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 Headache 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 Eye strain 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 Accommodation (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 Vision therapy 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 Headaches/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