into categories affecting: 1) balance and space or 2) near vision function (Padula- 1988). Following the neurological event, the person will of ten have binocular function difficulties in the form of strabismus (eye misalignment), convergen ce and accommodative (focusing) dysfunctions, photophobia (glare sensitivity), and difficulty with binocular function. These types of problems make compensation difficult leading in many cases to double vision (dipl opia), headaches, eye strain, blurred vision, and asthenopia (experiencing pain or discomfort partic ularly around the head, neck, and shoulder area).

Vision as a Process

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Dianne Simmons-Grab, MA, CCM, CDMS, CLCP, is Life Care Planning and Vocational Rehabilitation specialist with over 30 years of experience. She is a Certified Case Manager, Certified Disability Manager, and a Certified Life Care Planner.

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