Post on 06-May-2018
Michael Gallaway, OD, COVD 2017 4/16/2017
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Post-Concussion Vision Disorders: Diagnostic and Treatment Strategies
Michael Gallaway, OD, FCOVD, FAAOAssociate Professor PCO at Salus University
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Financial Disclosures
None
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Visual System and Concussion
Review prevalence of vision disorders after concussion
Diagnostic strategies
Review new data on treatment of post-concussion visual disorders
Other treatment strategies
Optometry and the concussion care team: growing your concussion practice
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Three Component Model of Vision
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Oculomotor Function
Oculomotor Function
Visual Information Processing
Visual Information Processing
Visual IntegrityVisual
Integrity
Visual Integrity
Visual acuity
Refraction
Eye health
Visual field
Oculomotor Function
Fixation, pursuits, saccades
Binocular vision: alignment, vergence, stereopsis
Accommodation
Vestibular ocular reflex (VOR)
Michael Gallaway, OD, COVD 2017 4/16/2017
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What Do We Know about Prevalence?
Prevalence in Normal Population
Convergence Insufficiency – 5%
Accommodative Disorders – 6%
Eye Movements – ?%
Prevalence Studies - Summary
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Problem GoodrichN=46Mean
age=28
Brahm
N=124
Mean age=30.5
Stelmack
N=192
Mean age=31
Cuiffreda
N=160
Mean age=42
Suchoff
N= 62
Mean age=49
Master/Scheiman/Gallaway
N= 100
Mean age=14
Convergence Insufficiency (5%)
30% 48% 28% 36% 42% 49%
Accommodative Dysfunction (6%)
22% 48% 47% 41% 10% 50%
Saccadic Dysfunction (?) 20% 23% 9% 57% 40% 29%
Soldiers Adult, Civilians Children
*Of adult studies only Brahm specified mTBI
Michael Gallaway, OD, COVD 2017 4/16/2017
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Concussion-Related Vision Problems in Children/Adolescents
Children’s Hospital of Philadelphia (CHOP) –2013/2014
Objective: Determine prevalence of vision problems in children 11-17 years old with a medical diagnosis of concussion
Method: Performed vision exam on 100 consecutive adolescents with diagnosis of concussion
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Master CL, Scheiman M, Gallaway M, et al. Vision Diagnoses are Common after
Concussion in Adolescents. Clin Pediatr 2016 Mar;55(3):260-7.
Vision Evaluation
Symptoms (Convergence Insufficiency Symptom Survey (CISS)Distance VABinocular Vision Testing
Maddox WingNPCStep VergenceVergence facility
Accommodative testingAccommodative amplitudeAccommodative facility
Eye Movement TestingDevelopmental Eye Movement Test (DEM)
Results
N = 100
Mean age = 14.3 years
42% male
29% - examined within 1 month
26% - examined within 1-3 months
45% - examined >3 months
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Results
69% had at least 1 vision problemAccommodative problems: 50%
Convergence insufficiency: 49%
Saccadic dysfunction: 29%
70% had vestibular dysfunction
54% had both vision and vestibular problems
Patients evaluated within 30 days after injury more likely to have vision problem
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Subtypes (Clinical Trajectories) in Post Concussion Syndrome (PCS)
PCS: 10% to 15% of patients with persistent signs and symptoms lasting >3 weeks
SubtypesCollins (2014): 6 subtypes:
Anxiety/mood, cervical, post-traumatic migraine, cognitive, vestibular, and ocular motor
Ellis, Leddy (2015): 3 subtypes physiologic, cervicogenic, and vestibular-ocular
Collins MW, Kontos AP, Reynolds E, Murawski CD, Fu FH. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports TraumatolArthrosc 2014;22:235-46.Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: An evidence-based classification system with directions for treatment. Brain Inj2015;29:238-48.
Predictors of PCS
reduced NPC
Sx on OM testing
dizziness
premorbid anxiety/depression
Prior concussion(s)
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Corwin, Zonfrillo, Master, et al. Characteristics of prolonged concussion recovery in a pediatric subspecialty referral population. J Pediatr2014;165:1207-15
Return to Learn and Concussion
UAB, 276 children post-concussion, >10 days and >30 days
Children with vision problems more likely to report school difficulty
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Swanson, Weise at al, Academic Difficulty and Vision Symptoms in Children with Concussion, OVS, Jan 2017.
Michael Gallaway, OD, COVD 2017 4/16/2017
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Why is the Prevalence Higher?
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Neural Networks Saccadic Function
Saccades: brainstem, FEF, Supp EF, Parietal EF, superior colliculus, dorso-lateral prefontalcortex, cerebellum
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Neural Networks Accommodation/Vergence
Optic tract / midbrain / Eidinger - Westphalnucleus
Primary visual cortex, posterior parietal cortex, superior colliculus, pons
FEF, cerebellum
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When this happens….
Summary
Ocular motor problems highly prevalent after concussion
May be a marker for prolonged Sx
Effects on performance can be significant
Can interfere with recovery and return to learn
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Supports need for routine assessment of vision function after concussion
VOMS (Vestibular/Ocular Motor Screening)
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Mucha, Collins et al. A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014 Oct;42(10):2479-86.
VOMS
Pursuits – look at reps
Saccades H/V
Near Point of Convergence (NPC) – 3 reps
Vestibular Ocular Reflex (VOR), H/V
Motion sensitivity/VOR cancellation
Sx: 1 to 10, dizziness, fogginess, headache, nausea
Our data: Accommodation should be included
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VOMS
Other than NPC, all based on Sx
Validity and reliability studies
Concussion physicians, PT’s, athletic trainers
Tina doing more of this?
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Visual Evaluation Post-concussion
We were made to do this!!
Thorough refraction and ocular health eval
Careful testing of vergence, accommodation, pursuits, saccades, VOR
Test over time: facility and reps
Sx profile often different
VergenceAlignment: cover test, maddox rod, phoria
NPC with accommodative and non-acc targets
www.bernell.com/category/427www.guldenophthalmics.com/products/index.php/near-pointrule.html
Vergence
Fusional Vergence Vergence facility 12BO/3BI
Michael Gallaway, OD, COVD 2017 4/16/2017
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Special Testing Considerations
Vergence and accommodative testingAsk whether testing evokes symptoms (1-10 scale)
May have to discontinuePatient complains of nausea during the testing
May have to move the prism bar or risley prisms more slowly
Patient reports discomfort or nausea
Fusion ranges may be overestimated Delayed cognitive response time
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Distance Vergence Facility
Tannen et al: 4BO/2BI worse in post-concussion, higher Sx scores, may be useful in Dx of concussion
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Tannen B, Rogers J, Ciuffreda K, Lyon E, Shelley-Tremblay J. Distance horizontal fusional facility (DFF): A proposed new diagnostic test for concussion patients. VDR 2016;2(3):170-75.
Distance Vergence Facility
Trieu et al, The value of vergence facility testing for the diagnosis of convergence insufficiency, AAO 11/16.26 subjects diagnosed with CI (mean age 13.1 years)Distance at which VF was performed had significant effect on the outcome5.4 cpm at distance vs. 9.0 cpm at near, p < 0.00127% of the subjects would have passed VF at near, but would have failed VF testing at distance27% of the subjects were unable to complete even one cpm at distance compared to 3.8% at near
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Vertical Deviations and Concussion
Rosner, Feinberg, et al: case series of 38 post-concussion patients with persistent Sx and vertical deviations
After prism Rx, significant changes in HA’s, dizziness, anxiety, and BV Sx with standardized scales
Watch for vertical deviations!
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Mark S. Rosner, Debby L. Feinberg, Jennifer E. Doble & Arthur J. RosnerTreatment of vertical heterophoria ameliorates persistent post-concussive symptoms: Aretrospective analysis utilizing a multi-faceted assessment battery, Brain Injury 2016, 30:3, 311-317.
Stereopsis
Reduced stereo with suppression: Pre-existing BV problem?
Possibly related to
concussion?
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Stereopsis
Study at UNC TBI Research Ctr used helmet sensors to measure frequency and severity of head impacts with college football players over a season (n=38)
Nike SPARQ Sensory Station: subjects with more severe head impacts (nearly twice as many) had lower performance on Depth Perception, Perception Span and 2 other visual performance tests
Cause or result?
Rec baseline vision testing for injury prevention
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Harpham et al. The Effect of Visual and Sensory Performance on Head Impact Biomechanics in College Football Players. Annals of Biomedical Engineering, Vol. 42,1:1-10,2014.
Michael Gallaway, OD, COVD 2017 4/16/2017
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Stereopsis
Study assessed stereo in 93 consecutive hospital admissions for head trauma
41% had significantly reduced stereo compared to controls
10% of those with normal CT also had reduced stereo
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Miller et al. Astereopsis Caused by Traumatic Brain Injury.Arch Clin Neuropsych, 14,6:537–543, 1999.
Accommodation
Accomm Facility Accom Amplitude Min expected =15 -1/4 (age)
Topomax and Accommodation
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**Can J Ophthal, 2016
Michael Gallaway, OD, COVD 2017 4/16/2017
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Pursuits, Saccades
Rate Sx Do reps, add vertical saccades
VOR
VOMS: 180 beats/min, 20 degrees, 10 reps
Developmental Eye Movement Test
Michael Gallaway, OD, COVD 2017 4/16/2017
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Developmental Eye Movement Test (DEM)
King-Devick Test
King-Devick Test
Michael Gallaway, OD, COVD 2017 4/16/2017
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DEM & K-D
Both have been used clinically in optometry for decades
K-D: research with concussion, Parkinson’s, MS, sleep deprivation
K-D has promise as sideline screening tool
DEM has more value clinically
Visagraph/Readalyzer
Objective assessment of eye movements very useful
Can help with possible
pre-existing issues
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Tannen B, Darner R, Ciuffreda K, Shelley-Tremblay J, Rogers J. Vision and reading deficits in post-concussion patients: A retrospective analysis. Vision Dev & Rehab 2015;1(3):206-13.
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Convergence Insufficiency - Symptom Questionnaire
Name _____________________________________ DATE __/__/__
Clinician instructions: Read the following subject instructions and then each item exactly as written. If subject responds with “yes” - please qualify with frequency choices. Do not give examples. Subject instructions: Please answer the following questions about how your eyes feel when reading or doing close work. Never (not very
often) Infrequently
Sometimes Fairly often Always
1. Do your eyes feel tired when reading or doing close work?
2. Do your eyes feel uncomfortable when reading or doing close work?
3. Do you have headaches when reading or doing close work?
4. Do you feel sleepy when reading or doing close work?
5. Do you lose concentration when reading or doing close work?
6. Do you have trouble remembering what you have read?
7. Do you have double vision when reading or doing close work?
8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?
9. Do you feel like you read slowly?
10. Do your eyes ever hurt when reading or doing close work?
11. Do your eyes ever feel sore when reading or doing close work?
12. Do you feel a "pulling" feeling around your eyes when reading or doing close work?
13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?
14. Do you lose your place while reading or doing close work?
15. Do you have to re-read the same line of words when reading?
__ x 0 __ x 1 __ x 2 __ x 3 __ x 4 Total Score: ____
CI Symptom Survey (CISS)
Expected: <16
Michael Gallaway, OD, COVD 2017 4/16/2017
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Laukkanen H, Scheiman M, Hayes J. Brain Injury Vision Symptom Survey (BIVSS) Questionnaire OVS, 2017
BIVSS
• 107 mild to moderate TBI compared to 156 normals
• 93.5% able to complete survey• Most serious symptoms
• What looks straight ahead….• Side vision distorted…• Have to close or cover eye…• Double vision…• Indoor lighting
uncomfortable…
• More research needed
Let’s Talk About Treatment
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Treatment Differences with Concussion
Treatment modalities similar to non-concussed OM/BV disorders
Sequence and emphasis of VT can be different
Differences in time frame
Sx often more dramatic and/or more easily elicited
May need to use more passive techniques (lenses, prism, tints) early if lots of Sx
Consider trial period of VT
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Why are there differences?
Acute onset, non-functional etiology
Accompanying Sx from:Light and noise sensitivity
Motion sensitivity
Vestibular symptoms
Non-vision-based overlays, ie attention, memory, language issues, depression
Concussion is a multi-system disorder
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Refractive Correction
Patients after concussion may be hypersensitive to small refractive errors
Consider correcting even small amounts of refractive error
Less able to compensate for hyperopia because of accommodative problems
Earlier onset of presbyopia
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Added lenses/bifocals
High prevalence of AI
Avoid PAL’s if any vestibular Sx (dizziness, nausea, motion sensitivity) even if patient previously adapted
Vestibular Tx and bifocals
Consider short term plus especially with AI
Michael Gallaway, OD, COVD 2017 4/16/2017
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Vision Therapy / Neuro-optometric Rehab Pearls
Length of Tx less predictable
Significant variability in concussions
Often need shorter durations of activities; can provoke dizziness, nausea, headache
Increased Sx: Rest, Recover, Restart
VT Pearls
Add target movement• Rotators, SVI, thumb rotations
Head and body movement for
vestibular stimulation• Saccadic/vergence activities with
head movement
• Infinity Walk
Balance board/walking rail
More frequent re-evaluations
Vision therapy / Neuro-optometric Rehab
Physical therapists getting involved in post-concussion “VT”
Frequent co-morbidity of ocular motor and vestibular dysfunction
Ocular motor exercises “VT lite”
Wide variety of competence
Michael Gallaway, OD, COVD 2017 4/16/2017
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What’s the Evidence for VT/Neuro-Optom Rehab in Concussion?
Success Rates of VT / Vision Rehab
More research in non-TBI
But Still…
Is there evidence that VT is effective for Concussion-Related Vision Disorders?
Etiology is different
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Research - Adults after mTBI
Funded by Department of DefenseCompared office-based VT to placebo VT in adult patients with mTBI > 1 year post injuryplacebo control first study to use objective measures of vergence, accommodation, and versional eye movements
Not susceptible to bias
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Thiagarajan, P, Ciuffreda et al. Effect of oculomotor rehabilitation on vergence responsivity in mTBI, J Rehab Res & Dev 2013;9:1223-1239Thiagarajan, P, Ciuffreda KJ. Effect of oculomotor rehabilitation on accommodative responsivity in mTBI. J Rehab Res Dev 2014
Results
Crossover design, 6 weeks of TX, 6 weeks of placeboObjective measures of vergence and accommodation improved markedlyNear-vision symptoms reduced along with improved visual attentionNone of the measures were found to change significantly following the placebo trainingDemonstrates brain visual system plasticity after mTBI in adult subjects
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Michael Gallaway, OD, COVD 2017 4/16/2017
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VT for Concussion
Retrospective study of 218 consecutive patients referred to 2 private practices
Medical Dx of concussion
Referred from concussion specialists, sports medicine, physiatry, PT
Standardized criteria for vision Dx
Cause of Concussion
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Cause of ConcussionSports-Related 56%
Work/School-Related 7%
Auto Accident 20%
Home/Other 16%
Frequency of Vision Problems by Diagnosis
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% of Vision Problems by DiagnosisBinocular Vision Problems 62%
Accommodative Problems 54%
Eye Movement Problems 21%
- 80% had an ocular motor Dx
Michael Gallaway, OD, COVD 2017 4/16/2017
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Binocular Vision Disorders
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Binocular Vision ConditionsConvergence Insufficiency 47%
Convergence Excess 7.7%
Vertical deviations 3.6%
Other 4.1%
*no cranial nerve palsies
Accommodative Disorders
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Accommodative DisordersAccommodative Insufficiency 41.9%
Accommodative Excess 1.3%
Accommodative Infacility 11.9%
Vision Therapy/ Rehabilitation
• Recommended for 80% (175)
• 80 (46%) either chose not to begin therapy or did not complete therapy
• 95 (54%)completed therapy
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Success Rates with Vision Therapy
Criteria
Had to complete the therapy program
Definition of success
Significant reduction in symptoms
Significant improvement in clinical signs
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Success Rates?
Convergence Insufficiency (n=41)Successful outcome: 85%
Improved: 15%
Accommodative Insufficiency (n=39)Successful outcome: 33%
Improved: 67%
Saccadic Dysfunction (n=18)Successful: 83%
Improved: 5%
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What About Other Visual and Non-Visual Deficits Post-
Concussion?
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Ciuffreda: Conceptual Model Pyramid
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Non-
Visual
based problems
Non-
Visual
based problems
Non-oculomotor-based problems
Non-oculomotor-based problems
Oculomotor-based problems (version, vergence, accommodation)
Oculomotor-based problems (version, vergence, accommodation)
Basic Vision Examination
(refractive error and ocular health)
Basic Vision Examination
(refractive error and ocular health)
Ciuffreda, Ludlam, Yadav. Conceptual model pyramid of optometric care in mTBI: A Perspective. Vis Dev Rehab 2015;1:105-108
Abnormal egocentric localization, photosensitivity, vestibular defects, VF defects, visual motion sensitivity, VIP
Depression, fatigue, cognitive, behavioral, attentional, medical, sleep, chronic headaches
Light Sensitivity
50% prevalence in TBI
Mechanisms poorly understood
May be trigeminal, or pain sensitive intracranial areas separate from visual pathway
Pupillary changes?
LS can be comorbid with TBI and migraine
Common migraine Sx even without TBI
Truong, Ciuffreda. Objective Pupillary Correlates of Photosensitivity in the Normal and Mild Traumatic Brain Injury Populations. Mil Med. 2016 Oct;181(10):1382-1390.
Light Sensitivity
TBI: elevated dark adaptation threshold
Chronic dark adaptation can increase perception of pain from LS
Prevents neural adaptation long-term
Discourage dark sunglasses indoors
http://aoa.uberflip.com/i/565739-brain-injury-manual-volume-1-b
Michael Gallaway, OD, COVD 2017 4/16/2017
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Light Sensitivity
UV and A/R coatings can be helpful
Polycarb, Trivex, high index all better UV prot
Hats, visors, wraparound sunglasses
Light Sensitivity
TintsFL-41 50% rose color tint*
BPI Omega light blue
Trial and error
*Blackburn MK. FL-41 Tint Improves Blink Frequency, Light Sensitivity, and Functional Limitations in Patients with Benign Essential Blepharospasm. Ophthalmol 2009
Vestibular Disorders
Visual motion sensitivity: dizziness, nausea, blur, headaches in car, walking, busy visual environments
Balance difficulty
Michael Gallaway, OD, COVD 2017 4/16/2017
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Vestibular Disorders
Vestibular rehab therapy well established
Co-manage with PT’s who do VRT
If present may interfere with VTPatients dizzy, nauseous during, after VT
Incorporate vestibular techniques in VTAdd walking and head movement, gaze stabilization activities
Visual Motion Sensitivity (VMS)
Co-morbidity of vergence deficits and motion sickness
We’ve been treating this for years!!
SEE-Sick Syndrome, Rod Gillian, ODSeesicksyndrome.com
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Visual Motion Sensitivity (VMS)
Oculomotor and vergence deficits often accompany VMS
• Winkler, Ciuffreda, Ocular fixation, vestibular dysfunction, and visual motion hypersensitivity. Optometry 2009;80:502-512.
Binasals can be helpful, changes in VEPCiuffreda et al. Effect of BNO on VEP. Brain Inj 2013;27:41–7.
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From Ciuffreda et al. Traumatic brain injury, visual consequences, diagnosis, and treatment. Advances in Ophthalmology and Optometry 1 (2016) 307–333.
Michael Gallaway, OD, COVD 2017 4/16/2017
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Visual Motion Sensitivity (VMS)
Tests: pursuits, vergence
VOR Cancellation (https://www.youtube.com/watch?v=ExOs7HSHv-c)
Central and peripheral
OKN
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Ciuffreda KJ. Visual vertigo syndrome: Clinical demonstration and diagnostic tool. Clin Eye Vis Care 1999;11:41-4.
Abnormal Egocentric Localization
Padula: ‘Visual midline shift syndrome’
Mismatch between objective and subjective sense of straight ahead
Yoked prism can be effective, more data needed
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*Ciuffreda, Ludlam in Suter. Vision Rehab 2011
Pre-Concussion Issues?
How do we know if some of the Sx being reported after concussion might be from pre-existing issues?
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Michael Gallaway, OD, COVD 2017 4/16/2017
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ImPACT
ImPACT® (Immediate Post-Concussion Assessment and Cognitive Test) – most commonly used neurocognitive test to Dxconcussion
Tests of verbal memory, visual memory, processing speed, executive function, visual attention
Appx 20 minute computer-administered test
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Case Report
ZD, 14 yo male, 1st concussion, football, 9/17/14
Referred from concussion doc
11/6/14 c/o HA’s, blur, eyestrain, LOP with reading
Some pre Sx, now worse;
ADHD w/ Concerta, average grades
Poor balance, receiving VRT with Brock String
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Case Report
My eval: CI (NPC 15/32cm, BO: x/18/16)AI (AA 15 cm OD, 16 cm OS, fails MAF & BAF) OMD (blur, dizzy on P/S, DEM 90 sec)Wearing OD -.75, OS -.50; Refraction: OD -.25, OS plCISS: 36
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Baseline ImPACT
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Treatment
21 sessions of VT over 4 ½ months
NPC 1 / 2 cm, BO > 40, BAF 14 cpm
DEM: 32 sec
CISS: 13
Cleared by concussion doc 4/30/15
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Post ImPACT
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Michael Gallaway, OD, COVD 2017 4/16/2017
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Post-Concussion
ImPACT confounders: ADHD, LD, anxiety/depression, and …..
Vision issues!!
Some kids are better than before the concussion!!
Very little awareness of baseline ImPACT scores among parents or school
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ImPACT Scores
Significant correlations between Verbal Memory and Visual-Motor Speed with presence of post concussion vision deficit
• Master CL, Scheiman M, Gallaway M, et al. Vision Diagnoses are Common after Concussion in Adolescents. Clin Pediatr 2016 Mar;55(3):260-7.
Children with CI do worse on Stroop test, “vergence is a vector of attentional and cognitive functions”
• Daniel, Kapoula. Binocular Vision and the Stroop Test. OVS 2015, 93:194-208.
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Take Home
Optometry well positioned to be part of the concussion team
We understand the functionality of the visual
system
Neuroplasticity and the visual brain
Michael Gallaway, OD, COVD 2017 4/16/2017
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Concussion Care Providers
Sports Medicine
Pediatrics
Physiatry/Rehab Medicine
Orthopedics
Neurology
Physical therapy
Neuropsychology
Psychology/psychiatry
Additional Resources
Suter P. Vision Rehabilitation. CRC Press 2011
Ciuffreda et al. Traumatic brain injury, visual consequences, diagnosis, and treatment. Advances in Ophthalmology and Optometry 1 (2016) 307–333.
AOA Brain Injury Electronic Resource Manual, Vol I A: Traumatic Brain Injury: Visual Dysfunction Diagnosis, Vol 1 B: Optometric Management
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Additional Resources
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Mgallaway@salus.edu
Thank you very much!