by Katharine Funari (Salus ’18)
The Veterans Health Administration Hospital system is a unique one. Most optometry and ophthalmological care here is centered around primary eye care and ocular disease, along with most specialties including medically-necessary contact lenses and low vision. During my 4th year VA rotation, I became aware of this population’s large need for binocular vision evaluations and vision therapy. (Learn all about vision therapy.)
Each period of conflict in the USA’s history brings its own changes to the medical field. Operation Iraqi Freedom (2003-2011) and Operation Enduring Freedom (2001-2014) in particular shone a spotlight on veterans’ challenges resulting from traumatic brain injury (TBI). (Waldorf, 2015) Veterans who served during these campaigns are currently returning or retiring from active duty, inundating the Veterans Administration Hospitals with a population in need of evaluation and treatment for binocular vision and accommodative disorders. (What can vision therapy do for brain injury recovery?)
While traumatic brain injury can be classified as mild, moderate, or severe, any brain injury can affect the visual system. These effects include: loss of visual acuity and color vision, brightness and contrast decrease, visual field defects, visual attention deficits, visual midline shift syndrome, decreased accommodation and convergence, nystagmus, deficits in pursuits and saccades, EOM deficiencies, diplopia, decrease in stereopsis, and reading difficulties. (American Academy of Ophthalmology, 2016)
Patient X was the first patient I encountered that truly gave me the desire to pursue vision therapy as a method of treatment for his symptoms. I did not feel that any other mode of treatment would give him the results that he needed. However, though my interest in the field of optometry gave me the drive to research methods of treatment, this would have been my first vision therapy case, and it was very easy to feel uncomfortable. I was grateful for the support of my preceptors in encouraging me to research techniques to treat and follow this patient. Because his case was not a very complicated one, I felt confident that given more research and some discussions with my mentors that I would be able to effectively start his treatment.
Patient X was 27 year old white male who presented to the clinic for blurry vision only during transition from near work to distance tasks. He had noticed a “severe downhill turn” in his symptoms in the last few months though they had been occurring for a year. His last eye examination was several years ago. Having just returned from active duty deployment and was retiring from the service, he decided to pursue more education. However, he was concerned as he had frequent headaches during near work. He had history of multiple traumatic brain injuries occurring in 2008, 2010, 2011. His pertinent medical history included: a seizure disorder, ADHD, chronic PTSD, migraine, anxiety disorder, and depression, all of which he was currently being treated for through the VA system. His diagnoses included a mild convergence insufficiency and accommodative insufficiency. We did prescribe a very minimal spectacle Rx as this evened out his accommodative demand since he was mildly antimetropic. We began vision therapy with Patient X and sent him home with homework.
One month later, we brought Patient X back in for a re-evaluation. At this visit, he noted that glasses and vision therapy had helped him immensely. He did not get headaches anymore when doing near work, and no longer noticed a blur when switching from near to far. His accommodative testing had improved, as well as his binocular function and midline shift. Patient X was sent home after reviewing therapy techniques and educated on continuing to challenge his visual skills and recovery.
Patient X showed great improvement in symptoms and in testing with only a small amount of intervention through vision therapy. Even though therapy was not typically performed at this VA, and I was a student rotating at the site who had not yet had much exposure to vision therapy techniques and procedures, I was able to help this patient regain an aspect of life that he had been struggling with for at least a year. While, scientifically, we can agree that office based vision therapy especially for Convergence Insufficiency, (Scheiman, 2005) has been proven to be more effective, we were able to prescribe at home therapy to help this patient and do some small tasks while in office to help him improve his quality of life post-traumatic brain injury. This demonstrates the effect that even a small amount of vision therapy can have on an individual’s life.
Student and resident members of COVD, as future optometrists and practicing optometrists, shouldn’t we work to improve our practice in the care and management of our patients? For simple cases such as Patient X’s, I think that this is possible. More complex cases…I would be more likely to refer him to a COVD Fellow and to try and learn from our co-management. I am incredibly thankful to have had mentors who were open to the opportunity to initiate therapy and help me learn from this patient’s experience.
Disclosure: (Information for this blog has been submitted as a scholarly article review as well as an essay regarding my work while on my VA hospital rotation.)