Traumatic Brain Injury, or TBI, was thrust in to the spotlight in 2012 when more than 2,000 retired NFL players filed a federal class-action lawsuit, accusing the football league of failure to inform them of the connection between concussions and brain injuries. In 2015, the NFL settled with the players, agreeing to pay up to $5 million per retired player, in addition to providing baseline exams to retired players and subsequent money to those diagnosed with conditions linked with TBI, such as Alzheimer’s disease, dementia and Parkinson’s disease. (At press time, JAMA released a study revealing that in a sample of deceased football players who donated their brains for research, a high proportion had neuropathological evidence of chronic traumatic encephalopathy.)

In addition to professional athletes, in 2012, an estimated 329,290 young people (age 19 or younger) were treated in U.S. emergency departments for sports and recreation-related injuries that included concussion or TBI, reveals the CDC. Further, hospitalization rates in 2013 for TBI were highest in those age 75 and older, according to the CDC.

As these brain injuries can result in blurred and double vision, deficits of saccades and convergence insufficiency, among other visual issues, we, as optometrists, play a crucial role in diagnosing and treating concussions and, thus, as important members of the integrated health care model.

This month, we hear from two optometrists who help patients who have TBIs.(Next month, we’ll hear from two more.)

Jack Schaeffer, O.D., F.A.A.O.,
Editor-in-Chief
O.D. Scene

BRAIN INJURY SPECIALISTS WEIGH IN . . .

STEVEN J. CURTIS, O.D., F.C.O.V.D., & BRENDA MONTECALVO, O.D.

Q: HOW AND WHY DID YOU GET INVOLVED IN THE TREATMENT OF CONCUSSION?

SC: After 20 years of developing a reputation for providing functional vision care for children, local rehabilitation specialists asked me, about seven years ago, to be a referral source for acquired brain injury adult patients. There was growing need for this and a shortage of qualified neuro-optometrists. I pulled out my neuro-anatomy notes and references from optometry school, read all the available current journals, attended as much related CE as possible, and I am nearly finished completing a five-year fellowship program in neuro-optometric rehabilitation.

BM: I became interested in concussions after being in a head-on car accident the year after graduating from optometry school. After experiencing visual problems, such as eyestrain and headaches when reading, light sensitivity and visual spatial disruption that affected my eye-hand coordination, I began exploring how to treat these issues using special lenses and vision therapy. I learned that special micro prescriptions of plus, prism and partial occlusion can be extremely effective in helping patients realize relief from debilitating visual symptoms post-concussion.

Q: WHAT IS YOUR MOST SUCCESSFUL TREATMENT STRATEGY FOR CONCUSSION-RELATED VISION ISSUES?

SC: There is one secret weapon I have been using that has dramatically provided success. It’s way too difficult to explain in a short interview, but I have labeled it “optometric phototherapy-based multisensory training.” Combining this with the use of prisms, vision therapy, filters and more, we can change the lives of patients who suffer persistent symptoms from concussion.

BM: My model for treating concussions involves using the visual-motor system to relearn how to accurately judge where one is in space and to move accurately through space in good balance. (If you’re interested in learning how to employ this, shoot me an email at bmontecalvo@novavisioncare.com.) I also provide a seminar series on this topic. You can see information about this at www.visiontherapyseminars.com .

Q: HOW DO YOU PRESENT THE TREATMENT STRATEGY TO PATIENTS?

SC: It’s critical to spend adequate time explaining it because it is so unique. The treatment retrains the brain’s ability to process sensory information from multiple sources, including vision, vestibular and auditory inputs. I explain that concussive symptoms are the result of a nervous system that is no longer able to perform these foundational skills on autopilot.

BM: I begin the visit by having a detailed conversation about what the patient can no longer do with ease and what the patient’s primary goals are. Intervention is very function based. I design the treatment program based on what the patient wants to accomplish. I instruct the patient to do the procedures at home and return in four weeks to assess changes in visual performance. With good compliance, patients frequently see positive changes and are willing to continue with intervention or are satisfied with what they have gained, and treatment is ended.

Q: HOW DO YOU GENERATE REFERRALS?

SC: Approximately 95% is from physicians and rehab specialists. I have a few O.D.s who refer to me occasionally.

BM: Most patients hear of us through coaches or educators. Some locate our services when searching for doctors who provide this type of care. Also, I have many colleagues who call, text or email questions to me as needed. I then walk them through the needed treatment. If a colleague decides to refer, I instruct him or her to have the patient fill all prescriptions through the referring optometrist.

Q: WHAT IS YOUR MOST MEMORABLE CASE AND WHY?

SC: One of my early cases, Kathy, comes to mind. She was so thankful for what we did for her, that she offered to adopt my eight children as she looked at my family picture on my exam room wall. She had been suffering from dizziness, blurred vision, inability to drive and severe anxiety as a result of a concussion from a car accident two years prior. Our website has a news story with her telling how it changed her life and that she felt herself again.

BM: My patient is an air traffic controller who was kicked in the head by a horse. Digital device use required by his job was making it impossible to return to a normal work day. He had a family, including three small sons. He presented with double vision and constant headaches. Exam revealed convergence insufficiency, vertical deviation, eye movement deficiencies, and his ability to localize was mismatched on the Z axis. He participated in our weekly in-office vision therapy with five weekly home sessions. In four months, he was back to work full-time with no symptoms.

Q: DO YOU SCREEN OR TREAT ANY SCHOOLS, ORGANIZATIONS OR TEAMS?

SC: Yes, our local professional soccer team after they added me to their medical team.

BM: Not at this time, but we provide individual screenings in our office for patients who may have suffered a concussion.

Q: HOW DO YOU WORK COLLABORATIVELY WITH OTHER MEDICAL PROFESSIONALS WHO DIAGNOSE AND TREAT CONCUSSION?

SC: A tremendous credit for my growth and recognition by the medical community goes to the physical therapists (PT) and occupational therapists (OT). They have begged the physicians to consider vision as a component in their patients’ recovery. They often call the patients’ physicians and ask them to refer to me. I have presented education to many PT and OT rehabilitation groups regarding post-concussion vision problems. I have also benefited from providing “lunch and learns” to physician groups that specialize in concussion.

BM: When we evaluate a patient who has a concussion, we send reports to all interested parties —physicians, therapists, educators and coaches. Also, a wide variety of health professionals are encouraged to consult as needed.

Q: WHAT DO YOU THINK IS THE BIGGEST MISCONCEPTION ABOUT CONCUSSIONS?

SC: That all patients recover from them within a couple weeks. Approximately 10% to 15% of concussion patients experience symptoms for months to years, and family, friends and employers start to doubt the legitimacy of the patient’s complaints. Unfortunately, it is an “invisible” injury and eventually can result in secondary psychological ramifications, as these patients lose self-esteem and trust from others.

BM: Probably the biggest misconception is for the patient to do nothing (no exercise, no reading) and to stay in a dimly lit room to heal. New research shows that mild exercise is much better for quicker recovery from a concussion.

Q: WHAT ADVICE DO YOU HAVE FOR OTHERS CONSIDERING THIS SPECIALTY?

SC: Become members of the organizations that provide training and resources, such as C.O.V.D., N.O.R.A., O.E.P., and C.S.O. Then attend their courses, and read the pertinent journals.

BM: Remember to use quality lens materials and to treat any dry eye disease for improved visual performance. If the patient stopped wearing contact lenses after the concussion, try to return him or her to the contact lenses, and prescribe a near lens over the contact lenses with appropriate anti-reflection coatings. Find a colleague who works in this area to help guide you through the first few cases. OM