Article Date: 9/1/2012

The How and Why of mTBI
brain injury

The How and Why of mTBI

Seeking patients who have mild traumatic brain injury (mTBI) is a no-brainer, your colleagues say.

Jennifer Kirby, senior editor

Brace yourself. Some primary care doctors are providing neuro-optometric rehabilitation (NR), says Mike Peters, O.D., a Raleigh, N.C. sports vision specialist and author of See to Play: The Eyes of Elite Athletes (Bascom Hill Publishing Group, 2012). The reason: The evergrowing press on sports-related concussions coupled with the availability of concussion-screening tools, such as the King-Devick Test, have placed a spotlight on concussion-induced visual abnormalities, and thus, the exercises to improve vision.

mTBI is “the disruption of brain function by trauma characterized by but not limited to a loss of consciousness, memory loss surrounding the trauma, confusion during the incident, loss of consciousness for no more than thirty minutes and posttraumatic amnesia lasting less than 24 hours,” says the Free Medical Dictionary.

The mTBI-caused visual issues: blurred vision, convergence insufficiency, deficits of saccades, fixation or pursuit, dizziness, double vision, eye strain, intermittent suppression, light sensitivity, visual field impairment and deficits in the visual vestibular system, say those interviewed for this article.

“If we, as a profession, don't start paying attention to mTBI, I believe it could fall under the jurisdiction of the primary care docs in the patients' view,” Dr. Peters explains. “This would make us obsolete in an area where we, as the eyecare practitioner, command the expertise.”

Here, your colleagues explain the other reasons you should seek mTBI patients, your role in this field and how to garner patient referrals.

The other reasons

The three additional reasons you should pursue mTBI patients:

1.mTBI is a “serious, public health problem.” Every year, traumatic brain injuries contribute to several deaths and permanent disability cases, says the Centers for Disease Control and Prevention. In fact, on average, approximately 1.7 million people sustain a traumatic brain injury annually, and the majority of TBIs are mild TBIs, such as concussions.1

In recognition of the seriousness of mTBI, the American Optometric Association's Vision Rehabilitation Section is now preparing a “comprehensive, optometric brain injury manual,” available later this year, says an article in the July 2012 issue of AOA News.

“Naysayers will say, ‘Come on, these things resolve on their own.’ But, the fact is if you don't get involved, it can take a lot longer for recovery,” explains Dr. Peters. “In fact, I've seen patients who sustained mTBIs 10 plus years prior to seeing me, and they tell me they still can't function at work.”

2. Identifying a possible mTBI patient and/or providing NR to these patients can improve your practice's revenue. Identification of mTBI creates a win-win for your patients and your practice.

“Third party payers will cover the examination, and most will cover the therapy,” explains Jason Clopton, O.D., F.C.O.V.D., of the Center for Vision Development, in Cookeville, Tenn.* “When not covered, these patients tend to be amenable to paying out-of-pocket, they stick with you for their other ocular conditions, such as dry eye, and they become a major referral source for all types of patients, all because they are just so grateful for your care.”

Billing for mTBI includes a comprehensive vision exam (99 code), a prolonged physician service visit (99 code), a sensorimotor exam (92 code), a visual field exam (92 code) and NR (97 code), if you offer it, which may not be health-insurance covered and can cost between $70 to $150 per a one hour session, say those interviewed. In addition, these sessions usually begin weekly for four-to-eight months before decreasing to every other week, monthly, etc., through a one-and-a-half to two-year period, says Neera Kapoor, O.D., M.S., F.A.A.O., F.C.O.V.D.-A., chief, Vision Rehabilitation Services/associate clinical professor at the SUNY College of Optometry. The typical mTBI patient can provide between $3,000 to $7,000 to one's practice, says Errol Rummel, O.D., of the Low Vision Center for Neuro-Optometric Rehabilitation in Jackson, N.J.

“Treating mTBI patients requires a lot of one-on-one time and the insight and knowledge and clinical skills, which can only be obtained by years of experience,” he says. “We have found that in-office neuro-optometric rehabilitation results in the best patient outcomes.”

Dr. Peters says he provides a home NR kit to mTBI patients for $149, rather than in-office NR, and that he has successfully dispensed new prescription glasses for upwards of $300 to mTBI patients who say they can't put their lives on hold while their visual system relaxes.

Credentials in NR can provide you with an additional revenue stream, as they enable you to become an expert witness and an independent medical examiner (IME), adds Dr. Rummel, who is a Fellow of the Neuro-Optometric Rehabilitation Association (F.N.O.RA), a Fellow of the College of Optometrists in Vision Development (F. C.O.V.D.) and a Fellow of The International Academy of Low Vision Specialists (I.A.L.V.S.).

mTBI Scriptopedia
The questions you should include on your patient history form to tease out mTBI patients, says Dr. Kapoor:
1. Do you experience excessive headaches? Most mTBI patients will reply “yes.” If this is the case, personally ask the patient how long it's been going on, Dr. Kapoor says. “This is the key follow-up question because the mTBI patient will associate the start of these headaches with an injury that may have or did indeed result in an undiagnosed head trauma,” she says.
2. Do you experience any difficulties with reading? This question is designed to identify mTBI-caused visual problems, such as blurred vision or tracking problems. “Most of the time, mTBI patients tell you they don't read very much. If you get this answer, ask whether this is a recent development,” Dr. Kapoor says. “If the answer is ‘yes,’ you may be dealing with a possible undiagnosed mTBI patient.”
3. Do you experience dizziness? A “yes” answer hints at visual vestibular, or balance problems, that may become exacerbated in several visually stimulating environments, Dr. Kapoor says. “When I get a “yes” answer, I'll follow up with ‘You have difficulties being in supermarkets and malls right?’ ‘I bet you hate scrolling on your computer?’ The mTBI patients immediately answer ‘Yes,’ and ‘how did you know?’ to these additional questions.
4. Do you experience trouble adapting to changes in light? A “Yes” answer indicates the patient may have incurred damage to their cortical or subcortical processing, making it difficult for their eyes to respond and adjust to varying illumination, Dr. Kapoor says. “Often times, these patients present wearing dark glasses and/or a baseball cap, like they're celebrities,” she explains. “When the lighting is dim, they'll often remove these things. Some of these patients can also perceive the subtle flickering of fluorescent lights.”

“As an expert witness, you spend hours of time in preparation for court, and fees range into thousands of dollars. You're paid to review the case, discuss the case with the attorney before it goes to trial, you're paid for your travel time, your time testifying in court, etc.,” he explains. “The fee for an IME includes a major evaluation of the patient's clinical symptoms and neuro-visual issues, and it often has to be done in one two-to-four hour visit. Plus you have to provide a comprehensive report. A reasonable fee is charged for my time and services based on my expertise. IME fees can range about $2,500 depending on the complexity of the case.”

3. Managing these patients is personally and professionally fulfilling. “There isn't a month that goes by that I don't work with someone or finish rehabilitation with someone and see the change and have them tell me how their life has been positively changed as a result,” says Dr. Kapoor.

Dr. Clopton says he relishes the challenge of manipulating how the brain processes visual information to make the eyes function in a more efficient manner. He adds that as a member of the rehabilitation team, optometry is held in high regard with other professionals, as an O.D.'s unique insights and care are often the missing piece of the rehabilitation process.

mTBI and the O.D.

Your two roles in mTBI:

1. Detective. “Early identification of an mTBI is essential, so the patient can be removed from harm's way, particularly with regard to sports,” says Leonard Messner, O.D., F.A.A.O., professor and vice president for Patient Care Services at the Illinois College of Optometry.* As the O.D., you are often the mTBI diagnosis gatekeeper, says Dr. Rummel.

The reason: “We [O.D.s] are the only healthcare professionals who have an educational foundation in the subtle and often esoteric visual symptoms associated with mTBI, such as visually related balance and postural deficits as well as visual field loss and ocular fixation deficiencies,” he explains. “These skills coupled with our in-depth evaluation of the patient's history, make us a valuable component in the mTBI diagnosis.”

Dr. Peters says your ability to refract and knowledge of the basic binocular tests, such as the Worth 4 Dot Test, are key here and can lead to referrals not just from the patient's primary care doctor, but also from the neurologist, among other medical professionals.

“Any primary care optometrist can aid in the diagnosis of these patients,” he says. “We have the basic knowledge to do it, we just have to make a point of seeking these patients.” (See “mTBI Scriptopedia,” page 44.)

2. NR specialist. “Most primary eyecare doctors can provide some level of introductory care for the basic accommodative, vergence and saccadic function issues,” says Dr. Kapoor. “For those who want to tackle the more complex cases, such as visual fields or the visual and vestibular systems, they should acquire education from the College of Optometrists in Vision Development (www.covd.org) and the Neuro-Optometric Rehabilitation Association (www.nora.cc).” Dr. Clopton adds you should check out The Neurology of Eye Movements (Oxford University Press, 2006).

While providing NR, you are maintaining contact with the patient's primary care doctor, neurologist and any other member of the patient's rehabilitation team to ensure the vision piece of the equation connects with the other forms of therapy, if any, explains Dr. Kapoor.

If you'd like to start offering NR, Dr. Kapoor says to start slow, as she says garnering these patients is initially “sluggish.”

“It took about two years to build up, and I think that's important for a primary eyecare doctor to know. If you're going to start this, there is no need to spend a significant amount of money on expensive equipment and end up doing nothing for a year,” she explains. “Start low key. Spend maybe $10,000 on rehabilitation equipment, dedicate some space in your practice, and reach out to your community,” she says.

In terms of an equipment beginner's set, Dr. Kapoor suggests you have a VTS system, vectograms, half a dozen spectograms, a spirangle crown, quoits, mother goose, a pair of red blue glasses, a pair of red green glasses, red-green anti-suppression strips, brock strings, eye patches, a prism set and loose lenses.

“ …By the time you're about a year-and-a-half out, you will find yourself consistently busy,” she says.

With regard to scheduling NR patients, Dr. Kapoor suggests you start by setting aside a few hours one afternoon a week to book three-or-four patients just for rehab. “Set a deadline on when that slot should be filled, and if you don't have these patients by that deadline, you can still book a primary eyecare appointment,” she explains.

Garnering referrals

The other ways you can get patient referrals:

Schedule presentations. Dr. Kapoor recommends you contact rehab hospitals and centers in your area and conduct presentations on mTBI-associated visual issues. “I do six talks a year at various rehab hospitals and rehab centers,” she says.

“Any primary care optometrist can aid in the diagnosis of these patients… We just have to make a point of seeking these patients.
Dr. Peters

Get involved with a hospital. As part of a hospital staff, you're exposed to neuropsychologists and neurologists, occupational therapists, speech and language pathologists and pediatricians, making a hospital an important source for patient referrals, says Dr. Rummel. He is the director of the Neuro-Optometric and Rehabilitation and Visual Perception Clinic at the Bacharach Institute for Rehabilitation, in Pomona, N.J. To obtain a hospital consulting position, write a letter to your area's rehabilitation hospital's medical director and include literature supporting the O.D.'s role and your CV. Then, follow-up with a call to visit with these directors, Dr. Rummel says.

Send marketing materials to possible referral sources. Regularly send NR-related brochures from your office as well as articles to related professionals in your area, says Dr. Rummel.

A must

For Dr. Kapoor, evaluating mTBI patients is an obligation: “It doesn't matter if you're into rehabilitation or not. As part of your due diligence, just as you know how to diagnose glaucoma and age-related macular degeneration, it's equally important to identify and diagnose sensorimotor vision dysfunctions in mTBI patients,” she says. “And if you're not interested in incorporating the rehab component into your practice, refer.” OM

* Dr. Clopton is a keynote panel speaker at the Concussion Compliance National Symposium in Austin, Texas, March 1-3, 2013.
* Dr. Messner, Laura Balcer, M.D., prof. of neurology, University of Pennsylvania Perelman School of Medicine, and former WWE wrestler Chris Nowinski will present the CE course “Neuro-Ophthalmic Disorders Update on Traumatic Brain Injury” at the Optometric Management Symposium on Contemporary Eye Care, Nov. 30 to Dec. 2 at Disney's Contemporary Resort in Orlando. For more information, visit www.springervisionevents.com.

1. Centers for Disease Control and Prevention. Injury Prevention & Control: Traumatic Brain Injury. www.cdc.gov/TraumaticBrainInjury/index.html. (Accessed 8/24/12')



Optometric Management, Volume: 47 , Issue: September 2012, page(s): 42 - 47