Background

 Education  Pacific University College of Optometry  Current  Primary Care OD ○ Retina Institute of Hawaii Dr. Kellen Kashiwa  Clinical Professor ○ Pacific University College of Optometry ○ University of Missouri College of Optometry  Research Consultant ○ Duke University  Principal ○ Engine Sports Lab

Lecture Outline Concussions

 Visual symptoms of Concussion and how it  Traumatic Brain Injury (TBI) impacts athletic and academic performance  Results from acute impact to the  Ocular evaluation for post-concussion head causing brain dysfunction syndrome  Concussion  Treatments for post-concussion  Form of a mild TBI  Future treatments and preventive measures  Induced by biomechanical forces  Direct or Indirect blow to head

Epidemiology Symptoms of Concussions

 Up to 3.8 million concussion   Light Sensitivity*** occur annually  Confusion  Blurry vision***  Boys HS Football - Highest Rate  Nausea / Vomiting  Double Vision***  Girls HS Soccer  Dizziness  Loss of Place when Reading***  About 80% of concussions  Balance Problems may go undiagnosed  Sensitivity to noise  Difficulty concentrating***  Seeing flashing lights*** ○ < 10% of sports related concussion  Difficulty remembering result in loss of consciousness  Loss of focus ***Visual symptoms ○ ~50% there are no immediate  Inability to think symptoms clearly Visual Symptoms Other Visual Problems

 Double vision   Reduced peripheral awareness  Blurry vision  Vision-Derived Nausea  Car Sickness  Light sensitivity  Visual Anxiety  Mid-line Shift  Reading difficulties  Visual Inattention  Poor balance  Visual Vestibular Mismatch  Oculomotor Dysfunction

Ocular health changes Concussion Patient Workup

 Dry eye  Concussion Questionnaire  Focus on near work symptoms  Retinal nerve fiber layer thinning  OCT of Macula and RNFL  Optic nerve head changes  Dilated Fundus Exam / Fundus photos  Macular thinning  Complete binocular vision assessment

 Consider future diagnostics  Visual field testing  VEP  Dry Eye workup

Visual Questions to Ask Accommodative Testing Norms  Distance/Near vision blur Testing Normative Range  Double vision in distance or near Accommodative Amplitude Avg: 18.5 – 1/3 Age Min: 15 – ¼ Age  Eye fatigue Binocular Crossed Cylinder +0.50 sph  Losing place while reading Negative Relative (NRA) +2.00 (+/- 0.50) Positive Relative Accommodation (PRA) -2.37 (+1.00)  Difficulty with screens Monocular Estimation Method +0.75  Dry eye Accommodative Facility Testing Monocular :+/- 2.00 (8-12yo – 7cpm) over 12 yo 11cpm)  Light sensitivity Binocular (+/- 2.00 (8-12yo – 5cpm) adults – 10cpm Most Common Visual Changes in Vergence Testing Norms Concussion Testing Normative Range  4 Visual Changes That Impact Learning Negative Fusional Vergence (BI) Distance x/7/4 Near – 13/21/13 1. Accommodative dysfunction Positive Fusional Vergence (BO) Distance 9/19/10 Near 17/21/11 2. Vergence dysfunction Vergence Facility 3 BI / 12 BO flipper – 15cpm 3. Saccadic dysfunction Near Point of Convergence Accommodative target 5cm/7cm Penlight &R/G glasses –7cm/10cm 4. Light Sensitivity (Photophobia)

Accommodative Dysfunction Accommodative Insufficiency (AI)

 Accommodative Insufficiency***  Low PRA, Large lag of Accommodation  Low amplitude of accommodation  Accommodative Infacility/Spasms  Low NRA/PRA, Low Accommodative facility  May have low NFV/PFV  Accommodative Excess  Lead on BCC, Low NRA, Low PFV

AI Evaluation AI Treatment

 Accommodative  Accommodative  Treatment Amplitude Facility  Low power readers  Positive Relative  Binocular Accommodation - Accommodative  Bifocal readers 2.00 or less facility  Multifocal contacts  Binocular crossed  Near-far quickness cylinder test   Base-out to blur  Less Flipper  Accommodative  Accommodative Lag facility training  Near point  Computer based retinoscopy training  MEM Vergence Dysfunction Convergence Insufficiency  Convergence Insufficiency  Near asthenopia, words moving on the  How it affects page, diplopia, poor concentration learning  May also have Accommodative  Decreased reading Insufficiency too  /Eyestrain  Reduced Near Point of Convergence  Double vision  Lead on BCC  Low NRA ranges  Hates reading  Low PFV ranges at near

Convergence Insufficiency Pseudo CI

 Amplitude  Truly AI  Base in/out ranges at  Plus acceptor near  Low PRA  Near point of  High NRA convergence  Lag on BCC  AI with a near  Facility Exophoria  Base in/out flippers  NPC more reduced  Accommodative on non- facility accommodative target

Near Point of Convergence Treatments for CI

 Base In Prism Glasses  Reading glasses  Vision therapy to improve convergence ability

 Quick evaluation of near point stress and risk for CI  42% of concussed athletes had CI Saccadic and Pursuit Eye Saccadic/Pursuit Dysfunction Movements  Saccades – Decreased reading speeds  How it affects  Assessment learning  VOMS testing  Pursuits – decreased tracking abilities  Nausea in crowded  Saccadic areas  Pursuits  Slow reading vision  VOR testing  Lose place while reading  Difficulty tracking

Treatment Light Sensitivity

 Symptoms  Discomfort/Eye pain with bright lights  Flashes of light or spots in vision  Causes  Photophobia ○ Traumatic Iritis ○ Pupil injury ○ Dry eye

Visual Signs of Worse than Light Sensitivity Treatment Concussion  Sunglasses / Tinted Lens  Afferent Pupillary Defect  Tinted Contacts  Flashes or Floaters  Dry eye medications  Visual Field Defects  Anti-Inflammatory drops  Cranial Nerve Palsy  Reduced Visual Acuity  Eye pain on movement Sensorimotor Evaluation VOMS

 VOMS (Vestibular Ocular Motility Screening)  Vestibular Ocular Motor Screening  King Devick Card  90% Accuracy  DEM (Developmental Eye Movement Test)  Five tests of the vestibular and ocular motor systems 1. Pursuits 2. Saccades 3. Near Point of Convergence 4. Vestibular Oculo-Reflex 5. Visual Motion Sensitivity

VOMS King Devick Card

 Quick sideline concussion screener  Test Saccadic Eye Movements  Ask if there are any symptoms of eye strain or discomfort  Learned affect is good here  Requires a baseline

King Devick Card Developmental Eye Movement Test Diagnostic Tools OCT - Macula

 OCT – Macula and Optic nerve head  Central retinal thickness has been  Visual evoked potential shown to change post concussion  Electroretinography  Retinal edema due to iritis  Visual field  Thickening of retinal vessels  Microperimetry  ERM/ILM thickening

OCT Macula OCT Optic Nerve Head

 Inner retinal thinning as been found in  Optic nerve head cupping patients with multiple concussions  Retinal nerve fiber layer changes  Majority of ganglion cells are located in the inner retinal layer  Optic neuropathy  Average GCIPL thickness was also significantly associated with better BCVA and visual functioning scores  Studies have also found significant macular thickening  Potentially due to CME from iritis or micro RVO

OCT of Optic Nerve Visual Evoked Potential

 Retinal nerve fiber thinning  For subtle/mild cases of TBI history,  RNFL and RGC become thin around 2 electrophysiology can help detect visual weeks after TBI pathway changes  Visual defects however are not always  Magnocellular (where stream) deficits present have been reported  Also possible to have RNFL thickening  Increased motion sensitivity  Due to edema  Elevated critical flicker frequency threshold  Possible association with anterior optic  Increased P100 latencies >119 ms neuritis  Decreased amplitude > 14.75mV Electroretinography Visual Field Changes

 Decrease in pattern ERG correlates with  Result of damage to any portion of the decrease in RNFL visual pathway from the visual cortex to  Reduced cellularity in ganglion cell layer the retina and damage to optic nerve  Constriction of the fields  Decrease in amplitude of the photopic  Isolated or multiple scattered defects negative response  Homonymous hemianopsia with/without  ERG detects morphometric changes neglect

Microperimetry Management

 Central visual field testing  80% of symptomatic concussions  Correlates with fundus photo to monitor resolve within 3 weeks vascular changes  Visual issues can last for 3 months to 1 year  Tracks fixation  No same day Return to Play  Must be cleared by Physician  Biofeedback training for visual field loss  Prescribed physical/cognitive rest until asymptomatic  1 week period of rest decreased Sx and increased cognitive score in 60% of patients

Team Management Future Tools

 Multidisciplinary team management  Family Physician  Sports Med  Physical therapy  Occupational therapy  Eye care physician  Vestibular  Behavioral Senaptec Tablet FitLight  Portable tablet  Baseline sensory profile  Reaction light stimulus  Sideline Retest  Evaluate players  Post Concussion Rehabilitation reaction time  Assessment and Enhancement tool  Improve and treat post concussion

Case 1 Binocular vision examination

 15 year old Female, concussion post  Phoria: 10 exophoria at near soccer injury 2 exophoria at distance  CC: Headaches, eye strain while  NPC: 9 cm reading  NRA: +2.00D (LOW)  VA: 20/20 OD,OS,OU at distance and  BCC: +0.50D near  NFV (BI range) – 14/20/12  Ocular health examination : WNL  PFV (BO range) – 9/11/4 (LOW)  PRA: -4.00D

Case 1 Case 1

 Diagnosis?  1 month Follow-Up  Convergence Insufficiency  Able to read comfortably and focus up close  Treatment for extended periods without headaches/discomfort  Base In Prismatic Lens with low power reading glass  Long term Follow-Up  Vision therapy to improve convergence  After 3 months her visual symptoms ranges resolved with vision therapy  Recent follow up, graduated and playing collegiate soccer Case 2 Binocular vision examination

 8 year old boy  Near phoria: 6 exophoria  CC: Nausea/Vomiting after near work.  Distance phoria: 1 exophoria Symptoms present for 6 months  NPC: 16 cm  Recent concussion playing football.  NRA: +3.00D  VA: 20/20 OD,OS,OU  BCC: +1.50D  Ocular health examination: WNL  NFV (BI range) – 6/10/2 (LOW)  PFV (BO range) – 20/25/14  PRA: -1.00D (LOW)

Accommodative Insuffieincy Management

 Large lag of accommodation  Prescribed  Decreased BI ranges at near  +1.50 add bifocal glasses  Low amplitude of accommodation  Home vision therapy with flippers and convergence exercises  1 month follow up  Pseudo-CI  Immediate reduction in symptoms with  NPC improved to 4 cm with +1.50 glasses readers  Able to read comfortably without having  AI with near exophoria nausea or vomitting

Questions

 Mahalo  Any specific questions  [email protected]  808-398-3766