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Lyndsey M Ferris, OD, FAAO, ACMOJoint Force Optometry ClinicJBSA-Lackland, TX

CC: 24 y/o active duty Caucasian male reports constant visual blur OU, right sided peripheral vision loss & difficulty reading

PMHx: Brain injury during basic training, 4 months prior

Meds: None currently

POHx: Intermittent accommodative right ET since childhood w/ overacting inferior oblique muscles OU

4 months prior…• Acute respiratory failure• Severe hyponatremia (Na 109 mEq/L)• Leukocytosis (WBC 26.2)• Rhabdomyolysis (CPK 3,475 IU/L)• Fever• Dysphagia• Acute encephalopathy

All other diagnostic testing normal

4 months prior…• Acute respiratory failure• Severe hyponatremia (Na 109 mEq/L)• Leukocytosis (WBC 26.2)• Rhabdomyolysis (CPK 3,475 IU/L)• Fever• Dysphagia• Acute encephalopathy

All other diagnostic testing normal

Diagnosis: Syndrome of Inappropriate

Antidiuretic Hormone Secretion with

Secondary Anoxic Brain Injury

Non-Military inpatient rehabilitation: • Aphasia / Ataxia• Mild right hemiparesis (right hand)

VA Neuro-ophthalmology visit:• BCVA: OD 20/30+1, OS 20/30+1

• Saccadic dysfunction• Oculomotor (fixation) dysfunction• Right homonymous hemianopsia

RL

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CC: • Mild visual blur OU at distance and near • Right sided vision loss • Difficulty reading and processing information• Strong desire to return to Active Duty service

Can you fix me, Doc?

Binocular vision exam:• BCVA: OD 20/32, OS 20/20-2

• 2^ CRET• Right homonymous hemianopsia -

ambulation slightly inhibited• Saccadic dysfunction – overshooting, worse

in right gaze• Visual information processing dysfunction –

abnormal form constancy

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Bolsters the inherent neuroplasticity process• Recovery – initially damaged tissue restores function• Compensation – new tissue takes over a function for

damaged tissue

Focus on techniques to improve oculomotor skills and visual exploration training• Wayne Saccadic Fixator• Brock string• Near/far accommodative panel• Computer-based ocular motility• Vergence and accommodative training

Saccadic dysfunction & visual information processing dysfunction: improved

Right homonymous hemianopsia• Subjectively improvement in ambulation

Will I continue to improve?

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Syndrome of inappropriateantidiuretic hormone

Hallmark signs:• Normal adrenal cortical function• Normal body water concentration (envolaemia)• Urinary sodium >40 mOsm/Kg• Hyponatremia <135 mmol/L• Effective serum osmolality < 275 mOsm/Kg

Secreted by the pituitary gland

Target of action: nephron distal tubule

Function: regulate blood solute concentration

• Blood water levels rise

• Solute concentration (NaCl-) drop

• Hyponatremia worsens

Five main categories• Malignancy• Lung Disease• Central Nervous System Disease• Drug Use• Miscellaneous

The most common electrolyte disorder in hospital patients• Common causes: neoplasms, pulmonary disorders,

intracranial pathology, medications, endurance exercise, inflammatory disease, hypopituitarism, trauma

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Five main categories• Malignancy• Lung Disease• Central Nervous System Disease• Drug Use• Miscellaneous

Transient SIADH: nausea, pain, stress Hereditary SIADHExercise-Associated SIADH Idiopathic

Sound familiar?

Symptoms progress rapidly: mild headaches confusion limb weakness seizures respiratory insufficiency …

Acute severe metabolic encephalopathy can result in permanent brain damage and death• Encephalopathy from rapid osmolality change

TraumaticNon Traumatic

Open: penetrating injuries• Assaults, falls, accidents, abuse, surgery

Closed: internal pressure/shearing• Assaults, falls, accidents, abuse, sports

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1.7-3.5M/yr$56-76.5B/yrNational Spotlight:

• NFL• Military operations:

OIF/OEF/OND

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Anoxia, infections, strokes, neoplasm, medication, metabolic disorders, pulmonary disorders, inflammatory disease

Dependent on location, severity and chronicity of damage

Often result in both short & long-term physical, cognitive and psychological symptoms, including visual dysfunction

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Saccadic dysfunction & visual information processing dysfunction: improved

Right homonymous hemianopsia• Subjective improvement

Will I continue to improve?

3 months 6 months

Likelihood of Recovery

Visual sequaele from metabolic brain injuries can cause a variety of visual and systemic disturbances.

Patient’s with a history of any brain injury should have a full visual evaluation, including visual function and information processing.

Comprehensive rehabilitative treatment is important and should be initiated as early as possible.

Some recovery can be expected but is affected by patient buy-in/participation.• Education & motivation are critical!

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