Q&A

In recognizing the seriousness of concussion, the AOA’s Vision Rehabilitation Section created the Brain Injury Electronic Resource Manual, which consists of two volumes: Volume 1A, Traumatic Brain Injury Visual Dysfunction Diagnosis and Volume 1B, Traumatic Brain Injury Visual Dysfunction: Optometric Management and Advanced Topics.

In addition, the organization that represents close to 45,000 O.D.s, had optometrist Brenda Montecalvo, immediate past chair of the AOA’s Vision Rehabilitation Section and one of the O.D.s featured in Part 1 of O.D. Scene’s Brain Injury Specialists, provide five things O.D.s should be aware of when it comes to concussions. Here’s a sample:

1. Causes and risks. Sports, such as football and soccer, are major causes and risks, but don’t forget about non-sports-related falls and accidents too.
2. Remember the patient’s entire visual system. This includes VA, VF, visual motor tests, spatial orientation, visual memory and figure-ground organization.

For the full list of five, see the article, “5 things optometrists should know about concussions,” on the AOA’s website (http://bit.ly/1VzXekl ). Also, check out, “Treat Post-Concussion Syndrome” and “The How and Why of mTBI,” which appeared in the June 2017 and September 2012 issues of OM, respectively.

As in other areas of health care, we can make a difference, we just need to step up to the plate.

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

BRAIN INJURY SPECIALISTS WEIGH IN . . .

MICHAEL PETERS, O.D., & TONYA TIRA, O.D.

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

MP: I was the team eye doctor for the Carolina Hurricanes. In 2006, I diagnosed one of the players with binocular vision dysfunction, secondary to a concussion. I was determined to learn more about how concussions affected the visual system and attended several seminars on traumatic brain injury. I discovered no clear-cut vision protocol existed regarding concussion, so I developed one (www.seetoplay.com ) for other optometrists with patients who had sports-related concussions.

TT: I graduated from the Illinois College of Optometry in 2005. After practicing general optometry in the Chicago area for five years, I had a strong interest in and saw a need for vision therapy. So, I decided to go back to school and complete a residency in vision therapy, rehabilitation, and pediatric optometry at Pacific University College of Optometry. It was during residency that I became involved in the treatment of concussion. I did not have any awareness of what optometrists could do for patients struggling with visual symptoms after brain injury before then.

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

MP: I use the 10-stage concussion protocol (performed mainly by optometric technicians, with the doctor monitoring) I developed. It involves patients wearing prism glasses, which change their perception of the world, and using a ball in a game of pitch and catch with a technician. The protocol also includes a home vision exercise program that is spelled out for athletes diagnosed with vision concussion syndrome. Patients must progress through the 10-stage protocol to pass and, ultimately, return to play.

TT: I find that each brain injury patient is unique, requiring individualized plans. The tools that I have at my disposal (in addition to standard binocular, accommodative and oculomotor vision therapy procedures) are NeuroTracker, VTS4 (HTS), the Sanet Vision Integrator (HTS) and the King Devick (K-D) Test Pro Monitoring. My standard evaluation includes a complete visual skills/binocular vision work up, health testing and VF. In addition, updated refraction and consideration of prism and tints or blue light filtering lenses are usually required. We also run a K-D Test Pro Baseline [iPad program that administers unlimited King-Devick Test Concussion Baseline tests]. If the patient can’t complete the baseline without errors, we run a K-D Test Pro Reading, which obtains an eye movement measurement, allowing for errors, and includes age-related normative data for comparison.

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

MP: When I confirm the presence of a visual component from a patient’s concussion, I introduce him or her to the 10-stage concussion protocol, and I explain that different schools of thought exist on how to get better, but that my experience has shown most patients can get better via home vision therapy and returning to the practice for follow-up appointments every 10 to 14 days. I refer patients who have more deep-seeded injuries to a TBI vision specialist for a vision therapy assessment, as I do not provide that type of service.

TT: I explain to patients that more than 50% of our brains are involved in processing vision and that many areas of visual abilities can be affected by concussion/brain injury. Most patients are symptomatic and just so thankful to have someone who can recognize and offer some form of treatment for the visual and cognitive difficulties they are struggling with.

Q: HOW DO YOU GENERATE REFERRALS?

MP: Patients are often referred to my practice by other doctors who are aware of my 10-step protocol, but I also see patients who have researched my methods through the Seetoplay website, Facebook and Instagram pages and twitter handle. I get many referrals from O.Ds.

TT: I am fortunate to work within a practice that generates in-office referrals. These patients are given a two-sided rack card with an abbreviated brain injury symptom list and an overview of our vision rehabilitation clinic.

Q: WHAT IS YOUR MOST MEMORABLE CASE AND WHY?

MP: A starting University of North Carolina baseball player was referred to me because he was concussed and seeing double after being hit by a foul tip. I used my FitLight Trainer (FitLight Corp.) with red/green lights and red/green glasses to start his rehabilitation in the office, and the University purchased a machine that would allow the athlete to continue this therapy daily on campus. After sitting out a semester to rehab, he returned to play as a senior and went on to start a baseball career in the minor leagues.

TT: A parent tracked me down at my current practice in Illinois because her daughter, who I treated at my previous practice in Virginia, sustained another concussion. The mother was distraught because she said she felt her daughter’s biggest factor in recovery with the first concussion was her vision rehabilitation, and the family couldn’t find another O.D. to treat her. The parents told me they were seriously considering flying their daughter to, at least, have me evaluate her, but I was able to connect them with another practitioner within an hour’s driving distance. The fact that her mother was motivated to bring her to see me after the second concussion, even though I was out of state, really reinforced what a difference we can make for these patients.

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

MP: I make sure I send reports to referring doctors on patients’ progress and, ultimately, information that helps them determine return-to-play status.

TT: I have a primary care physician in the community who does concussion testing and a sports medicine M.D. who refers to me currently. At my previous practice, I had an excellent referral relationship with a neuropsychiatrist and a physiatrist who worked with brain injury patients.

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

MP: I think that because concussions are brain injuries, some optometrists are leery to treat concussion-related eye injuries. But treatment for many of these injuries are as basic as prescribing maximum plus and taking care of convergence and accommodation issues. I believe optometry, as a profession, is missing out because concussion clinics are now providing vision exercises via physical therapists and physician assistants.

TT: That symptoms are obvious. We need to be screening for oculomotor, vergence and accommodative dysfunction in these patients even if they are not reporting obvious symptoms, such as diplopia or intermittent blur.

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

MP: Jump in. I’m accessible via email for those doctors starting out. (MPeters@myeyedr.com)

TT: It is crucial to have extended time with patients at the first visit to take a good history and allow them to “tell their story.” Many are photophobic and easily fatigued, presenting obvious challenges to thorough functional and ocular health testing. Sensitivities to busy environments, lighting and noise can also be difficult to accommodate in a busy practice. Proper scheduling is critical, preferably at less busy times if you are working these patients into a primary care schedule. Additionally, a physiatrist once told me, “the only consistent thing about brain injury is inconsistency.” This pearl is important to keep in mind as you work with these individuals: There can be setbacks and fluctuations in response to therapy that do not seem to make sense, frustrating to both the patient and clinician. OM