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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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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)


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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


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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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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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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.


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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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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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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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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


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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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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.


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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


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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


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Developmental Eye Movement Test (DEM)

King-Devick Test

King-Devick Test


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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


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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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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


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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


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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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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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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


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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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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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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


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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


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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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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.


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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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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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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


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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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[email protected]

Thank you very much!

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