“Veronica” has sustained not one, but two concussions. The first in September 2011, from hitting her head on a concrete ceiling when climbing out of a bunk bed, and the second, April 23, 2017, from falling backward onto a gravel road after losing her footing.
When she presented, she reported constant nausea, headaches, difficulty reading for longer than 30 minutes, occasionally losing her place when reading, poor reading comprehension, intermittent blurry vision during near work, occasional horizontal double vision, dizziness and difficulty with balance. (See: “Wrapping Your Head Around Concussion” in the online version of this article.)
Admittedly, this is a concussion case suited for neuro-optometrists. That said, it illustrates the fact that several of the most common symptoms of concussion involve vision. In fact, recent research suggests that more than 50% of patients with concussion have convergence, accommodative or eye movement disorders, causing symptoms, such as headaches or asthenopia, after short periods of near work, diplopia and blurred vision associated with near work and decreased reading speed and reading comprehension.
Something else to keep in mind: You, as a primary care optometrist, have the acumen to prescribe many of the solutions for the visual problems “Veronica,” among other less concussed patients, experience. After all, treating visual problems falls within your domain. With all this in mind, here, I provide the primary eye care practitioner’s guide to identifying and managing the visual issues associated with this mild traumatic brain injury and how “Veronica” is doing today.
1 GET A DETAILED ACCOUNT OF THE CAUSE
You want to find out:
- How much does the patient recall before and after the inciting event? Post-traumatic amnesia is common and may indicate a more serious injury.
- Was the patient unconscious and for how long? The same applies to loss of consciousness.
- What is the patient’s immediate symptoms and/or delayed symptoms? Delayed symptoms (more than seven days) may indicate secondary involvement from neurochemical inflammatory responses to the head trauma. These secondary symptoms may lead to post-concussion syndrome.
- What was the immediate treatment for symptoms, if any?
- When was the concussion diagnosed?
- What medications is the patient currently using? Sometimes, antidepressants and anti-anxiety medications are used in treating anxiety and depression in post-concussion patients. While these medications can be extremely useful, they also carry a slightly higher risk of inciting post-traumatic seizures.
- What are the patient’s current and past rehabilitation efforts, if any, and their results?
- Is the patient dizzy? (A lot of times, dizziness is the biggest indicator that the concussed patient is going to have long-term issues from the trauma.)
2 ENSURE PATIENT COMFORT
Make sure the post-concussion patient is comfortable, so you can get the most accurate data, which will help you determine the best treatment. To make the patient comfortable, minimize movements that surround them, keep the exam room’s illumination relatively dim (try to use incandescent, rather than fluorescent, lighting when possible), have the patient close their eyes in between tests, work slowly to allow for the patient to answer accurately, and shorten diagnostic testing when possible. Remember that all brain-injured patients have a limited cognitive and physical ability, so single lettering VA, for example, would be a good test to employ.
3 QUANTIFY PATIENT SYMPTOMS
Questionnaires, such as the COVD Quality of Life Survey (www.covd.org/page/QOLstart ), the Convergence Insufficiency Symptom Survey (https://bit.ly/2OhbfFi ) or the Brain Injury Vision Symptom Survey (https://noravisionrehab.org/uploads/media/brain_injury_vision_symptom_survey.pdf ) can be used to quantify patient symptoms. Components of the exam may also provoke certain symptoms and should be noted and quantified as well. It is helpful to document symptoms through surveys and during examination to provide a baseline guide to the patient’s recovery.
4 PRESCRIBE TREATMENT
The following are common visual findings associated with concussion and the treatments, many of which primary care O.D.s can prescribe, that work best. [If you are not comfortable prescribing one or more of these items, use the information to educate the patient on their visual symptoms, and then refer the patient to a neuro-optometrist. You can find such colleagues through The College of Optometrists in Vision Development (covd.org ) and the Neuro Optometric Rehabilitation Association (norarehab.org ).]
- Blur, asthenopia and headaches. Small prescriptions in hyperopia, myopia and astigmatism as little as 0.25D can be significant in reducing these symptoms. The magnitude of these are such that you would ordinarily not consider prescribing them, but they may be very helpful in post-concussion patients. Near vision prescriptions, usually in the form of low plus lenses, can be very helpful even in pre-presbyopic patients who have these findings.
- Basic exophoria, or esophoria, convergence excess, convergence insufficiency or hyperphoria. Small amounts of prism, as little as 1/2pd in these patients can be helpful in reducing symptoms. Depending on the specific clinical situation, these may be prescribed as ground in prism or Fresnel stick-on prisms. In cases of double vision, which you suspect to be transient, you would probably want to use a Fresnel prism. In cases where the prism is going to help with feelings of dizziness or visual motion sensitivity, you would probably want to use ground in prism.
- Photosensitivity. Prescribe polarized sunglasses or photochromatic lenses for photosensitivity. Avoid having these patients wear sunglasses constantly indoors. This potentially can make patients even more photophobic long-term, as their visual system is not forced to adapt to indoor lighting conditions. Instead, consider a blue or purplish tint for fluorescent lighting or blue-blocking lenses for computer use, phone screens, and other digital devices. Also, many phones allow you to set your screen to block blue light. (This Digital Trends article provides how-to steps: http://bit.ly/2NGXyeN .)
- Balance/dizziness. Avoid progressive addition lenses, and prescribe separate distance and near prescriptions to avoid exacerbation of dizziness and balance issues. These patients may be sensitive to even slight distortion that progressive lenses introduce in the periphery. Sometimes binasal occlusion strips applied to the lenses can be helpful in temporarily reducing these symptoms.
If a patient does not respond to primary care optometric intervention, it may be time to consider a referral to neuro-optometrist.
5 PRESCRIBE APPROPRIATE ACTIVITY CESSATION
You may be called on to give your opinion regarding return to sports, physical education class and school (return to learn). Here are guidelines:
- Return to sports. Remember you are to treat the visual symptoms and not necessarily give clearance. Also, don’t contradict the patient’s other doctors, who have been overseeing their healing.
- Return to physical education class. There are significant risks present in many gym class activities. Often, there can be contact games, such as dodge ball. Also, gym classes are often conducted in smaller spaces, they tend to be less structured and sometimes less supervised. Based on all this, I always advise students and parents that if there are any symptoms that weren’t present before the concussion, it’s a sign that the brain hasn’t fully healed.
- Return to learn. Not too many years ago, it was believed that if a student had a concussion they should sit home in a dark room and not do any activities for four to seven days. It was found that students who followed this protocol were actually out of school and had more symptoms than students who weren’t totally “shut down.” Current protocols have students out of school for a minimal number of days, dependent on the severity of the concussion. When they return, it is important that they receive temporary school accommodations to ease them back into the academic environment if concussion symptoms persist. This is an area in which optometrists are appropriately asked to give their input. Accommodations can be multi-varied and dependent on the individual student. For your part, you may be able to prescribe spectacles that keep symptoms at bay. Common accommodations for students returning to school during their concussion recovery include: having notes given to them (so that they don’t have to copy from the board to a paper), giving extended time on tests and assignments, starting with half time course load and slowly increasing, allowing the student to close their eyes and rest their head on their desk, having the student eat their lunch in a quiet place (e.g. library) and having students walk to the next class a few minutes early to avoid the noisy, visually stimulating hallways between class periods.
Testing revealed convergence insufficiency, accommodative insufficiency and infacility, oculomotor dysfunction, visual motion sensitivity (also known as visual-vertigo syndrome) and visual intake-visual memory deficits. As a result of these findings, the treatment plan for “Veronica” consisted of a spectacle prescription, OD Plano OS Plano-0.50x180, 20% purplish tint, to be worn inside, for computers and especially in fluorescent lighting; and vision rehabilitative therapy, consisting of a therapy plan Dr. Barry Tannen has written about previously. (See https://bit.ly/2BVoV2p .) Veronica completed 16 visits of therapy after which she reported feeling essentially completely normal. Most concussed patients will recover fully.
Let’s intervene to play a role in ensuring they do. Remember: You, as a primary care optometrist, can prescribe many of the solutions described above, or you can co-manage with a neuro-optometrist. OM
Special thanks to Amanda Nanasy, O.D., for reviewing this article.