Collaboration among optometrists and other health care providers is paramount for successful outcomes in patients who have post-concussion syndrome, a condition characterized by persistent symptoms, such as vision changes that can last weeks to months after the initial injury.^1,2 By working together, providers can ensure comprehensive care that facilitates optimal recovery. (Tragically, there is a 3 times higher prevalence rate of suicide in post-concussion syndrome patients compared to the general population.³)

With an eye — no pun intended — toward inspiring the OD reader to enter this care space, if they haven’t already, here, we discuss the optometrist’s specific importance in post-concussion syndrome, the treatment approaches they can provide, and we offer some suggestions on how to form a collaborative relationship with other health care providers.

OD’s importance

Studies reveal an estimated 50% to 90% of individuals who have persistent post-concussion syndrome experience clinically significant visual disturbances, including problems with vergence and accommodation.⁴ Additionally, research indicates that approximately 11% of athletes who have post-concussion syndrome exhibit convergence insufficiency alone.⁵ Further, as high as 25% of emergency room admissions in children are due to significant levels of persistent post-concussion issues.⁴

The good news: An optometrist’s timely assessment (i.e., several batteries of oculomotor, vergence, accommodative, and visual-processing tests) of these patients’ visual function can aid in the diagnosis or triage of visual impairments associated with concussions. This includes dynamic visual skills assessments (i.e., saccadic function, vergence and/or accommodation function), in addition to a comprehensive eye examination to rule out eye disease or systemic pathology, especially when significant visual symptoms are present. These visual symptoms are reading/tracking issues, photophobia, screen intolerance (scrolling in particular), poor tolerance of visually busy areas, double vision of any type, or rapid propensity to fatigue with any visual tasks.

Treatment approaches

Vision therapy for deficits directly resulting from physical disabilities and traumatic brain injuries, among other neurological insults, or neuro-optometric rehabilitation, has been shown to play a significant role in addressing oculomotor disorders and related visual impairments in these cases.

Specifically, neuro-optometric rehabilitation allows patients to recover visual function, improve their overall quality of life, reduce the risk of associated mental health challenges (such as the inability to socialize, or do basic grocery shopping due to photophobia or markedly increased visual motion hypersensitivity),^6,7,8 and decrease the risk of a subsequent concussion.⁹ This therapy may include the use of prisms, lenses, tints and/or selective occlusion strategies. The neuro-optometric rehabilitation aspect helps patients who are having issues with tasks that require a lot of eye movements (i.e., academics/reading or return to work tasks, such as computer use or driving). Therefore, children who have academic/reading issues, as well as post-concussion syndrome patients, can greatly benefit from these interventions:

• Dynamic visual skills training. This is comprised of various exercises and activities to improve eye tracking, fixation, saccades, pursuits, accommodation, and convergence. Examples (more detail can be found in “Applied Concepts in Vision Therapy,” by Leonard J. Press OD, FCOVD, FAAO) include, but are not limited to, saccadic training, accommodation training, vergence training, binocular training, and monocular fixation in binocular field training to mention a few approaches. These (mostly biofeedback) techniques aim to enhance the brain’s ability to coordinate the eyes and to improve the efficiency of eye movements, leading to improved visual tracking and accuracy.
• Visual processing and integration. This is the use of techniques, such as visual memory exercises, visual discrimination tasks, and perceptual activities, to enhance the brain’s ability to process and integrate visual information effectively. Examples of tools that can be used in the latter regard: Parquetry blocks and Multi-Matrix blocks.
• Balance and visual-vestibular integration. This includes exercises to help to alleviate symptoms of dizziness, imbalance, and spatial disorientation, often experienced by concussed individuals. This is achieved by increasing vestibular ocular reflex (VOR) gain, which is essentially enabling the vestibular and visual system to communicate more accurately, a concept which is taught in the mainstream in both physiotherapy and ENT circles. This can be achieved, for example, via bean bag toss games (i.e., keep your eyes on the bean bag as you throw it from one hand to the other but also move your head when doing so).
• Vision-related symptom management. This includes techniques, such as using tinted lenses, prisms, and proper visual hygiene, to alleviate symptoms. Fixation disparity testing can be invaluable to prescribing prisms, so, yes, dig out your old binocular vision notes and remember, the minimum amount of prism to alignment is what you are looking for.

Action steps. The OD can learn more about neuro-optometric rehabilitation treatment approaches for post-concussion syndrome by checking out related organizations, such as the College of Optometrists in Vision Development (COVD) (covd.org ), the Neuro-Optometric Rehabilitation Association (noravisionrehab.org ), and the Optometric Extension Program Foundation (oepf.org ). COVD, for example, helps optometrists attain a “mentor” (i.e., a current FCOVD). Also, as already mentioned, ODs should consider reading the book “Applied Concepts in Vision Therapy,” by Dr. Press, as a primer, and seek conferences and trade shows.

Forming a collaborative relationship

In our opinion, the difference between an average health care professional and an excellent one is that the excellent one actively works with others to ensure all the necessary bases are covered regarding a specific diagnosis and treatment. Collaborative care leads to excellent outcomes: As the adage goes, “It takes a village!”

Action steps. First, ODs should conduct a search of local primary care doctors, sports medicine doctors, and nurse practitioners in their area. Next, they should contact them about the treatment approaches optometrists can offer patients and the utility of standardized questionnaires, such as the Brain Injury Vision Symptom Survey¹⁰ (BIVSS) and protocols, such as vestibular ocular motor screening (VOMS). (The BIVSS questionnaire aids in flagging visual issues, so patients can be triaged, accordingly. The scale is from 0 to 112. Any score >32/112 is flagged for further assessment). The VOMS screening includes near point of convergence as part of its battery.¹¹

Resources that can be useful when speaking to other providers, include the medical book “Neurosensory Disorders in Mild Traumatic Brain Injury,” more specifically chapter 18, which includes over 200 PubMed references, by one of us (the authors of this article) and Dr. Eric Singman MD, PhD (of Johns Hopkins Neuro-Ophthalmology at time of this writing). Additionally, one of us (the authors of this article) and Dr. Singman recently published a study in the Journal of NeuroRehabilitation on headaches and vision,¹² showing the importance of the OD’s participation in the management of patients who have persistent post-concussion syndrome.

Once optometrists garner interest from providers in collaborating on care, they can start dedicating time in the patient schedule — think a half day a week to start — for sports-related cases, be they concussion-based, or, perhaps seeing athletes wishing to ensure they are at peak performance, and go from there!

Why wait?

An estimated 1.6 million to 3.8 million sports-related concussions occur annually in the United States alone, according to the Centers for Disease Control. While primary care providers, sports medicine doctors, and rehabilitation professionals, such as physiotherapists or athletic therapists, play a crucial role in the diagnosis and management of post-concussion syndrome, the involvement of ODs who have neuro-rehabilitation training can significantly contribute to comprehensive care. Why not pursue this interdisciplinary collaboration, if you haven’t already? Clearly ODs are needed. OM

References

1. Denis J, Yengo-Kah AM, Kirby P, Solomon GS, Cox NJ, Zuckerman SL. Diagnostic Algorithms to Study Post-Concussion Syndrome using Electronic Health Records: Validating a Method to Capture an Important Patient Population. J Neurotrauma. 2019;36(14):2167-2177. doi: 10.1089/neu.2018.5916.
2. Marshall S, Bayley M, McCullagh S. Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. Brain Inj. 2015;29(6):688-700. doi: 10.3109/02699052.2015.1004755.
3. Fralick M, Thiruchelvam D, Tien HC, Redelmeier DA. Risk of Suicide after a Concussion. CMAJ. 2016;188(7):497-504. doi: 10.1503/cmaj.150790.
4. Fried E, Balla U, Catalogna M Kozer E, Oren-Amit A, Hadanny A, Efrati S. Persistent Post-Concussion Syndrome (PPCS) in Children after mild Traumatic Brain Injury is prevalent and vastly underdiagnosed. Sci Rep. 2022;12(1):4364. doi: 10.1038/s41598-022-08302-0.
5. Badovinac, SD, Quaid P, Hutchison MG. Prevalence of oculomotor dysfunction in athletes pre-season: Implications for concussion in sport. Vision Development & Rehabilitation, 3(2), 75-89.
6. Smaakjaer P, Grønnegaard W, Rasmussen RS. Vision therapy improves binocular visual dysfunction in patients with mild traumatic brain injury. Neurol Res. 2022 May;44(5):439-445. doi: 10.1080/01616412.2021.2000825.
7. Gallaway M, Scheiman M, Mitchell GL. Vision therapy for post-concussion disorders. Optom Vis Sci. 2017 Jan;94(1):68-73. doi: 10.1097/OPX.0000000000000935.
8. Ciuffreda KJ, Ludlum DP, Yadav NK, Thiagarajan P, et al. Traumatic Brain Injury: Visual consequences diagnosis and treatment. Advances in Ophthalmology and Optometry, 2016;1, 307-333. DOI:10.1016/J.YAOO.2016.03.013
9. Clark, JF, Graman P, Ellis JK, et al An exploratory study of the potential effects of vision training on concussion incidence in football. Optometry & Visual Performance, 3(2), 116-125.
10. Laukkanen H, Scheiman M, Hayes JR. Brain Injury Vision Symptom Survey (BIVSS) Questionnaire. Optom Vis Sci. 2017 Jan;94(1):43-50. doi: 10.1097/OPX.0000000000000940.
11. Kaae C, Cadigan K, Lai K, Theis J. Vestibulo-ocular dysfunction in mTBI: Utility of the VOMS for evaluation and management- A review. NeuroRehabilitation. 2022;50(3):279-296. doi: 10.3233/NRE-228012.
12. Quaid PT, Singman EL. Post-traumatic headaches and vision: A review. NeuroRehabilitation. 2022;50(3):297-308. doi: 10.3233/NRE-228013.

DR. QUAID founded and heads optometric services at VUE Cubed Vision Therapy Clinics, in Ontario, Canada (www.vuetherapy.ca ). He is also an Ontario Superior Court Recognized Expert Witness.

MR. MOONEY is an athletic therapist and a consultant for both the Toronto Maple Leafs (NHL) and Toronto Marlies (AHL).