ACQUIRED BRAIN INJURY

Informed consent, full consideration of temporary and non-invasive treatments as well as a ‘wait and see’ approach are key components of the optimal treatment of ocular issues caused by acquired brain injuries, according to Ian Marsh MD, Consultant Ophthalmic Surgeon, Aintree University Hospital NHS Foundation Trust, UK, who spoke at the 2015 Irish College of Ophthalmologists annual conference in Westport, Ireland.

Common acquired brain injury ocular issues include diplopia, nerve palsies, as well as acuity and visual field loss, he said, adding that occult perforation or retinal detachment may occur in some traumatic injuries. However, penetrating ocular injuries are not as common now from road traffic accidents due to the use of seatbelts and shatter-proof windscreens, he explained.

Dr Marsh recommended a multidisciplinary approach to assessing acquired brain injury patients, with a full assessment of visual apparatus as well as determination of the patient’s mental capacity.

“Because the discussion you are going to be having about any type of intervention you are going to do is going to be at a very complex level, and if they don’t have the mental capacity to take that in, that can be very difficult for you,” he said.

There are a number of “basic” visual treatment options, some short-term or reversible for acquired brain injury patients, as some ocular problems will recover in time or will need surgery later on, Dr Marsh explained. Basic treatment includes prisms, and occlusion using contacts, intraocular lenses (IOLs) and patches. However, he cautioned against using IOLs for occlusion in diabetic patients because of the need to be able to monitor the retina.

REALISTIC EXPECTATIONS

Botox injections also have significant therapeutic and diagnostic uses in these patients, Dr Marsh told the conference, particularly in the treatment of the various nerve palsies, and in pre-surgical simulation and postoperative diplopia testing.

“For example, in a patient with third nerve palsy who asks for an operation, using Botox you can simulate surgically what you are going to do and say: ‘that is what you are likely to have after I have done any intervention, do you want it or not?’, which also helps with informed consent,” he commented.

In sixth nerve palsy, spontaneous recovery is quite common. “In diabetics for example, about 80 per cent of them will recover spontaneously without any intervention,” Dr Marsh added.

Dr Marsh stressed the need for realistic expectations about surgical outcomes, in both doctors themselves and patients, and for informed consent. Specifically, he said patients with an ocular paresis do better than those with actual palsies.

Ian Marsh: Ian.marsh2001@gmail.com