Amanda Nanasy, OD, on connecting the dots in professional sports vision care

Amanda Nanasy, OD, began her career in sports vision as an optometry student at Nova Southeastern University, where she had the opportunity to assist with performance vision evaluations for the Orlando Magic basketball team. This sparked her interest in vision training research, and worked with the Miami Dolphins shortly after graduating. She now has experience working with athletes across various sports, including Inter Miami CF and Miami HEATCheck gaming. Nanasy is also the Immediate Past Chair of AOA’s Sports and Performance Vision Board and an appointed member of the AOA TBI Taskforce. In this Q&A, she discusses the growing field of sports vision, and her advice for optometrists to maintain proper eye health among athletes they treat.

Note: transcript edited lightly for clarity and length.

What has been your most memorable experience as a team doctor?

Amanda Nanasy, OD: I definitely have a most memorable experience, but I have to tell you it wasn't necessarily as a team doctor. It’s something I think a lot of doctors can relate to. I had a… cheerleader come in for a regular comprehensive eye exam, just because she was due for an exam and hadn’t had one in a while. Long story short, we ended up finding out that she had a brain tumor. She was missing areas on her confrontation fields, and she had surgery within 3 days. That was really early after I got out of school. I kind of said jokingly, “You know, I think I did what I was meant to do. Everything that I do from here is helping more people that I was meant to help.”

My journey working with concussion patients didn't start until I had my own concussion from a car accident in 2018. From that point forward, I feel like it's one of the best things that ever happened to me…because I understood all of the visual symptoms that were possible. I don't think we were serving that population as well as we could as eye care providers. I’ve kind of made that one of my things that I want to change. Athletes are at a very high chance of having head injuries compared to the general population, so the two go hand in hand.

What are optometrists most often missing when caring for athletes?

Nanasy: I wouldn't say they're necessarily overlooking something, but what they may not be doing is taking that extra little step to educate and connect the dots. It could be a contact lens patient that’s not seeing well, and you say, “I’m going to put you in a different lens. Does that patient know that you’re putting them in a lens for astigmatism, and how that’s different?

If I have a tennis player that is complaining about vision in her contacts, and it turns out that when she's going to the side and changing angles, she's losing stability on her astigmatism lens. I tell her, specifically, "I'm changing your lens because you're not always in this head posture. You’re in a dynamic sport where you're moving, so it's extra important that this lens is really stable on your eye." Now, she thinks I'm fitting some kind of magical special lens for tennis, and I'm not. It's just saying how it's going to relate to [her].

I think it’s very similar to when you get a patient that…says their contacts dry out around 5 o'clock every day. Don't just stop there. Say, "How does that affect you?" and connect it to their life. An athlete may say, "When I'm looking up at the lights trying to catch a ball out of the sky, I've got a lot of glare, and I lose things." And then, we would do all the normal optometry stuff. Let’s address visual acuity and see if it’s as good as it can be. Maybe they have an ocular surface issue, which is more common now in younger paitnets because they’re on their screens all the time. My best piece of advice is to connect the dots. [Optometrists] are so smart, [but] sometimes we don't tell the patients why [they’re] doing what [they’re] doing, and that is a huge difference maker for athletes.

What do you include in a performance vision evaluation, and how does it vary by sport?

Nanasy: When we go in and we do our performance vision evaluations, it varies. It might even be different if we’re seeing rookies versus vets. But some of the things we will always do, we’re obviously going to check visual acuity. We’re always going to do an autorefraction, because… they could easily squint a little bit, and we want to see where they're ultimately relaxed. I always like to check depth perception…every time, and we do all the really boring stuff that's very important: [for the extraocular muscle function tests, or] EOMs, you’re doing pupils, not because I think people have [afferent pupillary defects, or] APDs, but to get a baseline. When we saw the hockey players last week, we had 3 players with a little bit of [anisocoria] of their pupils for a baseline. That’s important to recall [and] to give the training team. If they get in a fight and someone notices their pupils are different, that's the difference between being sent for a [neurological evaluation] vs, "Oh yeah, that was on the notes."

Near point of convergence (NPC), if you could just add one thing to every exam you do with athletes and regular patients, do it. It's fast, and it's a really great baseline. [The NPC] is going to be receded if they do have an injury. We also check the back of the eye one way or another. We have Optos, a full retinal camera, set up at some facilities for the players. If there’s a fight on the ice and there’s any question, I can retake a picture. Obviously, dilation is what we want to do, but in a game time situation, people tend to get really angry when I want to dilate someone and take them out of the second half of a Dolphins game because I can’t get a good view.

Sometimes we’ll do a King-Devick. I used to do it more with the pros than I do now, because every time has their own set of baselines that they have to do for concussion protocol. I think that any time that you’re doing a high school, or a college, it’s a really great test to do because it’s easily repeatable. When I’m doing baseball, I’m doing full I'm doing full M&S dynamic visual acuity, contrast sensitivity, and a tachistoscope-type program where I’m seeing how their visual processing is. I’m doing right eye to look at all their eye movements, and… it definitely varies based on sports, but, it’s the regular, most important ones that you all do that are my baselines in general.

What advice do you have for optometrists who want to get started?

Nanasy: September was Sports Eye Safety Awareness Month, and maybe you didn’t see a whole lot of athletes come in from your local high school. So maybe it's a… great opportunity to reach out to the athletic trainers at your local high school and say "this month went by, and I realized I didn’t see anybody from your team. How about if I do a lunch and learn and come in and help you?”

There are a ton of great resources, [such as] sportsvisionpros.com. We have a lot of free education. International Sports Vision Association has a great yearly meeting. You just got to make that first step, and make yourself accessible. Don't be afraid to give your cell phone number to those athletic trainers and say, "Call me if you have a problem. Call me if you have a question. I’m here for you." I try not to put myself on a pedestal as the doctor coming in. Come in as a part of their team. That's what's worked for me over and over.

For more information about the connection between neurological disorders and optometry, eye health accessibility for athletes, and advice for the broader coaching team, check out Nanasy’s full interview, which will be released on Optometry Times soon.