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Summer 2002 Table of Contents
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Brain Injury and Associated Vision and Hearing Loss

By Kate Moss, Teacher Trainer, TSBVI, Texas Deafblind Outreach

Adapted in part from Teaching Students with Visual and Multiple Impairments: A Resource Guide, by Millie Smith and Nancy Levack

Editor’s note:  According to the Brain Injury Association website (http://www.biausa.org/brain_injury_and_you.htm) traumatic brain injury (TBI) is defined as “An insult to the brain, not of degenerative or congenital nature caused by an external physical force that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning.  Acquired brain injury (ABI) is defined as “Injury  to  the  brain  which  is  not  hereditary,  congenital  or degenerative that has occurred after birth.” (Includes anoxia, aneurysms, infections to the brain and stroke.)

 Individuals with brain injury often experience problems with both vision and hearing loss.  On the BIA websites, Carolyn Rocchio shares the following information about traumatic brain injury (TBI):

“Hearing problems can occur for a number of reasons, both mechanical and neurologic, particularly when the inner ear and/or temporal lobes have been damaged. All patients should have an otoscopic examination and hearing screening followed by behavioral testing. External bleeding in the ear canal, middle ear damage, cochlear injury, and/or temporal lobe lesions can cause auditory dysfunction.”  (Rocchio, 1998)

This can result in children who have auditory processing problems, conductive hearing loss, and/or sensorineural hearing loss.  They may also have balance problems associated with any damage to the vestibular system. 

Some of the vision problems associated with traumatic brain injury include infections caused by the mist from nebulizers on tracheostomy patients resulting in corneal ulcers and other problems, problems with visual processing and visuo-motor ability such as double vision, field loss, nystagmus and near-sightedness. (Rocchio, 1998).

Children with traumatic brain injury typically face additional problems in the areas of communication, acquiring new information, spatial orientation, attention and concentration, task completion, impulse control, dealing with anger, social integration, and social conversation.  There are many organizations  and  websites  offering excellent information on brain injury.  Several that we have accessed include:

International Brain Injury Association, Inc. (BIA) 105 North Alfred Street Alexandria, VA 22314 Phone: 703-236-6000 and Family Helpline: (800) 444-6443 E-mail: FamilyHelpline@biausa.org  Web: http://www.biausa.org/ 

International Brain Injury Association (IBIA) 505 Wythe Street Alexandria, VA 22314 USA 703/683-8400 E-mail: info@internationalbrain.org  Web: http://www.internationalbrain.org/ 

Lash and Associates Publishing/Training, Inc.
708 Young Forest Drive
Wake Forest, NC 27587
By Phone or FAX:  919-562-0015
E-mail:  mlash@lapublishing.com 
Web: http://www.lapublishing.com/ 

In Texas, 120 children were reported as having traumatic brain injury as a disability label on the 2002 Annual Registration of Students who are Visually Impaired.  Nine children on the 2002 Texas Deafblind Census are reported as having severe head injury.  Additionally many children have acquired vision and hearing loss (occurring after normal birth) as a result of anoxia, stroke, aneurisms and brain infections such as meningitis.

Some alarming statistics from the Brain Injury Association website (2002) include the following:

In 1996 we ran an article, “A Different Point of View” by Marnee Loftin, in which she gives a firsthand account of the effects of traumatic brain injury and talks about the problems she experienced in her vision, cognitive and emotional functioning.  You may be interested in reading her article, which can be found on the TSBVI website at http://www.tsbvi.edu/Outreach/seehear/archive/ptvs.htm.  There is also some good information about the visual issues related to TBI in Teaching Students with Visual and Multiple Impairments: A Resource Guide,  by  Millie  Smith  and  Nancy  Levack.  The information that follows is adapted from that book and was first published in SEE/HEAR, Fall 1996.  We thought it was worth reprinting.

Sensory problems are common after traumatic brain injury.  The problems these children have with their vision are referred to as Post Trauma Vision Syndrome or PTVS.  Over half of the children who have experienced brain injury have vision problems, such as blurred or double vision and visual field defects.  Blurred or double vision may improve during the first six months after the trauma event, but the field abnormalities are more likely to persist (Mira, Tucker, & Tyler, 1992).

Binocular vision is what allows us to blend the two images seen by each of the eyes into only one perceived image. Long-term difficulties with binocular vision are common.  These include:

When these conditions are present from birth, the brain adapts by suppressing the vision in one eye. In post trauma vision syndrome the condition occurs abruptly. The brain does not have a chance to adapt gradually and abnormal vision persists. It is important that any child who suffers traumatic brain injury receive a comprehensive ophthalmologic exam (Mira, Tucker, & Tyler, 1992).

Double vision in particular interferes with depth perception, locating objects, and the ability to match visual information with kinesthetic, proprioceptive, and vestibular experiences. These terms are explained below:

Because of double vision, which occurs with PTVS, balance, coordination, and movement become impaired (Padula, Shapiro, & Jasin, 1988).

Many individuals with a post trauma brain injury experience a variety of visual-perceptual abnormalities. Students with post trauma vision syndrome (PTVS) have a difficult time transferring the visual information they learned prior to injury to present situations. Problems with spatial organization are common. They may also develop abnormal head posture along with high tone in muscle tissues in other parts of the body, particularly about the head, neck, and shoulder areas. This happens because the child will try to correct or improve his visual functioning by tilting or holding his head in an unnatural position (Padula, Shapiro, & Jasin, 1988).

Children with traumatic brain injury may also have damage to their ears. Mira, Tucker, and Tyler (1992) also describe the types of ear damage that frequently occurs with a traumatic brain injury. There may be damage to the middle ear, which can cause a conductive type of hearing loss. There may be damage to the inner ear or the auditory pathways into the brain, which can cause a sensorineural hearing loss. Children with visual impairments generally rely on their hearing to compensate for the loss of visual functioning. For this reason, it is critical that children with PTVS have a complete audiological evaluation.

Characteristics of PTVS

The characteristics of post trauma vision syndrome include:

(Adapted from Padula, Shaprio, & Jasin, 1988)

Suggestions and Interventions

The following is a list of suggestions and interventions that can be tried with students who have PTVS. Some of the items are interventions which should be prescribed by eye specialists or require input from motor specialists.

Spatial Disorganization

Abnormal posture

Double vision

Poor fixations and pursuits (difficulty scanning for a specific object or following a progression)

Poor concentration and attention

Poor visual memory

Movement abnormalities - Objects/words appear to move around the page

Inability to take in all but a fragment of a visual scene or the disappearance of visual objects due to abnormal perception

Inability to read despite the ability to write

Failure to attend to objects in affected hemisphere

Inability to visually guide limbs

Field abnormalities

References

Blosser, J. L. & de Pompei, R., (1994). Pediatric traumatic brain injury: proactive intervention, Singular Publishing Group, San Diego, CA.

Brain Injury – Fact Sheet. (2002).  Brain Injury Association, Alexandria, VA, website 2002: www.biausa.org

Mira, M.P., Tucker, B.F., & Tyler, J.S. (1992). Traumatic brain injury in children and adolescents: sourcebook for teachers and other school personnel, Pro•Ed, Austin, TX.

Padula, W.V., Shapiro, J. B., & Jasin, P. (1988).  Head injury causing post trauma vision syndrome.  New England Journal of Optometry, 41(2), 16-20.

Carolyn Rocchio, (1998).  Unexpected medical problems can surface after brain injury.  Family News and Views, Vol. 5, No. 6 October 1998.  Brain Injury Association website 2002. http://www.biausa.org/famviewnews/unexpected_medical_problems.htm

Smith, Millie and Levack, Nancy, (1996). Teaching students with visual and multiple impairments: resource guide, Texas School for the Blind and Visually Impaired, Austin, TX, p. 215-238.

The cost and causes of brain injury.  (2002).  Brain Injury Association, Alexandria, VA 22314, website 2002: www.biausa.org


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