WORLDWIDE, ABOUT 42 million concussions occur annually, according to May’s Molecular and Cellular Neuroscience. Due, in part, to the fact that a majority of concussions do not result in a loss of consciousness, diagnosis is difficult, when it is done at all.

What often appears to be a mild bump on the head can end up resulting in drastic, persistent neurological effects, such as post-concussion syndrome (PCS) — which occurs up to 30% of the time from closed head trauma — headaches and dizziness, which can occur up to 70% of the time following traumatic brain injury, according to Sept. 2011’s Journal of Neurotrauma. PCS results in incomplete recovery and debilitating persistence of mild to severe symptoms. (See “Use the PCS Checklist” on p.25.)

At least 67% of the neural connections within the brain are involved with some aspect of vision, whether it is visual input, visual perception or visual integration, according to January 1999’s Cerebral Cortex. Thus, PCS affects a wide array of visual skills, explained below, that optometrists are well trained to assess and treat.

Here, I discuss how to identify and treat your PCS patients.

ASSESS VISION AND EYE HEALTH

When a patient presents for his or her annual comprehensive exam, obtain a recent patient history that includes the question, “Have you sustained any type of head injury since your last visit?” If the answer is “yes,” you know to keep an eye out for concussion-related ocular issues, such as abnormal saccades, which relate closely to the functional integrity of the injured brain. In fact, disparities in eye movement function can be identified up to five months following an incidence of concussion, reports Brain in October 2009.

The visual skills affected by PCS are extremely important for daily activities, such as digital device use, reading, sports performance, walking and/or driving.

Deficient visual skills can include:

• Photosensitivity
• Vertical deviation (CN IV damage)
• Poor control of eye fixation associated with visual attention
• Inability to pursue or follow a target
• Difficulty performing a saccade
• Reduced accommodative amplitude
• Deficient accommodative flexibility
• Over or under convergence
• Poor visual recognition memory
• Hand/eye coordination
• Slow visual processing and reaction time
• Inability to judge visual closure situations
• Visual spatial disorganization causing disequilibrium
• Confusion with visual discrimination or figure ground
• Difficulty with visualization when problem solving
• Refractive changes, particularly increase in myopic progression

Eye health conditions to rule out include:

• Dry eye
• VF loss
• Glaucoma
• Retinal detachment

USE THE PCS CHECKLIST

Should your comprehensive exam reveal any form of PCS, use the following checklist to identify post-concussion patients who can benefit from optometric treatment. The checklist is meant to be used as a monitoring tool. Use it pre-treatment, to identify a starting point, and post treatment, to measure the effectiveness. For example, if a PCS patient scored a 20 pre-treatment, the optometrist should expect a score less than 20 post treatment. (The checklist should be scored at each subsequent visit during treatment.)

“Please rank the following symptoms that have materialized since the concussion occurred. Score each symptom on a scale of 0 to 4. 0: never, 1: sometimes, 2: frequently, 3: often, 4: always.

• Photosensitivity
• Headache
• Double Vision
• Dizziness
• Vertigo
• Nausea
• Extreme fatigue
• Blur at distance
• Blur when reading
• Reduced comprehension
• Change in speech pattern
• Delayed response to simple questions
• Increased irritability
• Coordination problems
• Disorientation
• Memory difficulties
• Unequal pupil response or size
• Loss of balance or unsteady walking
• Overly emotional, such as crying more often
• Problems with visual attention

PRESCRIBE SOLUTIONS

A variety of chair-side rehabilitation tools can be prescribed to PCS patients who have the following symptoms: (These treatment suggestions can begin giving the patient much-needed relief.)

Photosensitivity. This is one of the more common symptoms after injury. Even indoor lighting, especially fluorescent, can cause patient discomfort. Treatment prescriptions can include all or one of the following: narrow bi-nasal occlusion, light yellow filter for indoor lens, dark grey No. 3 filter for outdoor wear and a visor or hat for outdoor and indoor activities. Note that for students and some employees, you may need to write a prescription for dark filters and/or visors for the classroom or on the job, since the aforementioned prescriptions may not be allowed.

Headaches. These are due to near eyestrain in PCS patients and can be treated with low plus lenses, a small amount of base in prism and/or narrow bi-nasal occlusion. Note that the injured visual system can be very “tight,” or inflexible. An example of a tight visual system would be the inability to move eyes in any direction without discomfort, reduced accommodative flexibility, significantly reduced convergence recovery and difficulty measuring a comfortable subjective refraction.

A tight visual system makes it difficult to accept strong prescriptions. When this is the case, the light-tinted filter and/or bi-nasal occlusion may be the only treatment options that provides relief. Once the visual system gains some flexibility, stronger prescriptions may be warranted, reports March 2007’s Optometry.

Eyestrain. Your assessment will determine which visual skills are contributing to the patient’s eyestrain. An example for this may be that when placing a low plus lens in front of the patient while performing a pursuit and near point convergence activity, the eyes perform better with the lens then without. From these results, prescribe the appropriate combination of filter, lens power and prism based on the primary visual demand the patient is required to work in. This is usually a prescription for near.

When these chairside recommendations are unsuccessful, a more comprehensive program of optometric rehabilitative vision therapy is warranted.

OPTOMETRIC NEURO-REHABILITATION (ONR)

The next step is to investigate further treatment via optometric neuro-rehabilitation (ONR). ONR generally includes the incorporation of optometric vision therapy and direct communication with other rehabilitation health care professionals, such as an optometrist specializing in the area of neuro-rehabilitation. (The number of ways to locate such an optometrist with this specialty: College of Optometrists in Vision Development website, covd.org ; Neuro-Optometric Rehabilitation Association’s provider locator, at nora.cc ; and Optometric Extension Program Foundation, oepf.org .)

Patients suffering from persistent symptoms that involve the visual process, reaction time and memory, respond well to optometric vision therapy, according to the AOA Brain Injury Electronic Resource Manual. For example, stimulating the visual system from a relaxed state can help to correct binocularity issues of PCS patients. Some examples of how to do this may be working with parquetry blocks, geometric boards or a saccadic eye fixator. Specifically, an optometric vision therapist might place four random parquetry blocks on a table in front of patient, let him or her look at them for 10 seconds, then cover them up and ask the patient to make a design to match the one covered with a second set of blocks.

It’s important to note, when working with this population: It takes time, and you should temper patient’s expectations as such.

ADDRESS THE BUMPS AND BRUISES

Concussion can create significant visual skill deficits that interfere with a variety of daily living activities. A comprehensive optometric eye health and vision evaluation is essential to address all patient’s eye health and visual needs. For optimum patient outcomes, you should be included in the rehabilitative team when assessing and treating patients with concussion. When chairside optometric care is not sufficient to solve the patient’s visual deficits, optometric neuro-rehabilitation, including optometric vision therapy, is warranted to better find solutions for patients with concussion. OM

DR. MONTECALVO has provided primary care optometry to her patients in a successful private practice setting for over 30 years. She presents the Cedarville Seminar Series for Optometric Vision Therapy and is a co-author of the AOA Brain Injury Electronic Resource Manual. Dr. Montecalvo is past chair of the AOA Vision Rehabilitation Section, a member of AOA VRS Brain Injury Committee, past president of the Ohio Optometric Association, past president of the Neuro-Optometric Rehabilitation Association, co-chair of the John Streff Invitational Lens Symposium and trustee of the Vision Leads Foundation.