Start with a thorough history, then choose the best therapy for the patient’s visual needs
Due to increased awareness and reporting, concussions-especially among children-are becoming a public health concern.
Identifying signs and symptoms of concussions are key to early detection and treatment. The Centers for Disease Control and Prevention (CDC) has developed an initiative called Heads Up Concussion in Youth Sports. Heads Up provides information to parents, schools, and sports teams to help prevent concussions as well as identify when a child has suffered from a concussion. Information is also provided about what treatment to seek as well as return-to-learning and return-to-play guidelines.1
About 2.5 million people present to the emergency department with some form of traumatic brain injury each year. Of these 2.5 million people, 75 percent of them are considered mild injury or concussion. This number is likely an underestimate because many concussions go unreported.2
The most common causes of brain injury are falls, motor vehicle accidents, assaults, and being struck by an object. Sports and recreation-related injuries make up a large majority of concussions. Estimates show that slightly less than 250,000 children aged 19 and younger suffered from sports and recreation-related injuries that resulted in emergency department visits.2
Concussions are defined by the CDC as a mild form of brain injury that can be caused by a bump, blow, or jolt to the head.1 Brain injuries can cause changes in mental state and consciousness as well as many neurological sequelae, such as headaches, dizziness, visual changes, balance problems, and changes in emotions or behavior.
Many sports teams run pre-season baseline tests to determine players’ norms that can be used as comparison if a concussion is suspected. The King-Devick test, which can be used on the sideline, has been shown to be sensitive for the detection of concussion, with players scoring significantly worse post-concussion than baseline.3
Many studies have shown that cognitive and physical rest following a concussion can help reduce the duration of post-concussion symptoms and long-term sequelae.1,2,4,5 Following a concussion, students are often prescribed cognitive rest and modifications in school, and players are required to have clearance to return to play based on their state’s return-to-play law.1
Concussions, although often considered mild, can cause serious symptoms that often last two to three weeks. A study by Eisenberg showed that the most common initial presenting symptom of concussion was headache; the emotional and cognitive symptoms occur later on.
Most symptoms improved in the first two weeks, with headaches lasting the longest, sometimes months after the injury.5
Pervasive symptoms lasting longer than two to three weeks are labeled as post-concussion syndrome. Common symptoms following concussion include headaches, dizziness, light sensitivity, fatigue, nausea, noise sensitivity, blurry vision, double vision, difficulty reading, trouble sleeping, difficulty concentrating, emotional changes, and behavioral changes.2,4,5
Post-concussion visual symptoms include eyestrain, headaches, blurry vision at distance and/or near, difficulty shifting focus from distance to near, trouble reading, losing place when reading, skipping lines when reading and light sensitivity.
The most common visual problems following concussion are saccadic dysfunction (30 percent), convergence dysfunction (47–64 percent), and accommodative dysfunctions (65 percent).1
A thorough optometric evaluation can help diagnose visual changes and changes in visual skills or binocularity following a concussion. Visual-related changes can cause
many of the common post-concussion symptoms as well as difficulties learning and reading.
The most important part of the initial optometric evaluation is the case history. The case history will give the doctor information about the injury and what parts of the brain were potentially affected as well as serve as a guide for further testing.
Important questions to ask about the injury include:
• How did the injury occur?
• When did the injury occur?
• What treatment was sought?
• What therapies have taken place?
In addition, a thorough review of symptoms will help guide further testing, treatment, and referrals. Table 1 shows several surveys that can be used to evaluate symptoms post-concussion as well as their pros and cons. It may be advisable to use more than one survey to elicit the desired information.
An expanded optometric evaluation that includes assessment of binocular, accommodative, and oculomotor visual skills will help identify areas of the visual system that
have been affected by a concussion. Table 2 shows the tests that should be included in a post-concussion optometric evaluation.
These tests can be performed in one exam or broken up into multiple sessions, depending on the patient’s stamina. The overall goals of the evaluation are to determine which areas of the visual system are affected, establish a pre-therapy baseline, and allow the practitioner to determine a starting point for rehabilitation.
Note that this assessment focuses on visual skills and does not address specific visual-perceptual or vestibular testing. Your detailed history and symptom survey evaluation should uncover the need for additional visual-perceptual or vestibular evaluation.
Consulting with or referring to a provider listed on either the Neuro-Optometric Rehabilitation Association (www.nora.cc) or the College of Optometrists in Vision Development (www.covd.org) websites will help with additional perceptual testing.
If non-optometrists in your region are performing this testing, consider consultation with occupational or speech therapy. For a comprehensive vestibular evaluation, a physical therapy referral should be obtained; when making this referral, ensure that the therapist is experienced in specific vestibular evaluation and therapy.
Concussion patients suffer from a wide range of visual problems. Treatment is targeted at the specific visual problem and patient symptoms. Common treatment modalities include lenses, frosted occlusion, spot occlusion, bi-nasal occlusion, prism, and visual rehabilitation for visual skills, binocular and accommodative dysfunction, and visual perceptual deficits.
Frosted occlusion, spot occlusion, bi-nasal occlusion, prism
Diplopia can occur in a particular field or across the whole field and can be visually disturbing and disorienting. The goal for treating diplopia is to optically create a single image while maintaining peripheral fusion and binocularity.
Choosing a treatment option that is least occlusive will allow the most peripheral fusion. Peripheral fusion is used to help with motor planning and will thus allow patients to have better ambulation as well as a better rehabilitation potential.
If diplopia occurs in only one field of gaze, spot or sectoral occlusion can be used to eliminate the diplopia in that field. If diplopia is comitant, usually secondary to a strabismus, Fresnel prism (press-on prism) can be applied to the glasses to neutralize the deviation. (Fresnel prism can also be used in patients with field loss by applying the prism on both lenses with the base in the direction of the field loss to shift the non-seeing field into the seeing field.
Occasionally, patients can experience diplopia from medication interactions; this type of diplopia is frequently a result of decreased accommodation. Patients with this type of diplopia may present with symptoms that are significantly disproportional to their clinical findings.
Alternately, they may have an exaggerated exotropia and hypertropia presentation due to the inability to coordinate their eyes, causing the non-dominant eye to go into a habitual rest position. These patients may have highly variable diplopia and respond best to some form of occlusion rather than prism treatment.
Patients with spatial disorientation have trouble judging where they are in space. Disequilibrium patients feel unsteady in space.
Both types of patients suffer from an inability to interpret the space around them. Bi-nasal occlusion can be used to re-establish spatial orientation. Bi-nasal occlusion can also be used as a treatment for esotropia.
The Streff Wedge is a measurement tool used to determine the placement of each nasal occlusion wedge. The Streff Wedge should be lined up with the nasal edge of the pupil and the angle marked on the glasses so the occlusive tape can be applied. The pupillary distance measurement on the wedge should be recorded. In the case of esotropia, the amount of occlusion can gradually be decreased as the eye begins to straighten.
Tints can be prescribed in a variety of shades and levels of darkness. Tints are useful for treating photophobia, glare, migraine, seizure, disequilibrium and visual changes
from vestibular conditions. A recent paper by Harris and Esposito highlighted several cases in which colorimetry was used to identify tints that were most favorable, and those tints were prescribed in either spectacles (CR-39 lenses only) or contact lenses to help reduce symptoms.8
Anecdotally, patients with persistent photosensitive migraines or fluorescent light sensitivity tend to benefit the most from specific color tinting while general photosensitive patients tend to prefer any dark tint.
Visual rehabilitation can be useful in retraining visual deficits after a concussion.
Groce and Bansal outline three cases in which visual rehabilitation was used to treat post-concussion visual symptoms in children with sports-related concussions.9 Complaints which are not resolved by addressing binocular skills rehabilitation will require additional interventions, such as visual perceptual rehabilitation or vestibular rehabilitation.
1. Ventura RE, Jancuska JM, Balcer LJ, Galetta SL. Diagnostic tests for concussion: is vision part of the puzzle? J Neuroophthalmol. 2015 Mar;35(1):73-81.
2. Centers for Disease Control. Traumatic Brain Injury and Concussion. Available at: http://www.cdc.gov/traumaticbraininjury/basics.html. Accessed 04/04/16.
3. Centers for Diseases Control. HEADS UP. Available at: http://www.cdc.gov/headsup/index.html. Accessed 04/04/16.
4. Brain Injury Association of America. Concussion Information Center. Available at: http://www.biausa.org/concussion/concussion-information-center. Accessed 04/04/16.
5. Eisenberg M1, Meehan WP 3rd, Mannix R. Duration and course of post-concussive symptoms. xs. 2014 Jun;133(6):999-1006.
6. Leong DF, Balcer LJ, Galetta SL, Evans G, Gimre M, Watt D.The King-Devick test for sideline concussion screening in collegiate football. J Optom. 2015 Apr-Jun;8(2):131-9
7. American Optometric Association. Convergence Insufficiency Symptom Survey (CISS). Available at: http://www.aoa.org/documents/optometrists/PLRG-CI-Card.pdf. Accessed 04/19/16.
8. College of Optometrists in Vision Development. Signs & Symptoms of Learning-Related Vision Problems. Available at: http://www.covd.org/?page=Symptoms. Accessed 04/19/16.
9. Chen J, Johnston KM, Collie A, McCrory P, Ptito A. A validation of the post concussion symptom scale in the assessment of complex concussion using cognitive testing and functional MRI. J Neurol Neurosurg Psychiatry. 2007 Nov;78(11):1231-8.
10. Centers for Disease Control. HEADS UP Concussion ACE Test. Available at: http://www.cdc.gov/headsup/pdfs/providers/ace-a.pdf. Accessed 04/19/16.
11. CapÃ³-Aponte JE, Urosevich TG, Temme LA, Tarbett AK, Sanghera NK. Visual dysfunctions and symptoms during the subacute stage of blast-induced mild traumatic brain injury. Mil Med. 2012 Jul;177(7):804-13.
12. Esposito, C, Harris, P. Relieve migraines with tinted contact lenses. Optometry Times. 2015 Jan 15. Available at: http://optometrytimes.modernmedicine.com/optometrytimes/news/relieve-migraines-tinted-contact-lenses. Accessed 4/19/16.
13. Groce, A, Bansal, S. Optometric Management of Sports-related Post-concussion Visual Symptoms in Teenagers with Vision Therapy: A Case Series. Vis Dev Rehab. 2016 Mar. 2(1): 34-51.
14. Maples, WC, Ficklin, T. Comparison of Eye Movement Skills Between Above Average and Below Average Readers. J Behav Optom. 1990. 1(4):87-91.