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Concussion–AnEvidence-BasedApproachtoOptometricManagement

JacquelineTheis,OD,FAAOOptoWest

FinancialDisclosures

-C.LightTechnologies•  ClinicalResearchConsultant,NIHSBIR

ObjecOves•  GiveabriefoverviewoftheevoluOonofthecurrentdefiniOonandpathophysiologyofconcussion

•  Discusscurrentparadigms(orlackthereof)forvisionscreeningaXerconcussionbynon-optometricproviders

•  GothroughthemostcommonvisualsignsandsymptomsseenaXeraconcussionandtheirOmelinesforresoluOon(acutevs.chronic–PCS)– AfferentVisualPathway(OcularHealth,ColorVision,VisualFields,Pupils,RefracOveError)

– EfferentVisualPathway(OcularmoOlity)– HigherOrderPathways(Visualprocessing)

•  Current/Futureroleforvisioninconcussion

GlasgowComaScale(GCS)● MotorResponse

○  (4)WithdrawsfromnoxioussOmuli○  (1)NoResponse○  (2)ExtensorResponse○  (3)AbnormalFlexion○  (5)LocalizestonoxioussOmuli○  (6)Obeyscommandsfully

● VerbalResponse○  (1)Nosounds○  (2)IncomprehensibleSounds○  (3)Inappropriatewordsandjumbledphrases

○  (4)Confused,yetcoherentspeech○  (5)Alertandoriented

●  EyeOpening○  (1)Noeyeopening○  (2)Eyesopentopain○  (3)Eyesopentospeech○  (4)Spontaneouseyeopening

•  LevelofTBI–  Mild(13-15)

•  +/-lossofconsciousness<30min•  Normalneuroimaging

–  Moderate(9-12)•  Lossofconsciousness>30min,<24hrs•  Normal/abnormalneuroimaging

–  Severe(3-8)•  Coma•  Normal/abnormalneuroimaging

–  VegetaOve(<3)

TeasdaleG,JennehB.AssessmentofComaandImpairedConsciousness:ApracOcalscale.Lancet304,81-84.VossJ,ConnollyJ,SchwabK,ScherA.Updateontheepidemiologyofconcussion/mildtraumaOcbraininjury.CurrPainHeadacheReports.2015;19(7):32.

Concussion-Controversyovera“DefiniOon”

●  McCroryP,MeeuwisseWH,AubryMetal.Consensusstatementonconcussioninsport:the4thInternaOonalConferenceonConcussioninSportheldinZurich,November2012.BrJSportsMed2013;47:250-8.

●  HarmonKG,DreznerJA,GammonsM,etal.AmericanMedicalSocietyforSportsMedicineposiOonstatement:concussioninsport.BrJSportMed2013;47:15-26.

●  KimparaH,IwamotoM.MildtraumaOcbraininjurypredictorsbasedonangularacceleraOonsduringimpacts.AnnBiomedEng2012;40:114-26.

●  ZhangL,YangK,KingA.AproposedinjurythresholdformildtraumaOcbraininjury.JBiomechEng2004;126:226-36.●  PReilly,RBullock.HeadInjury2ed:PathophysiologyandManagement,CRCPress2005TaylorandFrancis,Florida

TypeofmildtraumaOcbraininjury

ExternalforceorsuddenmovementcausesrapidacceleraOon/deceleraOonofthebrainOssuewithintheskull

Internallinear,translaOonal,androtaOonalforcesleadstoacomplexpathophysiologicalprocess

ResultsinafuncOonaldisturbanceinbrainfuncOon

Anever-changingdefiniOon•  +/-Lossofconsciousness•  +/-Directblowtothehead•  Rapidonsetofshort-livedimpairmentofneurologicalfuncOonthatresolvesspontaneously–  HOWEVER,signsandsymptomsmayevolveoverminutestohoursinsomecases

•  AcuteclinicalsignsandsymptomslargelyreflectafuncOonaldisturbanceratherthanastructuralinjury–  HOWEVER,itmayresultinneuropathologicalchanges

•  ResoluOonofclinicalfeaturestypicallyfollowsasequenOalcourse–  HOWEVER,insomecasesitmaybeprolonged

McCroryP,MeeuwisseW,DvorakJetal.Consensusstatementonconcussioninsport–the5thinternaOonalconferenceonconcussioninsportheldinBerlin,October2016.BrJSportsMed.2017;0:1010.

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TraumaOcBrainInjury-Pathophysiology

•  PrimarytraumaOcbraindamage– Mechanicalforces→OssuedeformaOonATthemomentofinjury–  Directdamagetobloodvessels,axons,neurons,glia,etc–  Diffuseaxonalinjury(DAI)/vascularinjury(DVI)–  FocalInjury

•  Vascular(intracerebral,subdural,extradural,subarachnoidinjury)•  Axonalinjury•  Contusion•  LaceraOon

•  SecondarytraumaOcbraindamage–  ComplicaOonofprimarydamage–  Ischemicandhypoxicdamage,cerebralswelling,increasedintracranialpressure,infecOon,etc

ReillyP,BullockR.HeadInjury2ed:PathophysiologyandManagement,CRCPress2005TaylorandFrancis,Florida

Imagefrom:LienJ.PediatricConcussionandothertraumaOcbraininjuries.Medscape.com.AccessedApril15,2017.hhp://reference.medscape.com/features/slideshow/pediatric-concussion

TEAMApproachtoConcussion-2015•  Mul$disciplinaryAssessment

–  ReviewmechanismofInjury–  Relevantmedicalhistory–  SymptomChecklist–  NeurocogniOveScreening/Neuropsychological

EvaluaOon–  BalanceAssessment–  VesObularScreening/ExaminaOon–  OculomotorFuncOonScreening/ExaminaOon–  NeurologicalEvaluaOon–  CervicalSpineEvaluaOon–  PsychologicalEvaluaOon–  Neuroimagingprn

CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaOonandAcOveManagement(TEAM)ApproachestoTreaOngConcussionMeeOngHeldinPihsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.

PediatricConcussion-Whatwedoknow-

•  ChildrenandadolescentshavelongerrecoveryOmesthanadults

•  ExpectedduraOonofsymptomsassociatedwithsports-relatedconcussion<4weeks

•  ProlongedrecoveryisdefinedassymptomaOcfor>4weeks

•  MechanismforlongerrecoveryOmeisunknown– Proposedtobeduetodifferencesinresponsetoexcitotoxicinjurybydevelopingadolescentbrain

•  DavisGA,AndersonV,BablFE,GioiaGA,GizaCC,etal.Whatisthedifferenceinconcussionmanagementinchildrenascomparedwithadults?AsystemaOcreview.BrJSportsMed2017;51:949-957.

•  GradyM.Concussionintheadolescentathlete.CurrProblPediatrAdolescHealthCare.2010;40:154-169•  EisenbergMA,MeehanWP,MannixR.DuraOonandcourseofpost-concussivesymptoms.Pediatrics.2014;133(6):999-1006•  McDonaldJW,JohnstonMV.Physiologicalandpathophysiologicalrolesofexcitatoryaminoacidsduringcentralnervoussystem

development.BrainResRev.1990;15:41-70

PediatricConcussion–Whatwedon’tknow-

•  Minimalclinicaltrialsinpediatricconcussion•  Literaturedoesnotaddresshowtomanagedifferentagegroupsofchildrendifferentlyfromadults

EpidemiologyofConcussion•  CDC2010-2.5millionpeoplewenttoERforTBIbasedonICD9data

–  75%mTBI–  UnderesOmatesinceonlyincludes

thosewhopresentedtotheERandhadarelevantdiagnosOccode(Voss)

•  PediatricpopulaOon–  173,285<19yononfatalconcussion

annually2001-2009–  Increasefrom153,375to248,418

•  Mostcommonmechanism–Falls•  HighRiskPopulaOons

–  Military–  Athletes

•  1.6-3.8millionSRCsannually•  5.8%ofallcollegiateinjuries,

8.9%ofhighschoolinjuries

www.cdc.gov/traumaOcbraininjuryGesselLM,FieldsSK,CollinsCL,DickRW,ComstockRD.ConcussionsamongUnitedStateshighschoolandcollegiateathletes.JAthlTrain2007;42:495-503

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Epidemiology•  USCentersforDiseaseControlandPrevenOon

–  173,285childrenandadolescents<19yearsoldtreatedforanonfatalrecreaOonandsport-relatedconcussioninERsannuallyfrom2001-2009

–  Increasefrom153,375(2001)to248,418(2009)•  4millionchildrenpresentwithconcussiontoemergencyroomsannuallyworldwide–  EsOmatedtorepresentonly12%ofchildrenwithconcussion–  EsOmatedthat33millionchildrensustainaconcussionworldwide

•  CentersforDiseaseControlandPrevenOon.NonfataltraumaOcbraininjuriesrelatedtosportsandrecreaOonacOviOesamongpersonsaged≤19years—UnitedStates,2001–2009.MMWR.2011;60(39):1337-1342

•  PedenMMU.WorldHealthOrganizaOon.WorldreportonchildinjuryprevenOon.Geneva,SwitzerlandNewYork,NY:UNICEF,2008.

•  CroweL,BablF,AndersonV,etal.Theepidemiologyofpaediatricheadinjuries:datafromareferralcentreinVictoria,Australia.JPaediatrChildHealth2009;45:346–50.

•  LyhleMD,CroweL,OakleyE,etal.ComparingCATCH,CHALICEandPECARNclinicaldecisionrulesforpaediatricheadinjuries.EmergMedJ2012;29:785–94.

•  ArbogastKB,CurryAE,PfeifferMR,etal.Pointofhealthcareentryforyouthwithconcussionwithinalargepediatriccarenetwork.JAMAPediatr2016;170:e160294.

CommonDiagnosOc/ScreeningTestsforConcussion

•  Self-reportSymptomChecklists•  BriefcogniOveassessment

–  StandardizedAssessmentofConcussion(SAC)–  SportConcussionAssessmentTool5(ChildSCAT5)

•  Balance/GaitTests–  TandemGaitTest(TGT)–  BalanceErrorSymptomScore(BESS)

•  ComputerBasedNeuropsychologicalTests–  ImPACT–  CogSport–  Headminder

•  OculomotorSidelineScreener–  King-Devick

LimitaOons/DifficulOesinConcussionDiagnosisandManagement

•  SubjecOvenatureofdiagnosis– SymptomScales– IntenOonallowbaselinescores

•  Incompleteunderstandingofpathophysiology

•  Lackofdata•  Variabilityamongphysicians

•  NostructuralinjuryonconvenOonalneuroimaging

•  AdvancedneuroimagingcanshowfuncOonal/structuraldamageBUT$$andnotreadilyavailable

•  Under/overreporOngofsymptoms

•  Under/overdiagnosis•  EvolvingdefiniOon

•  McCroryP,MeeuwisseWH,DvorakJetal.Consensusstatementonconcussioninsport:the5thInternaOonalConferenceonConcussioninSportheldinBerlin,October2016.BrJSportsMed2017;51:838-847.

•  HarmonKG,DreznerJA,GammonsM,etal.AmericanMedicalSocietyforSportsMedicineposiOonstatement:concussioninsport.BrJSportMed2013;47:15-26.

•  KimparaH,IwamotoM.MildtraumaOcbraininjurypredictorsbasedonangularacceleraOonsduringimpacts.AnnBiomedEng2012;40:114-26.

•  ZhangL,YangK,KingA.AproposedinjurythresholdformildtraumaOcbraininjury.JBiomechEng2004;126:226-36.•  ReillyP,BullockR.HeadInjury2ed:PathophysiologyandManagement,CRCPress2005TaylorandFrancis,Florida

Whydoesdiagnosismaher?

hhp://www.bu.edu/cte/about/what-is-cte/

ChronicTraumaOcEncephalopathyRoleofEyesinConcussionDiagnosis

andManagement:

1)ObjecCvebiomarkerforbraindysfuncCon

2)Treatmentofconcussion

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VisualPathwaysintheBrain

Post-ConcussiveVisualSignsandSymptoms

•  CurrentlyScreened–  DoubleVision–  BlurredVision–  LightSensiOvity

•  InAddiOon/Actuality–  ReadingDifficulOes–  Eyestrain/FaOgue–  Eyefocusingproblems–  EyeTrackingProblems–  Vision-DerivedNausea–  VisualInahenOon–  VisualAnxiety/Crowding

LaukkanenH,ScheimanM,HayesJR.Braininjuryvisionsymptomsurvey(BIVSS)quesOonnaire.OptomVisSci.2016;94(1):43-50.

AfferentVisualPathway

Imagefrom-HannulaDe,SimonsDJ,CohenNJ.ImagingimplicitpercepOon:promiseandpizalls.NatureRevNeurosci.2005;6:247-255/

AfferentVisualPathway–CNII

BarnehBP,SingmanEL.VisionconcernsaXermildtraumaOcbraininjury.CurrTreatOpConsNeurol.2015;17:5(1-14).

Post-ConcussionVisualSigns

OcularHealth•  TraumaOcIriOs•  TraumaOcOpOcNeuropathy•  ReOnalchanges•  CommoOoReOnae•  ReOnalTear/Detachment

PupilFindings•  Afferent

–  IncreasedaverageconstricOonlatency

•  Efferent–  ParasympatheOc

•  SloweraverageconstricOonvelocity

–  SympatheOc•  Decreasedpupillarydiameter•  SlowerpeakdilaOonvelocity

•  Anisocoria?

ThiagarajanP,CiuffredaK.Pupillaryresponsestolightinchronicnon-blast-inducedmTBI.BrainInjury.2015;29(12):1420-1425

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Photophobia-LightSensiOvity

E$ology??–Photophobiapathway?

•  OcularPhotophobia–  IriOs

•  Flashlighttest•  Asymmetric

–  Pupilproblems–  DryEye

•  NeurologicalPhotophobia–  TBI–  Migraines

•  Pharmacologic

Management•  SunglassesoutsideOKAY•  Sunglassesinside–TRYTOAVOID

–  WearingdarkglassesindoorsàdarkadaptaOonofthereOnaàaggravaOonoflightsensiOvity

•  Visors/Hats•  MildTints

–  Wavelengthmahers

KatzBJ,DigreKB.Diagnosis,pathophysiology,andtreatmentofphotophobia.SurvOphth.2016;61:466-477

VisualSignsitmaybeMOREthanaConcussion

•  Pupils–  Dilated/Fixed–  APD–  Anisocoria

•  ReducedBCVA•  VisualFieldDefects•  CranialNervePalsy•  OcularHealthProblem

–  OpOcnerveedema,pallor,etc

EfferentVisualPathwayCNIII,IV,VI,ParasympatheOc,SympatheOc

-EyeMovements

Imagefromhhp://what-when-how.com/neuroscience/the-cranial-nerves-organizaOon-of-the-central-nervous-system-part-4/

VesObulo-oculardysfuncOoninpediatricsport-relatedconcussion(SRC)

•  RetrospecOvereviewofallpaOentswithacuteSRC(presenOng30daysorlesspostinjury)andPCS(3ormoresymptomsforatleast1month)referredtoamulOdisciplinarypediatricconcussionprogramfrom9/2013-7/2014

•  Methods-ClinicalHx,Physical,PCSS,VOD–  VODComplaint(dizziness,blurredvision,etc)+Sign(Abnormal

pursuits,saccades,VOR)•  Results-n=101,age14.2+/-2.3years,76.2%withacuteSRC(n=77)and

23.8%withPCS(n=24)–  MeanduraOonofSxwas40daysforptsw/acuteSRCandVODvs.21

daysforacuteSRCwithoutVOD.•  Conclusions:EvidenceofVODinacuteSRCandPCS.

–  VODwasasignificantriskfactorfordevelopmentofPCS

EllisMJ,CordingleyD,VisS,ReimerK,LeiterJ,RussellK.VesObulo-oculardysfuncOoninpediatricsports-relatedconcussion.JNeurosurgPediatr2015:16:248-255

WhatDeterminesConcussionResoluOon?

•  BalanceRecovery<7days•  SymptomScores5-14days•  CogniOveRecovery7-21days•  OculomotorRecovery21-28days

OtherFactors

LiOgaOonWorker’sCompensaOonIndividualMoOvaOon(Athlete,Military)AgeGenderConcussionHistoryPremorbidFactorsInjurySeverityType/TimingofTreatment

CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaOonandAcOveManagement(TEAM)ApproachestoTreaOngConcussionMeeOngHeldinPihsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.

RoleofEyesinConcussionDiagnosis:VOMS(VesCbular/OcularMotorScreening)

AssessmentVesCbular/OcularDomainsAssessed

1. SmoothPursuit2. HorizontalandVerOcalSaccades3. Convergence4. HorizontalandVerOcalVOR5. VisualMoOonSensiOvity

•  61%ofadolescentconcussedathletesreportedsymptomprovocaOonaXeratleast1VOMSitem

•  AllVOMSitemswereposiOvelycorrelatedtothePCSS(PostConcussionSymptomScale)totalsymptomscore

•  VOMSwasnearly90%accurateinidenOfyingpaOentswithconcussionfromcontrols

MuchaA,CollinsMW,ElbinRJ,etal.AbriefvesObular/ocularmotorscreening(VOMS)assessmenttoevaluateconcussions:preliminaryfindings.AmJSportsMed2014;42:2479-86.

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VOMSConOnued…•  WomenhavehigherVOMSscoresthenmales(Sufrinko2017)•  SymptomprovocaOon/clinicalabnormalityassociatedwithalldomains(except

convergenceandaccommodaOon)candelayrecoveryOmeaXerSRCinyouthandadolescents(Anzalone2017)

•  VOMSdoesNOTprovokevesObularsymptomsinhealthyadolescents(Yorke2017)•  VOMSmeasuresuniqueaspectsofvesObular-ocularfuncOonotherthanthose

measuredintheBESS(BalanceErrorScoringSystem)orKD(King-DevickTest)withgoodreliability(Yorke2017)

•  Incollegiateathletes,VOMShadahighinternalconsistencywithan11%false-posiOverateatbaseline–mostlyfemaleorhistoryofmoOonsickness(Kontos2016).

AnzaloneAJ,BlueihD,CaseT,McGuffinT,PollardK,GarrisonJC,JonesMT,PavurR,TurnerS,OliverJM.AposiOveVesObular/OcularMotorScreening(VOMS)isassociatedwithincreasedrecovertyOmeaXersports-relatedconcussioninyouthandadolescentathletes.AJSM2017;45(2)474-479KontosAP,SufrinjoA,ElbinRJ,PuskarA,CollinsMW.ReliabilityandassociatedriskfactorsforperformanceontheVesObular/OcularMotorScreening(VOMS)toolinhealthycollegiateathletes.AJSM2016;44(6):1400-1406SufrinkoAM,MuchaA,CovassinT,Marche~G,ElbinRJ,CollinsMW,KontosAP.SexdifferencesinvesObular/ocularandneurocogniOveoutcomesaXersport-relatedconcussion.ClinJSportMed2017;27:133-138.YorkeAM,SmithL,BabcockM,AlsalaheenB.ValidityandreliabilityoftheVesObular/OcularMotorScreeningandassociaOonswithcommonconcussionscreeningtools.SportsHealth.2017;9(2):174-180.

YorkeAM,SmithL,BabcockM,AlsalaheenB.ValidityandreliabilityoftheVesObular/OcularMotorScreeningandassociaOonswithcommonconcussionscreeningtools.SportsHealth.2017;9(2):174-180.

Pursuits

Saccades

Imagefrom:KrauzlisRJ.RecasOngtheSmoothPursuitEyeMovementSystem,JNeurophysiology.2004;91(2):591-603

NormalSmoothPursuits

•  VIDEO

AbnormalPursuits(i.e.SaccadicIntrusions)

Symptoms:DifficulOesreading,nauseawithvisualmoOon,difficulOesscrollingonascreen

VIDEO

NormalSaccades

•  VIDEO

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AbnormalSaccades–Hypometric/Hypermetric

Symptoms:DifficulOesreading,difficulOes“tracking”,losingplacewhilereading,re-reading

•  VIDEO

VisualConsequencesofConcussioninSport

Calhasreallygreatathletes.Theyare

smartandenjoygoingtoclassandto

pracOce.Whentheyarenotonthe

fieldtheyareinthelibrary.

Calhasreallygreatathletes.Theyare

smartandenjoygoingtoclassandto

pracOce.Whentheyarenotonthe

fieldtheyareinthelibrary.

King-Devick

•  n=9,7dayspost-concussion•  n=9,age,sexmatchnormal

volunteers•  FixaOon,Reflexivesaccades,anO-

saccades,memoryguidedsaccades,self-pacedsaccades

•  fMRI-widespreadincreasedacOvaOonofmulOplebrainareasfollowingconcussioninresponsetooculomotortasks

–  LongerlatencyOme,worseposiOonerrors,fewernumberofself-pacedsaccades

JohnsonB,ZhangK,HallehM,SlobounovS.FuncOonalneuroimagingofacuteoculomotordeficitsinconcussedathletes.BrainImagingBehav2015;9:564-73

fMRIofAcuteOculomotorDeficitsinConcussedAthletes

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AccommodaOon•  WhentheeyechangesrefracOvepowerbyalteringtheshapeof

thelenstofocusonobjectsatdifferentdistances•  ie–Howtheeyefocusesonthings

AccommodaOvePathway

Imagefromhhp://what-when-how.com/neuroscience/the-cranial-nerves-organizaOon-of-the-central-nervous-system-part-4/

AccommodaOveInsufficiency AccommodaOveInfacility

AccommodaOveSpasmConvergence/Divergence

Distance Near

Divergence

Convergence

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NPC(NearPointofConvergence)

•  VIDEO

VergencePathway

GamlinP.NeuralMechanismsfortheControlofVergenceEyeMovements.AnnNYAcadSci.2002Apr;856:264-72

ConvergenceInsufficiencyVergenceDysfuncOon

ConvergenceInsufficiencySigns•  TrueCI(basedonthe

ConvergenceInsufficiencyTreatmentTrial)1.  DecreasedNPC>6cm2.  Exophoriaatleast4pd

greateratnearthandistance3.  Decreasedfusional

convergenceatnear•  “Gross”CI

–  ReducedNPCDevelopmentalCIiscommoninthegeneralpopulaCon~2.5-13%

Symptoms•  Headache•  Eyestrain•  Doublevision•  Blurryvision•  Lossofplacewhilereading/

wordsmovingonthepage•  ExcessiveOrednesswhen

reading•  Closinganeye•  ShortahenOonspanfor

readingScheimanM,MitchellGL,CoherS,etal.Theconvergenceinsufficiencytreatmenttrial(CITT)studygroup.Arandomizedclinicaltrialoftreatmentsforconvergenceinsufficiencyinchildren.ArchOphthalmol.2005;123:14-24.RouseMW,BorsOngE,HymanL,etal.FrequencyofconvergenceinsufficiencyamongfiXhandsixthgraders.OptomVisSci.1999;76(9):643-9.LetourneauJE,DucicS.Prevalenceofconvergenceinsufficiencyamongelementaryschoolchildren.CanJOptom.1988;50:194-7.McGregorML.Convergenceinsufficiencyandvisiontherapy.PediatrClinNAm.2014;61:621-630

ConvergenceInsufficiencyTreatmentTrialCITTStudyGroup

•  RandomizedclinicaltrialslookingatthedifferenttreatmentmethodscomparedtoplaceboforconvergenceinsufficiencyandaccommodaOvedysfuncOon–  Home-basedpencilpushups–  Home-basedcomputervergence/

accommodaOvetherapyandpencilpushups

–  Office-basedvergence/accommodaOvetherapywithhomereinforcement

–  Office-basedplacebotherapy–  BIprismreaders

•  Conclusion–  MosteffecOvewasoffice-

basedvergence/accommodaOvetherapy

–  StaOsOcallydifferentfromoffice-basedplacebotherapy

–  Home-basedremediesnotaseffecOveasoffice-based

–  Prismglassesdidnottreatsymptoms/signsbeherthanplacebo

ScheimanM,CoherS,RouseM,etal.RandomizedclinicaltrialoftheeffecOvenessofbase-inprismreadingglassesversusplaceboreadingglassesforsymptomaOcconvergenceinsufficiencyinchildren.BrJOphthalmol.2005;89:1318-1323CITTStudyGroup.RandomizedclinicaltrialoftreatmentsforsymptomaOcconvergenceinsufficiencyinchildren.ArchOphthalmol.2008;126(10:1336-1349ScheimanM,MitchellGL,CoherS,etal.Arandomizedclinicaltrialofvisiontherapy/orthopOcsversuspencilpushupsforthetreatmentofconvergenceinsufficiencyinyoungadults.OptomVisSci.2005;82(7):E583-E595ScheimanM,CoherS,KulpMT,etal.TreatmentofaccommodaOvedysfuncOoninchildren:resultsfromarandomizedclinicaltrial.OptomVisSci.2011;88(11):1343-1352

ConvergenceInsufficiency

TreatmentOp$onsPassive•  ObservaOon•  Prism/Readingglasses

–  Helpwithsymptoms–  DonotactuallytreatCI

AcOve•  OrthopOcsVisionTherapy

–  Home-based–  Office-based

SecondaryCausesofCI•  OculomotorPalsy/

RestricOon–  CNIV–  CNIII–  DuaneSyndrome

•  NeurologicalDisease–  Pseudotumorcerebri–  TBI/concussion–  BehavioralmedicaOons–  Parkinson’sDisease–  LymeDisease

SignificantReduc$on:5cmbreak,7cmrecovery

MaplesWC,HoenesR.NearPointofConvergenceNormsMeasuredinElementarySchoolChildren.OptomVisSci.2007;84(3):224-228McGregorML.Convergenceinsufficiencyandvisiontherapy.PediatrClinNAm.2014;61:621-630

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NPCinConcussionNPCaYerconcussioninchildren

•  N=275pediatricpaOentsaged5-18presenOngtoterOarycarechildren’shospitalsubspecialtyconcussionprogramatChildren’sHospitalofPhiladelphia

•  67(24%)hadabnormalNPC–  26(46%)recoveredwithstandard

clinicalcareovermedianof4.5weeks–  23(41%)recoveredamedianof11

weekspostinjuryaXerreferralforformalvesibulartherapy

–  7(13%)withpersistentabnormalNPCnecessitatedreferralforformalOBVT,withrecoveryof23weekspost-injury,medianof16weeksaXerreferraltoVT

NPCaYerSRC–rela$onshiptoneurocogni$veimpairment•  N=78athletes,meanage14years•  Seen~5daysaXerSRCand

comparedNPCtoIMPACTandsymptomassessments

•  CIwascommon~42%•  PaOentswithCIperformedworse

on–  Verbalmemory–  Visualmotorspeed–  ReacOonOme–  Symptomscores

StoreyEP,MasterSR,LockyerJE,etal.NearpointofconvergenceaXerconcussioninchildren.OptomVisSci.94(1):96-100

PearceKL,SufrinkoA,LauBC,etal.NearpointofconvergenceaXerasport-relatedconcussion:measurementreliabilityandrelaOonshiptoneurocogniOveimpairmentandsymptoms.AmerJSportsMed.2015.XX(X)

OculomotorProblemsinTBI

•  100post-concussionadolescentsaged11-17years–  51%accommodaOvedisorders–  49%convergenceinsufficiency–  29%saccadicdysfuncOon–  46%morethanoneofpreviouslymenOonedvision-relateddiagnoses

Arewejustfindingpre-exis$ngcondi$onswedidn’tlookforbefore?

MasterCL,ScheimanM,GallawayM,etal.VisiondiagnosesarecommonaXerconcussioninadolescents.ClinPediatr(Phila).2016;55(3):260-267.

VesObular-OcularReflexVesObular-OculomotorVisualMoOonSensiOvity

andEyeMovements(Saccades/Pursuits)

Visual-EvokedNausea

VisualMoOoninDailyLife Visual-VesObularMoOoninSport

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HigherOrderVisualProcessing

Spa$alProcessing-LocaOon-Movement-SpaOaltransformaOons-SpaOalRelaOons

ObjectProcessing-Color-Texture-Pictorialdetail-Shape-Size

VisualAhenOonandVisualProcessing

GilbertC,LiW.Top-downinfluencesonvisualprocessing.NatureRevNeurosci.2013;14:350-363RaffoneA,SrinivasanN,vanLeeuwenC.TheinterplayofahenOonandconsciousnessinvisualsearch,ahenOonalblinkandworkingmemoryconsolidaOon.PhilTransRSocB.2014:369.

VisualCrowding(Simultanagnosia) VisualCrowdinginDailyLife

ConcussionManagement

CurrentApproachtoTx•  NosamedayReturn-to-Play

(RTP)•  Needtobeclearedby

PhysicianforRTP•  Prescribedphysical/cogniOve

restunOlasymptomaOc•  AccommodaOonsatschool/

work•  Progressivesymptom-based

aerobicexerOon-basedRTP

Limita$ons•  LimitedguidanceonacOve

treatment•  Limitedevidencefor

effecOvenessofprescribedrest–  Norandomizedcontrolled

trials•  LackofdefiniOonof“rest”•  Recoveryisinfluencedby

severityofinjury,typeandOmingoftreatment

Wait–soRestisGood…orisit??Pros

•  RestdecreasesexposuretoaddiOonalimpacts

•  PhysicalandcogniOveacOvityexacerbatesymptomsposOnjury,prolongingrecovery

•  1-weekperiodofrestdecreasedSxandincreasedcogniOvescoresin60%ofpaOents–  Evenwhenusedseveralweeks/

monthsaXerinjury•  IniOalbriefrestmaybebeneficial

Cons•  Youcanavoidcontactwithoutavoiding

allacOvity•  PhysicalandcogniOveacOvitydonot

worsenpathophysiologicalinjuryorcauseaddiOonalharm

•  NoassociaOonbetweenprescribedrestanddecreaseorSxorrecoveryOme

•  PaOentswithhighestandlowestlevelsofacOvityhadworseoutcomes–  Toolihleortoomuchrestmaydelay

recovery•  Whattype,howlong–sOllTBD•  Prolongedrestcanleadtosocial

isolaOon,anxiety,lossofacademic/workstanding

CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaOonandAcOveManagement(TEAM)ApproachestoTreaOngConcussionMeeOngHeldinPihsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.

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HowLongShouldChildrenRest?•  NovalidateddatademonstraOng

theappropriateduraOonofcogniOveorphysicalrestinchildrenwithSRC

•  ThomasetalRCTassessingpost-SRCin11-22yo–showednosignificantdifferenceinprescribedrestandthosereceivingusualcare–  Thosereceivingstrictrest

reportedmoresymptomsandlongersymptomduraOon

•  Exerciseatmildorself-selectedlevelsdoesnotappeartoprolongsymptomsandmayshortensymptomduraOonandmaybeparOcularlybeneficialforadolescentathletes(103)

•  Restinfirstfewdaysmaybebeneficial,prolongedrestmaydelayrecovery(bothphysicalandcogniOverest)

•  ThomasDG,AppsJN,HoffmannRG,etal.BenefitsofstrictrestaXeracuteconcussion:arandomizedcontrolledtrial.Pediatrics2015;135:213–23

•  LeddyJ,HindsA,SiricaD,etal.Theroleofcontrolledexerciseinconcussionmanagement.PMR2016;8(Suppl 3):S91–S100•  BrownNJ,MannixRC,O’BrienMJ,etal.EffectofcogniOveacOvitylevelonduraOonofpost-concussionsymptoms.Pediatrics

2014;133:e299–304.•  ThomasDG,AppsJN,HoffmannRG,etal.BenefitsofstrictrestaXeracuteconcussion:arandomizedcontrolledtrial.Pediatrics

2015;135:213–23.•  HowellDR,MannixRC,QuinnB,etal.PhysicalacOvitylevelandsymptomduraOonarenotassociatedaXerconcussion.AmJ

SportsMed2016;44:1040–6

TEAMApproachtoConcussion-2015

•  Concussionsareatreatableinjury– MoreacOve/targetapproachesarebeherthanprescribedrestalone

•  AcOveRehabilitaOon–  VesObularTherapy–  Oculomotor/VisionTherapy–  BehavioralTherapy

CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaOonandAcOveManagement(TEAM)ApproachestoTreaOngConcussionMeeOngHeldinPihsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.

RoleforVisionTherapy?•  n=220individualswithTBI(n=160)orCVA

(n=60)•  ComputerbasedqueryinclinicalpopulaOon

2000-2003,selectedthosewhocompletedoptometricVTprogramTBI(n=33),CVA(n=7)

•  Results:90%ofTBIand100%withCVIhadtreatmentsuccess

–  Marked/totalimprovementinatleast1primarysymptomandatleast1primarysign

–  ImprovementsremainedstableatretesOng2-3monthslater

CiuffredaKJ,RutnerD,KapoorN,SuchoffI,CraidS,HanME.VisiontherapyforoculomotordysfuncOonsinacquiredbraininjury:AretrospecOveanalysis.Optom2008:79:18-22.

Post-ConcussionVisionExam•  AfferentVisualPathway

–  VisualAcuity•  Crowded/Isolated•  VORacuity(DynamicAcuity)

–  Pupils–  ConfrontaOonVFs

•  Eyemovements–  FixaOon–  Saccades–  Pursuits–  VOR–  NumberReadingTest(KD,

DEM)•  OcularPosture–CoverTest•  EOMs

•  AccommodaOon–  MonocularNPA–  MonocularFlippers–  MonocularMEM

•  Vergences–  NPC–  VergenceRanges–  VergenceFacility

•  OcularHealth–  Adnexa/OrbitalExam

•  Exophthalmometry–  AnteriorSegment–  PosteriorSegment

Optometry’sRole?

•  PressingneedforobjecOvediagnosOctoolsforconcussionassessmentthatarestraighzorwardtoadminister

•  CurrentresearchinusingeyemovementsandoculomotorfuncOonforsensiOveandobjecOvebiomarkersofcerebraldysfuncOon–  Canwetrackconcussionwiththevisualsystem??

•  ManagementofPost-Concussion/HeadInjuryVisionProblems

HeitgerMH,JonesRD,MacLeoda.D,SnellDL,FramptonCM,AndersonTJ.Impairedeyemovementsinpost-concussionsyndromeindicatesubopOmalbrainfuncOonbeyondtheinfluenceofdepression,malingeringorintellectualability.Brain2009;132:2850-70.JohnsonB,ZhangK,HallehM,SlobounovS.FuncOonalneuroimagingofacuteoculomotordeficitsinconcussedathletes.BrainImagingBehav2015;9:564-73.

OptometricManagementPrimaryCare

•  Vergence(Ranges,NPC,Facility)•  AccommodaOon(NPA,Facility)•  DEM•  Crowding(crowdedacuitysymbols)•  Rx

– Focusing/vergenceissues– Sunglasses

•  Reassurance

Ter$aryCare-PCS•  ComprehensiveBinocularVisionAssessment

•  VisualPerceptualSkillsAssessment

•  VisionTherapy•  VesObulo-OculomotorTherapy

AcOveparOcipaOoninmulOdisciplinarycare!

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13

PrescribedAccommodaOons/AdvocaOons

•  VisualMoOonSensiOvity/VisualCrowding– Removalfromgym/danceclass,band/orchestra,schoolassemblies

– Doublespacedtext,increasedfontsize,lineguides•  OculomotorDysfuncOon

– Delaytests/quizes– Reduceamountofhomework–  IncreaseOmeontests/assignments

•  Plannedbreaks– Notetaker

•  TEMPORARYMODIFICATIONS

ClinicalPearls

•  Thevisualsystemiscommonlyaffectedinconcussion

•  Themajorityofvisualproblemsself-resolveaXerconcussionin3-4weeks,butsomepaOentsmayneedacOvetherapyforfullrecovery

•  OptometryhasaroletofillinthemulO-disciplinarymanagementofconcussion

•  Whenindoubtrefertoacolleague!

Thankyou!QuesOons?

Dr.jaci.od@gmail.com

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•  Slide64-hhps://i.yOmg.com/vi/v8O0xzD6Ax0/hqdefault.jpg