Vision Therapy and Post-Concussion Syndrome Management: a Case Report Elizabeth Murray OD, Katie Connolly OD

Vision Therapy and Post-Concussion Syndrome Management: A Case Report Elizabeth Murray OD, Katie Connolly OD

Abstract: Current therapy for post-concussion syndrome with visual symptoms are to rest and decrease visual demand. This case looks at vision therapy for first line treatment when decreasing visual demand is not ideal.

I. Case History

On 5/30/2017, a 37 year old white male presented for persistent visual symptoms following a traumatic brain injury to the occipital lobe with torsion on the brain stem. The injury occurred on 4/3/2017 from a motor vehicle accident, and he had since been cleared from cognitive rest. At the time of the accident, he reported no loss of consciousness but did have post traumatic amnesia. Initially, he reported feeling fine, but his symptoms progressively worsened. He denied blur and diplopia, but was symptomatic for significant cognitive fatigue, gaze instability, visual stimuli triggered headaches, photophobia, and noise sensitivity. He is a pediatric oncologist with significant visual and cognitive demanding duties that exacerbate his symptoms. Ocular and medical history were unremarkable prior to the accident. At the time, he was taking Fioricet and Amitriptyline as directed for headaches and to aid in sleep, respectively. He had been seeing a Chiropractor for vestibular therapy that included some oculomotor therapy and planned to begin cognitive therapy at an outpatient rehabilitation hospital.

II. Pertinent findings

Entering distance visual acuities were 20/20 OD, OS and OU and near visual acuities were 20/20 OD, 20/25-1 OS, and 20/15-1 OU, without correction. Pupils and extraocular muscles were unremarkable. He had no significant refractive error. Cover test was 2 prism diopters exophoria at both distance and near and near point of convergence was to the nose. Base in and base out smooth vergences ranges were reduced at both distance and near; base in was more reduced than base out. Monocular accommodative amplitude in the left eye was reduced and accommodative facility was reduced monocularly more than binocularly. Positive relative accommodation was reduced and accommodative posture was relaxed. Saccades and pursuits were unremarkable. Convergence Insufficiency Symptoms Survey, score was 29 and he reported having to re-read journal articles due to poor comprehension as well as eyestrain subjectively worse in the left eye than the right.

Following in office vision therapy for accommodative dysfunction, Visual Information Processing testing was completed. Developmental Eye Movements Test was unremarkable. On all categories of the Developmental Test of Visual Perception - Adult, he scored average or above average, but performed poorest in visual motor search. He scored in the 83rd percentile for his age on the Test of Information Processing Skills suggesting good short term and working memory, but had significant fatigue over time. Visigraph showed adequate regressions and fixations, but an overall reduced reading rate.

III. Differential diagnosis

Primary: Unspecified intracranial injury w/o loss of consciousness Assessment: Traumatic Brain Injury—main symptoms are cognitive fatigue and headaches. Secondary: Paresis of accommodation, bilateral Assessment: Accommodative dysfunction—presence of BI blur at distance, poor monocular facility, reduced PRA. Overall relatively normal amplitudes with OS subjectively worse than OD.

IV. Diagnosis and discussion

Post-concussion syndrome is defined as persistent symptoms beyond the normal recovery time and is often related to cognitive deficits as well as headaches, fatigue, dizziness, and a decrease in oculomotor function. The current therapy for concussions is cognitive and physical rest initially. However, there is no standardized therapy long term for persistent symptoms. Bramley et al suggests decreasing visual demand as a therapy for decreasing visual symptoms; but that may not always be possible for patients with cognitively demanding occupations. Patients with high visual demanding duties need other therapeutic alternatives to manage their symptoms. As eye care physicians, it is our duty to diagnose binocular vision conditions and provide therapy to help manage symptoms.

Although patients score above average on standardized testing, their demand need to be factored in. As a pediatric oncologist, the cognitive and visual demand is very high for this patient and must be considered when weighing the options of treatment. The patient’s goal is to return to full duties as soon as possible, therefore vision therapy is a good option to assist in recovery.

V. Treatment, management

Vision therapy was recommended for accommodative paresis as to improve working memory. Following in office vision therapy with consistent at home reinforcement activities, accommodative facility greatly improved and visual symptoms decreased. The patient reports resolution of visual symptoms and is now transitioning to maintenance vision therapy to reinforce skills. Due to a highly demanding job, patient has not been cleared for going back to full duties and at this time and has been referred for advanced neuropsychological testing. Patient reports feeling delayed in thinking but no longer feels his eyes pulling and reports a significant decrease in headaches.

Bibliography 1. Bramley H, Hong J, Zacho C, Royer C, Silvis M. Mild Traumatic Brain Injury and Post-concussion Syndrome: Treatment and Related Sequela for Persistent Symtomatic Disease. Sports Medicine and Athroscopy Review 2016: 24:123-129. 2. Heitger M, Jones R, Macleod A, Snell D, et al. Impaired Eye Movements in Post-Concussion Syndrome Indicate Suboptimal Brain Function Beyond the Inﬂuence of Depression, Malingering or Intellectual Ability. Brain 2009:132: 2850-2870. 3. Gallaway M, Scheiman M, Mitchell G. Vision Therapy for Post-Concussion Vision Disorders. Optometry and Vision Science 2017: 94:68-73. 4. Leddy J, Sandhu H, Sodhi V, Baker J, et al. Rehabilitation of Concussion and Post-Concussion Syndrome. Sports Health 2012:4(2):147-54.

VI. Conclusion

Current concussion first line therapy is cognitive and physical rest. If symptoms persist for more than a few weeks, some evidence suggests symptom based therapy. There is no randomized clinical trials at this time and should be considered in the future. This case suggests vision therapy can be of benefit in decreasing visual symptoms.