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The prevalence of vision deficits in the pediatric/young adult concussion population in the private optometric practice setting remains unknown. Thus, a retrospective chart review in this area was conducted in the practice of the first author. Twenty-five consecutive patients with a medical diagnosis of concussion received a comprehensive vision and ocular health examination, which also included an objectively-based Visagraph reading assessment and clinical vergence/accommodative facility testing. Three primary categories of oculomotor-based deficits were found: convergence insufficiency (56%), accommodative insufficiency (76%), and oculomotor-based reading dysfunctions (68-82%). The most common symptom was headaches (84%), with 25% of the symptoms related to reading. 68% (15/22) were categorized as reading at least 2 grade levels below their current school grade level for reading eye movements based on the Visagraph findings. These overall findings are consistent with the general oculomotor-based/reading findings in the concussion/mTBI literature. The present results have important practical ramifications regarding the importance of pre-concussion baseline oculomotor and Visagraph testing, as well as post-concussion follow-up testing, to help assess a student's ability to return-to-learn (RTL).
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Vision Development & Rehabilitation Volume 1, Issue 3 • October 2015
Article: Vision and Reading Deficits in Post-Concussion Patients:
A Retrospective Analysis
Barry Tannen, OD, Private Practice, Hamilton Square, NJ and
SUNY College of Optometry, Vision Rehabilitation Service
Reagan Darner, OD, Salem VA Medical Center Optometry Service
Kenneth J Ciuffreda, OD, PhD, SUNY College of Optometry, Department of
Biological and Vision Sciences
Jack Shelley-Tremblay, PhD, University of South Alabama,
Department of Psychology
Jenna Rogers, OD, Resident in Vision Therapy and Neuro-Optometric
Rehabilitation, EyeCare Professionals, PC Hamilton Square, NJ
The prevalence of vision deficits in the
pediatric/young adult concussion population in
the private optometric practice setting remains
unknown. Thus, a retrospective chart review in
this area was conducted in the practice of the
first author. Twenty-five consecutive patients
with a medical diagnosis of concussion
received a comprehensive vision and ocular
health examination, which also included an objectively-based Visagraph reading assessment and
clinical vergence/accommodative facility testing. Three primary categories of oculomotor-based
deficits were found: convergence insufficiency (56%), accommodative insufficiency (76%),
and oculomotor-based reading dysfunctions
(68-82%). The most common symptom was
headaches (84%), with 25% of the symptoms
related to reading. 68% (15/22) were
categorized as reading at least 2 grade levels
below their current school grade level for
reading eye movements based on the Visagraph
findings. These overall findings are consistent
with the general oculomotor-based/reading
findings in the concussion/mTBI literature.
The present results have important practical
ramifications regarding the importance of pre-
concussion baseline oculomotor and Visagraph
testing, as well as post-concussion follow-up
testing, to help assess a student’s ability to
return-to-learn (RTL).
Correspondence regarding this article should be emailed
to Barry Tannen, OD, at All state-
ments are the author’s personal opinion and may not
reflect the opinions of the College of Optometrists in
Vision Development, Vision Development & Rehabilitation
or any institu tion or organization to which the author
may be affiliated. Permission to use reprints of this article
must be obtained from the editor. Copyright 2015 College
of Optometrists in Vision Development. VDR is indexed
in the Directory of Open Access Journals. Online access is
available at
Tannen B, Darner R, Ciuffreda K, Shelley-Tremblay J,
Rogers J. Vision and reading deficits in post-concussion
patients: A retrospective analysis. Vision Dev & Rehab
Keywords: accommodation, abnormal
binocular vision, concussion, mild
traumatic brain injury (mTBI), optometry,
reading deficits, reading rate, vergence,
version, vision deficits
Vision Development & Rehabilitation Volume 1, Issue 3 • October 2015
The topic of concussion/mild traumatic brain
injury (mTBI) has come to the forefront of the
clinical vision world due to the constellation of
visual problems/visual dysfunctions secondary to
sports-related concussions/head injuries,1,2 and
also the recent war efforts.3 Vision problems
are present in thousands of our soldiers and are
likely in a similarly large but unknown number
of athletes, especially in contact sports such as
football, boxing, and soccer. However, the most
common etiologies of a concussion are the result
of motor vehicle accidents, assaults, and falls.4,5
Together, they represent a relatively large and
important segment of patients examined by the
contemporary neuro-rehabilitative optometrist.
A concussion/mTBI results in a constellation
of general sensory, motor, perceptual, linguistic,
behavioral, cognitive, and psychological deficits.4,5
For example, an individual may report general
headaches/migraines, short-term memory prob-
lems, muscle stiffness and spasms, chronic
fatigue, and impulse control issues. More
specific to the present paper, they can manifest
a wide array of visual problems, such as blur,
intermittent diplopia, oculomotor-based reading
difficulties, and impaired visual memory, to name
a few.4-6 Presence of such visual deficits can have
an adverse impact on an individual’s vocational
and avocational goals, as well as negatively
affect the general rehabilitative process.7,8 For
example, impaired saccadic scanning and poor
visual discrimination skills can hinder progress in
cognitive rehabilitation-based visual search tasks
incorporating a complex array of finely-detailed
Over the past decade, there have been a
number of clinical studies focusing on the visual
deficits found in the concussed/mTBI patient in
hospital9,1 0 and academic11 -14 settings. In all cases,
the prevalence of visual deficits, in particular
those that are oculomotor based, has been well
documented. Deficits of the vergence (e.g.,
convergence insufficiency), accommodative
(e.g., accommodative insufficiency), and/or
versional (e.g., saccadic inaccuracy) systems,
with reading problems (e.g., skipping lines,
rereading) being the primary symptom both
in non-blast and blast-related concussion/
mTBI cases.15 These findings suggest generality
and pervasiveness of the traumatic event
and correlated visual problems. For example,
Ciuffreda et al.16 determined the frequency
of occurrence of oculomotor dysfunctions
encompassing vergence, accommodation,
version, strabismus, and cranial nerve palsy in
160 individuals with mTBI and reporting visual
symptoms. Vergence system abnormality was
the most common dysfunction: 56.3% of the
population had one or more vergence-related
abnormalities, with convergence insufficiency
being most common (42.5%). In addition,
51.3% of the population manifested one or
more versional dysfunctions, with saccadic
deficits (e.g., saccadic dysmetria) being the
most common anomaly. Among those who
were below 40 years of age (51 out of the 160
subjects), 41.1% exhibited an accommodative
dysfunction, with accommodative insufficiency
(AI) being the most common problem. Strabismus
in the form of constant/intermittent deviations
was present in 25.6% of the population.
In contrast, there has been a paucity of such
studies that are based on the findings in the
optometric clinical practice setting. To the best
of our knowledge, the only one similar in setting
to the current study was that of Hellerstein et
al,17 where adults (mean age 39 years) were
assessed in her optometric practice. They tested
16 individuals with medically-diagnosed mTBI
and compared them with 16 visually-normal,
age-matched control subjects. A battery of
clinical tests was performed with an emphasis
on those that were binocular/oculomotor in
nature. There were several significant differences
(p<0.05) in the binocular/oculomotor clinical
measures between the mTBI and control
groups. The following findings were abnormal
in the mTBI group: near point of convergence
break and recovery, base-in vergence break and
recovery at distance and near, base-out vergence
recovery at distance, near cover test, pursuit
Vision Development & Rehabilitation Volume 1, Issue 3 • October 2015
tracking, and stereopsis; vertical phoria at near
exhibited a trend (p=0.058). Furthermore, there
were several significant differences (p<0.05)
in symptoms between the two groups: blur,
diplopia, and reading problems were much
more frequent in the mTBI group. Hence, as
found in other non-practice-based settings as
described earlier, binocular/oculomotor clinical
signs and related symptoms are more prevalent
in the mTBI population.
The purpose of the present optometric,
clinical practice-based, record review was to
extend the study of Hellerstein et al17 in children
and young adults, with inclusion of objectively-
based Visagraph assessment of reading ability, as
well as dynamic facility assessment of vergence
and accommodation.
The clinical records of the consecutive patients
referred with a medical diagnosis of concussion
were reviewed from October 2011 through
October 2012. These were all patients who
were referred from physicians who specialized
in concussion management. Excluded from the
chart review were any patients with strabismus,
amblyopia, ocular disease, developmental
disabilities (such as autism spectrum disorder),
neurologic disease, or psychiatric disorders
which did not exist prior to the first concussion.
Twenty five patients met the criteria for
chart review. Two of these patients had a
prior diagnosis of reading disability; they were
included in the binocular/accommodative analy-
sis, but excluded from the Visagraph reading
eye movement analysis.
Patient’s ages ranged from 12 years to 31
years, with a mean of 17.1 years. There were 14
males and 11 females. Their last concussion was
diagnosed from 1-35 months prior to the vision
examination/consultation, with the average
time being 5.2 months from last concussion to
Table 1 presents a summary of the tests
performed on the concussion/mTBI patients.
Included were those used in the basic refractive
assessment,18 as well as those typically performed
in the specialty oculomotor/binocular-vision-
based evaluation.18 They were performed per
standard clinical guidelines/protocols.18 ,19 All
testing was conducted with the patient’s habitual
distance spectacle correction in place, unless
the new distance refraction indicated a change,
or a near prescription was deemed appropriate.
Some additional details include: distance and
near phorias were assessed using the alternate
cover test; the near point of convergence was
measured with both an accommodative (20/30
letter at near) and a non-accommodative target
(penlight)20 each taken three times, with the
most reduced value recorded; distance and
near horizontal vergence ranges; negative and
positive relative accommodation; and amplitude
of accommodation (minus lens technique); all
were assessed in the phoropter. Accommodative
facility was tested using +/-2.00D lens flippers,
whereas vergence facility was assessed using 12
base-out (BO)/3 base-in (BI) prism. Stereopsis
was assessed using a Randot Test. Lastly, the
Visagraph was used to assess reading eye
movement efficiency.21 Two paragraphs were
tested, with each being one grade level below
the independent reading level.22 Then, a third
Table 1: Visual tests included in analysis.
Symbols: pd=prism diopters, D=diopters, cm=centimeters,
and sec arc=seconds of arc
Clinical test
Near cover test (pd)
NPC break (cm)
NPC recovery (cm)
Monocular accommodative facility (cpm)
Minus lens amplitude of accommodation (D)
Near base in blur/break/recovery (pd)
Near base out blur/break/recovery (pd)
Distance base in break/recovery (pd)
Distance base out blur/break/recovery (pd)
Vergence facility (cpm)
Stereopsis (sec arc)
Visagraph (Reading rate and grade level efficiency)
Vision Development & Rehabilitation Volume 1, Issue 3 • October 2015
paragraph, 5 grade levels below the independent
reading level, was tested. This dual-level of
testing differentiated between a linguistic
versus oculomotor basis for the reading deficit.
Lastly, if the individual could not obtain a 70%
or better comprehension level on a given test
paragraph, the grade level was reduced further,
until they could attain this criterion. Due to the
fact that this was a chart review, some clinical
and Visagraph tests were missing. Hence, the
actual number tested is specified in the tables
out of a possible 25 patients.
Due to the number of variables assessed in
this study, the standard t-test analysis would
produce a greater potential for false positive
errors. Thus, to correct for this likely problem,
a more rigorous test/criterion was used, namely
the Holms method.23 Hence, effectively a
more stringent alpha level was calculated to
characterize each of the variables tested as
being ‘statistically significant’ (p<0.05).
The 3 primary oculomotor/binocular diag-
noses and their percentages are presented in
Table 2. These included vergence dysfunction
(64%), accommodative insufficiency (76%),
and oculomotor-based reading dysfunctions
(68% had reduced reading efficiency and 82%
had reduced reading speed). The diagnosis
of convergence excess was 8%. 92% of the
patients had more than one such diagnosis.
The primary symptoms are presented in
Table 3 in order of the frequency reported
out of the 25 patients. These were assessed
through case history and as reported on a
symptom questionnaire that is used in the
primary author’s private practice (Table 4).
Only symptoms that were checked off as
occurring “sometimes,” “usually”, or “always”
were reported in Table 3. The most frequent
symptom was headache (84%), whereas the
least reported symptoms were distance diplopia
and poor depth perception (8%). Four of the
16 symptoms (25%) related to reading at near
(skipping or loss of place, decreased reading
comprehension, decreased reading speed, and
words running together when reading.)
Table 5 presents the vision findings for the
mTBI group as compared to Morgan’s normative
data.24 There were several significant differences.
Eight out of the 13 clinical tests (62%) were
significantly different, i.e., abnormal when
Table 2: Vergence, accommodative, and reading deficits
by percent (%) occurrence
Diagnosis Percent
Convergence Insufficiency
Near point of convergence of 6 cm break and
- Reduced positive fusional convergence at
near (<20 pd or fails Sheard’s criterion) or
- Vergence facility (distance or near) 9
cpm with more difficulty with base-out1
Convergence Excess
3 pd esophoria at near and
- Reduced negative fusional convergence at
near (<8 pd or fails Sheard’s criterion) or
- Vergence facility at near 9 cpm
with difficulty with base-in1
Accommodative Insufficiency
Amplitude of accommodation 2 diopters
below mean for age (15-1/4 age) or
Monocular accommodative facility 6
cpm (difficulty with minus lenses)1
Reduced Reading Rate282%
Reduced Reading Efficiency268%
1. Adapted from Master et al10
2. Based on a Visagraph grade-level equivalent of 2 or
more grades below their actual grade level
Table 3: Primary symptoms in order of frequency reported.
Headache (21)
Light sensitivity (13)
Skip/lose place (13)
Blur (12)
Visual motion sensitivity (11)
Decreased reading comprehension (10)
Eyestrain (9)
Near diplopia (8)
Dizziness/nausea (7)
Decreased concentration (6)
Decreased balance (6)
Visual fatigue (5)
Decreased reading speed (4)
Words running together when reading (4)
Distance diplopia (2)
Poor depth perception (2)
Vision Development & Rehabilitation Volume 1, Issue 3 • October 2015
grade level was 10.1, whereas the measured
reading speed was grade level 5.
25 based on the
Visagraph norms, a 45% difference. Similarly,
reading grade-level efficiency was 6.0 based on
the Visagraph norms, a 40% difference. 68%
(15/22) had reading efficiency at least 2 grade
levels below their current school grade level,
and 82% (18/22) had reading speed at least
2 grade levels below their current school level,
based on the Visagraph findings.
The results of the present study have several
new and important clinical implications. It is the
first optometric, office-based study investigating
the prevalence of these three main oculomotor-
based visual diagnoses in the pediatric and
young-adult population, with all patients having
a medically-based diagnosis of concussion. It
Table 4: Symptom checklist used in the primary author’s
private practice for patients with a history of ABI.
Please consider each symptom and place a check in the box:
1 if never present, 2 rarely present, 3 sometimes present,
4 usually present, 5 always present
SYMPTOM 1 2 3 4 5
Difficulty moving or turning eyes
Pain with movement of the eyes
Pain in or around eyes
Wandering eye
Double vision
Blurred vision, distance viewing
Blurred vision, near viewing
Slow to shift focus from far to near
Difficulty taking notes
Pulling or tugging sensation around eyes
Face or head turn
Head tilt
Covering or closing one eye
Bothered by movement around you
Bothered by noises in environment
Light sensitivity
Discomfort while reading
Unable to sustain near work/
reading for adequate periods
General fatigue while reading
Loss of place while reading
Eyes get tired while reading
Easily distracted
Decreased attention span
Reduced concentration ability
Difficulty remembering what has been read
Loss of balance
Poor handwriting
Poor posture
Poor coordination/eye hand coordination
Table 5: Statistically significant findings compared with
Morgan’s normative values23 (p<0.05).
Test N Morgan’s
Normative Data
(mean value)
(mean value)
Near cover test (pd) 25 3 exophoria 6 exophoria
NPC break (cm) 24 5.00 12.81
NPC recovery (cm) 24 7.00 19.37
PRA (D) 21 - 2.37 -1.51
Distance BO recovery (pd) 20 10.00 5.90
Near BI recovery (pd) 25 13.00 10.72
Accommodative amplitude 21 10.53* 6.37
Vergence facility (cpm) 24 15.00** 10.42
* Expected mean accommodative amplitude
by age of patient (minus lens method)
** Vergence facility based on a norm of 15cycles/minute18
Symbols: pd =prism diopters, D=diopters, cm=centimeters
Table 6: Statistically significant (p<0.05) measures of
Visagraph recordings (n=22)
Actual Grade
Reading Rate
(grade level
Grade Level
Mean 10.1 5.6 6.0
Standard Deviation 1.8 3.8 4.0
*Grade level norms of relative efficiency.
(Relative efficiency= rate (wpm)/ fixations per
100 words + regressions per 100 words)21
compared to the normative data.
Table 6 compares two components of the
Visagraph-based findings, which were found to
be statistically different (p<0.05) than grade-level
normative data,25 namely reading rate and grade
level efficiency. The subject’s actual mean school-
Vision Development & Rehabilitation Volume 1, Issue 3 • October 2015
is also the first in this same population and
setting to have the objectively-based Visagraph
reading eye movement findings analyzed and
compared to grade level norms. The objective
reading test results revealed a high prevalence
of reduced reading speed and efficiency. It
has been reported26 that it is common to have
cognitive difficulties, such as learning new tasks
or remembering previously learned material,
after concussion. Add to this the possibility of
reduced reading speed and efficiency, and the
likelihood of successful return–to-learn (RTL)
becomes even more daunting. Furthermore,
the high prevalence of these visual problems
suggests the need for a comprehensive
optometric visual evaluation in post-concussion
patients. The results also indicate the need for
visual intervention to reduce their symptoms and
improve visual function. Treatment may include
lenses, prisms, tints, and partial occlusion, as well
as concurrent, longer term interventions, such
as vision therapy, which has been demonstrated
to be highly effective in the adult, concussion/
mTBI population.11-15, 27
The present results are consistent with a
recent hospital-based study of Master et al10
in the pediatric population (n=100; ages 11-
17 years, mean=14.5 years), with a diagnosis
of concussion ranging from less than one
month to more than three months after their
injury. Those of more recent-onset concussion
were more likely to manifest a visual diagnosis.
Overall, they found that nearly 70% of their
adolescent population had associated abnormal
oculomotor findings. In addition, there were
related visual diagnoses and symptoms, namely
convergence insufficiency (49%), accom moda-
tive insufficiency/infacility (51%), and saccadic
dysfunction (29%), which is similar in frequency
and diagnostic category to the present study.
Also, many had more than one of these three
clinical oculomotor diagnoses in both studies.
This is consistent with an earlier retrospective
investigation performed in a clinical, academic
setting in adults (n=160) with visual symptoms
and a diagnosis of mTBI.16 The present findings
are also similar to the only other optometric,
practice-based study, but again this was in an
adult concussion/mTBI population,
17 as described
earlier. Lastly, our results are in agreement with
a host of other studies in the adult population
with concussion/mTBI, both in clinical10,28 and
academic/laboratory11-15,29 settings, with patients
primarily being in the chronic phase of the brain
insult several months to years later. Thus, there
is evidence across a wide range of ages and test
settings for the high prevalence and persistence
of symptomatic oculomotor deficits, in the
concussion/mTBI population.
The Visagraph findings lend a new and
important dimension. Such objective testing of
reading ability/reading efficiency has never been
performed in a pediatric/young-adult, optometric,
clinic practice-based population having a
medically-based concussion diagnosis. Objective
findings are convincing in terms of determining/
demonstrating quantatively the effects of an
oculomotor-based visual dysfunction, such as
saccadic dysmetria/inaccuracy12,29 on such a
universal and naturalistic task, namely reading.
In those with the diagnosis of concussion/mTBI,
and persistent visual symptoms, oculomotor-
based “reading problems” are the most common
symptom.11-15, 28 One cannot function efficiently
in the modern world with such a debilitating
visual problem. Furthermore, presence of basic
oculomotor/visual scanning problems will have
an adverse impact on other forms of testing
and/or remediation, such as cognitive testing/
training incorporating visual scanning and/or
fine discrimination tasks.7,8
There were some potential limitations to the
present study. First, it was a retrospectively-based
and not a prospectively-based investigation.
Second, the sample size was relatively small.
Third, it was a skewed population; that is,
all patients came to a neuro-optometric
rehabilitative practice for a comprehensive vision
assessment, as they were all medically-diagnosed
as having a concussion with related visual
symptoms. Furthermore, they were specifically
referred to the first author’s private optometric
Vision Development & Rehabilitation Volume 1, Issue 3 • October 2015
1. May, K.H., Marshall, D.L., Burns, T.G., Popoli, D.M. and
Polikandriotis, J.A. Pediatric sports and specific return
to play guidelines following concussion. International
Journal of Sports Physical Therapy 9, 242-255, (2014).
2. Laker, S.R. Sports-related concussion. Current Pain and
Headache Reports 19, 510-513, (2015).
3. Warden, D. Military TBI during the Iraq and Afghanistan wars.
Journal of Head Trauma Rehabilitation 21, 398-402, (2006).
4. Suchoff, I.B., Ciuffreda, K.J. and Kapoor N. (editors).
Visual and Vestibular Consequences of Acquired Brain
Injury. Optometric Extension Program Foundation, Santa
Ana, CA, (2001).
5. Suter, P.S. and Harvey, L.H. (editors). Vision Rehabilitation,
CRC Press, Taylor and Francis Group, Boca Raton, FL, (2011).
6. Ciuffreda, K.J. and Ludlam, D.P. Conceptual model of
optometric vision care in mild traumatic brain injury.
Journal of Behavioral Optometry 22, 10-12, (2011).
7. Reding, M.J. and Potes, E. Rehabilitation outcome
following initial unilateral hemispheric stroke: life table
analysis. Stroke 19, 1354-1358, (1998).
8. Groswasser, W., Cohen, M. and Blankstein, E. Polytrauma
associated with traumatic brain injury: incidence, nature,
and impact on rehabilitation outcome. Brain Injury 4,
161-166, (1990).
9. Corwin, D.J. et al. Characteristics of prolonged concussion
recovery in a pediatric subspecialty referral population.
The Journal of Pediatrics 165, 1207-1215, (2014).
10. Master, C.L., Scheiman, M., Gallaway, M., Goodman, A.,
Robinson, R.L., Master, S.R., Grady, M.F. Vision diagnoses
are common after concussion in adolescents. Clinical
Pediatrics, in press.
11. Thiagarajan, P. and Ciuffreda, K.J. Effect of oculomotor
rehabilitation on accommodative responsivity in mild
traumatic brain injury. Journal of Rehabilitation Research
and Development 51, 175-191, (2014).
12. Thiagarajan, P. and Ciuffreda, K.J. Versional eye tracking in
mild traumatic brain injury (mTBI): effects of oculomotor
training (OMT). Brain Injury 28, 430-443, (2014).
13. Thiagarajan, P. and Ciuffreda, K.J. Effect of oculomotor
rehabilitation on vergence responsivity in mild traumatic
brain injury. Journal of Rehabilitation Research and
Development 50, 1223-1240, (2013).
14. Thiagarajan, P., Ciuffreda, K.J., Capo-Aponte, J.E., Ludlam,
D.P. and Kapoor, N. Oculomotor rehabilitation for reading
in mild traumatic brain injury (mTBI): an integrative
approach. NeuroRehabilitation 34, 129 -146, (2014).
15. Thiagarajan, P., Ciuffreda, K.J. and Ludlam, D.P. Vergence
dysfunction in mild traumatic brain injury (mTBI): a review.
Ophthalmic and Physiological Optics 31, 456-468, (2011).
16. Ciuffreda, K.J., Kapoor, N., Rutner, D., Suchoff, I.B., Han,
M.E. and Craig, S. Occurrence of oculomotor dysfunctions
in acquired brain injury; a retrospective analysis. Optometry
78, 155-161, (2007).
17. Hellerstein, L.F., Freed, S. and Maples, W.C. Vision profile
of patients with mild traumatic brain injury. Journal of the
American Optometric Association 66, 634-639, (1995).
18. Benjamin, W.J. (editor) Borish’s Clinical Refraction, 2nd
ed., Butterworth-Heinemann, Oxford (UK), (2006).
practice because of his experience in working
with this population. Lastly, an informative but
non-validated symptom survey was used, (Table
4) rather than a validated one, as there is no
validated symptom survey for concussion/mTBI
patients at this time.
There are some important directions for
future investigations. First, a more powerful
and larger prospectively-based study in
the optometric practice setting should be
conducted in the pediatric and young-adult
populations in those with medically-diagnosed
concussion/mTBI, especially for those active in
sports where return-to-play (RTP) is frequently
a key consideration,1 as well as educationally
for return-to-learn (RTL).26 Second, formal,
conventional reading tests, such as the Wide
Range Achievement Test (WRAT4),30 could be
incorporated in conjunction with the objectively-
based Visagraph reading testing, along with
the binocular/oculomotor clinical testing. Third,
the effect of vision therapy should be assessed
in this population. Recent retrospective and
prospective studies have demonstrated rapid,
efficacious, and positive results with oculomotor
therapy in the mTBI adult population.11-14,27,31,32
Larger clinical trials would be very helpful to
establish the most effective treatment protocols.
Lastly, some simple temporal processing tests
should be incorporated to assess more subtle
and demanding aspects of visual performance,
such as critical flicker frequency (CFF)33,34 and
coherent motion,35 in this vulnerable population.
In conclusion, there were several vision and
reading related deficits that were found in this
retrospective study of post-concussion patients.
Specifically, the accommodative and vergence
dysfunctions were in agreement with earlier
studies in academic/clinical centers, as well as
those conducted with military personnel. The
objective Visagraph recordings, which showed
reduction of reading speed and efficiency, are
new findings. Together, these findings can be
used to help develop visual guidelines to for RTL
in post-concussion school-aged children and
young adults.
Vision Development & Rehabilitation Volume 1, Issue 3 • October 2015
19. Scheiman, M. and Wick, B. Clinical Management of
Binocular Vision. Lippincott, 4th edition, Philadelphia,
20. Ciuffreda, K.J. Near point of convergence as a function
of target accommodative demand. Optical Journal and
Review of Optometry 111, 9-10, (1974).
21. Ciuffreda, M.A., Ciuffreda, K.J. and Santos, D. Visagraph
baseline analysis and procedural guidelines. Journal of
Behavioral Optometry 14, 60-68, (2003).
22. Tannen, B. and Ciuffreda, K.J. A proposed addition to
the standard protocol for the VisagraphTM eye movement
recording system. Journal of Behavioral Optometry 18,
143-147, (2007).
23. Abdi H. Holm’s sequential Bonferroni procedure. In:
Salkind, Neil (ed.) Encyclopedia of Research Design, Sage,
Thousand Oaks, CA, (2010).
24. Morgan, M.W. The clinical aspects of accommodation
and convergence. American Journal of Optometry and
the Archives of the American Academy of Optometry 21,
183-195, (1944).
25. Taylor, E.A. The Fundamental Reading Skill. Charles C.
Thomas, Springfield, IL, (1966).
26. Halstead M.E. et al. Returning to learning following a
concussion. Pediatrics 132, 948-957, (2013).
27. Ciuffreda, K.J., Han, Y. Kapoor, N. and Ficarra, A.P.
Oculomotor rehabilitation for reading in acquired brain
injury. NeuroRehabilitation 21, 9-21, (2006).
28. Craig, S. Kapoor, N., Ciuffreda, K.J., Suchoff, I.B., Han,
M.E. and Rutner, D. Profile of selected aspects of visually-
symptomatic individuals with acquired brain injury. Journal
of Behavioral Optometry 19, 7-10, (2008).
29. Ron, S. Najenson, T., Hary, D. and Pryworkin, W. Eye
movements in brain damaged patients. Scandinavian
Journal of Rehabilitation Medicine 10, 39-44, (1978).
30. Wilkinson, G. S., & Robertson, G. J. (2006). Wide Range
Achievement Test 4 Professional Manual. Lutz, FL:
Psychological Assessment Resources.
31. Ciuffreda, K.J., Suchoff, I.B., Marrone, M.A. and Ahmann,
E. Oculomotor rehabilitation in traumatic brain-injured
patients. Journal of Behavioral Optometry 7, 31-38,
32. Ciuffreda, K.J., Rutner, D., Kapoor, N., Suchoff, I.B.,
Craig, S. and Han, M.E. Vision therapy for oculomotor
dysfunctions in acquired brain injury: a retrospective
analysis. Optometry 79, 18-22, (2008).
33. Werner, H. and Thuma, B.D. Critical flicker frequency
in children with brain injury. The American Journal of
Psychology 55, 394-399, (1942).
34. Tannen, B., Desmond, A.M., Shelley-Tremblay, J., Ciuffreda,
K.J. and Larson, S.M. Correlation of magnocellular
function with measurements of reading in children. Vision
Development and Rehabilitation, 1,109-118, (2015).
35. Patel, R., Ciuffreda, K.J., Tannen, B. and Kapoor, N.
Elevated coherent motion thresholds in mild traumatic
brain injury. Optometry 82, 284-289, (2011).
Pacific University, a prestigious private institution that blends a College of Optometry, College of Health Professions, College of
Education, College of Business and a College of Arts & Sciences, is located in the Portland metropolitan area, one hour from the
Cascade Mountains and Pacific Ocean. Optometry and MS/PhD students enjoy a rich educational environment, learning full -scope
optometry with state-of-the-art educational, research and clinical technology.
Pacific University College of Optometry is seeking applicants for a tenure-track faculty position with emphasis in binocular vision,
pediatrics and vision therapy rehabilitation, and interest in research. Classroom, laboratory, and clinical assignments will reflect OD
and/or MS/PhD programmatic needs, as well as the successful candidate’s expertise and interests.
The successful candidate will have the OD degree and be eligible for licensure to practice optometry in the State of Oregon. Prefer-
ence will be given to applicants with an advanced degree, residency/fellowship training, and/or advanced professional develop-
ment. A commitment to excellence in optometric education, lifelong learning, and the expansion of knowledge through optometric
research is essential.
Candidates should submit a letter of application, a current, comprehensive curriculum vitae, and three references to:
Karl Citek, OD, PhD, FAAO
Chair of Search Committee
Pacific University College of Optometry
2043 College Way
Forest Grove, OR 97116
The review of applications will begin January 29, 2016 and continue until the position is filled.
... 9,12,[17][18][19] In recent years, there has been a significant increase in research examining the utility of oculomotor tests post-concussion. 10,[21][22][23][24]46,47 Although promising, the influence of premorbid oculomotor dysfunction on post-injury performance or the natural history of oculomotor function throughout clinical recovery is less well-understood. A recent systematic review found that few studies (20%) have assessed and reported oculomotor performance prior to injury. ...
... Performance on this test has been found to be highly correlated with reading efficiency (using infrared eye tracking methods), therefore appearing to be a logical oculomotor test to utilize as an indicator of reading efficiency, 38 an issue which is often reported post-concussion. 8,38,46 We observed the proportion of athletes with vergence infacility to be substantially higher than the percentage of athletes with convergence insufficiency. Given the natural link between near-distance visual system "flexibility" which is important in sports, vergence facility testing likely represents a more sensitive "litmus test" for rapidly identifying the presence of overall oculomotor dysfunction, and particularly when tested at distance. ...
... This is particularly relevant in the context of postconcussion evaluations, as clinical vision assessments have become more frequent due to the constellation of visual problems secondary to sports-related concussions. 46 It is largely assumed that post-injury oculomotor abnormalities are most likely directly due to the concussive insult. Although this may be true to some extent, given the high proportion of oculomotor and basic visual acuity issues among athletes in this study, pre-morbid oculomotor dysfunction must be controlled for as a variable. ...
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Background: Measures of oculomotor function are becoming more frequently employed as part of comprehensive concussion assessments. However, performances on many of these oculomotor measures have not been examined in a healthy athletic cohort. The purpose of this study was to characterize performance of university level athletes on a battery of oculomotor tests and identify any potential influence of gender and history of concussion. Methods: 259 healthy university level athletes (males, n = 150; females, n = 109) completed an oculomotor screening battery prior to the start of their competitive season. The battery assessed stereopsis, visual acuity, monocular amplitude of accommodation, near point of convergence, monocular and binocular accommodative facility, vergence facility, positive and negative fusional vergence, and saccades. Athletes also completed the Convergence Insufficiency Symptom Survey (CISS). Results: Three oculomotor tests (stereopsis, convergence, saccades) showed significant differences between male and female athletes at P<0.05, uncorrected. A high percentage of athletes were identified as having oculomotor deficiencies including abnormal acuity (34.2%), vergence infacility (28.6%), abnormal horizontal saccades (21.7%) and accommodative infacility (18.7%). Convergence insufficiency differed by method of assessment, ranging from 11.0-15.7%. Conclusion: A significant proportion of healthy athletes displayed abnormal performance across a variety of oculomotor indices. A history of lifetime concussion (i.e., greater than 12 months prior to study) did not significantly influence oculomotor test performance. Clinicians should be aware of such differences and potential implications associated with post concussion evaluations.
... Although mTBI is associated with more diffuse injury, affected regions could lead to impaired connectivity or brain activity. This may result in impaired saccadic programming, causing individuals to over-or undershoot fixation targets (e.g., Tannen et al., 2015;Thiagarajan, Ciuffreda & Ludlam, 2011;Wetzel et al., 2018). Increased saccades may indicate lower saccadic accuracy as the individual makes more saccades to shift the fovea to target objects (e.g., Williams et al., 1997). ...
Introduction Individuals who sustain a mild traumatic brain injury (mTBI) can suffer from executive function, working memory, and attention deficits, which can impact functional task performance, including reading comprehension. Individuals with mTBI commonly report reading difficulties, but such difficulties have been historically difficult to capture using behavioral measures. The current study examined reading performance in those with and without mTBI using eye-tracking measures, which may be more sensitive to reading impairment in mTBI. Method/Results In Experiment 1, 26 participants with a history of mTBI and 26 healthy control participants completed working memory (WM) and reading comprehension tasks. We found no differences in behavioral measures but found that spontaneous eye-blinking frequency was lower during the reading task in the mTBI group. In Experiment 2, we explored the impact of auditory distraction (e.g., multi-talker babble) on reading and memory performance. Twenty-three new participants with a history of mTBI and 26 healthy control participants completed a short-term memory (STM) task, a WM task, and a reading comprehension task under two distraction conditions. As in Experiment 1, we found no differences on behavioral measures, but observed significant differences on spontaneous eye-blinking frequency between those with and without mTBI. Group differences in distraction effects were also observed and performance on the WM task predicted reading comprehension performance. Conclusions The lack of differences on behavioral measures between groups, but lower frequencies of spontaneous eye blinking in the mTBI group suggests that while these individuals successfully completed the reading comprehension task, they may require more cognitive resources to do so.
... 7 This is supported by a more recent clinical practice, retrospective study in concussion patients. 8 Thus, vision care in this population, both of a diagnostic and therapeutic nature, is critical for a patient's recovery and reintegration into society as a productive individual. ...
... 7 This is supported by a more recent clinical practice, retrospective study in concussion patients. 8 Thus, vision care in this population, both of a diagnostic and therapeutic nature, is critical for a patient's recovery and reintegration into society as a productive individual. ...
The purpose of this chapter is to provide the main indications, background, and procedures when assessing eye movement function in the pediatric patient. The assessment of extraocular motility function includes version and ductions using the H pattern test in order to determine the presence of underaction or overactions of the extraocular muscles (EOM). EOM testing detects abnormalities in the structural and neurological integrity caused by an acquired or congenital disease of the central nervous system. Deficits in eye movement function can also contribute to poor academic performance which requires a developmental approach to the assessment of saccadic and pursuit eye movements to determine if a referral for optometric vision therapy is indicated. For the older child who is reading to learn, an assessment of reading eye movements using objective tests, such as the Visagraph and/or the ReadAlyzer, will guide the direction of the management plan.
The purpose of this study was to investigate how concussion history affects neurovascular coupling in Special Operations Forces (SOF) combat Soldiers. We studied 100 SOF combat Soldiers [age = 33.5 ± 4.3 years; height = 180.4 ± 6.0 cm; 55 (55.0%) with self-reported concussion history]. We employed transcranial Doppler (TCD) ultrasound to assess neurovascular coupling (NVC) via changes in posterior cerebral artery (PCA) velocity in response to a reading and a visual search task. Baseline TCD data were collected for 2 min. NVC was quantified by the percent change in overall PCA response curves. We employed linear mixed effect models using a linear spline with one knot to assess group differences in percent change observed in the PCA velocity response curves between SOF combat Soldiers with and without a concussion history. Baseline PCA velocity did not significantly differ (t98 = 1.28, p = 0.20) between those with and without concussion history. Relative PCA velocity response curves did not differ between those with and without a concussion history during the reading task (F1,98 = 0.80, p = 0.37) or the visual search task (F1,98 = 0.52, p = 0.47). When assessing only SOF combat Soldiers with a concussion history, differential response to task was significantly greater in those with 3 or more concussions (F1,4341 = 27.24, p < 0.0001) relative to those with 1-2 concussions. Despite no main effect of concussion history on neurovascular coupling response in SOF combat Soldiers, we observed a dose-response based on lifetime concussion incidence. While long-term neurophysiological effects associated with head impact and blast-related injury are currently unknown, assessing NVC response may provide further insight into cerebrovascular function and overall physiological health.
Neuro-optometric rehabilitation is a specialized field within optometry, involving the evaluation and management of visual sequela secondary to neurological events affecting and interfering with normal visual information processing. These sequelae adversely impact the patient’s ability to perform many activities of daily living (ADLs). The most common etiologies are mild traumatic brain injuries (mTBIs), such as concussion and cerebrovascular accidents (CVAs). However, systemic conditions with associated neurological consequences, such as vestibular dysfunctions, autoimmune diseases, and/or viral infections, can also adversely affect the visual system in ways other than visual clarity.
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Purpose: To assess the prevalence of esophoria at near in concussed patients in a neuro-optometric private practice setting. Methods: A retrospective analysis was performed involving a chart review in a neuro-optometric, private practice setting of consecutive patients with a medical diagnosis of concussion from January 1st 2016 to December 31st 2016. A total of 71 patients were included in the analysis. All received a comprehensive vision examination, with a near vision emphasis. The near horizontal phoria was assessed with the cover test and the von Graefe test. Results: Approximately 30% of the patients with a medically based diagnosis of concussion exhibited esophoria at near, with good agreement (95%) between the two tests. Mean esophoria was 5.2 (SD=2.8) prism diopters (pd), with a range from 2pd to 14pd of esophoria. Convergence excess was diagnosed in 23%. Discussion: Near esophoria was found in nearly one-third of this practice-based sample of concussed patients. Thus, it was more common than typically believed to be the case. Two proposed oculomotor-based mechanisms related to these symptomatic esophoric patients included phoria decompensation and excessive accommodative vergence.
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Accommodative dysfunction is a common oculomotor sequelae of mild traumatic brain injury (mTBI). This study evaluated a range of dynamic (objective) and static (subjective) measures of accommodation in 12 nonstrabismic individuals with mTBI and near vision-related symptoms before and after oculomotor training (OMT) and placebo (P) training (6 wk, two sessions per week, 3 h of training each). Following OMT, the dynamics of accommodation improved markedly. Clinically, there was a significant increase in the maximum accommodative amplitude both monocularly and binocularly. In addition, the near vision symptoms reduced along with improved visual attention. None of the measures were found to change significantly following P training. These results provide evidence for a significant positive effect of the accommodatively based OMT on accommodative responsivity. Such improvement is suggestive of oculomotor learning, demonstrating considerable residual brain-visual system plasticity in the adult compromised brain.
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Purpose: Children with reading disability frequently exhibit reduced sensitivity to motion, as assessed by coherent motion thresholds (CMT) and critical flicker frequency (CFF). A retrospective analysis was conducted to evaluate whether there was a correlation between reading fluency as measured by the Test of Silent Word Reading Fluency (TOSWRF), reading rate (as measured with the Visagraph II Eye Movement System), and pseudoword decoding (as measured with the pseudoword decoding subtest of the Wechsler Intelligence Achievement Test, WIAT-II), and these two visual motion sensitivity tests. Methods: 68 children between the ages of 7-16 years presented to the principal investigator's optometric practice for a vision therapy evaluation between June 1st 2010 and March 31st 2011. As part of the standard protocol for vision therapy evaluations, they were assessed using the CMT, CFF, TOSWRF, WIAT-II (pseudoword decoding subtest), and Visagraph II. The patients were divided into reading ability groups based on the published recommendations from the TOSWRF manual. Individuals at the 25% or below level were labeled as poor fluency, individuals in the 26th to 74th% level were labeled average fluency, and those in the 75% or higher level were labeled as good fluency.
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To determine the prevalence of vision diagnoses after concussion in adolescents. Cross-sectional study from July 1, 2013 to February 28, 2014, of patients aged 11 to 17 years with concussion evaluated in a comprehensive concussion program. A total of 100 adolescents were examined, with a mean age of 14.5 years. Overall, 69% had one or more of the following vision diagnoses: accommodative disorders (51%), convergence insufficiency (49%), and saccadic dysfunction (29%). In all, 46% of patients had more than one vision diagnosis. A high prevalence of vision diagnoses (accommodative, binocular convergence, and saccadic eye movement disorders) was found in this sample of adolescents with concussion, with some manifesting more than one vision diagnosis. These data indicate that a comprehensive visual examination may be helpful in the evaluation of a subset of adolescents with concussion. Academic accommodations for students with concussion returning to the classroom setting should account for these vision diagnoses. © The Author(s) 2015.
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Following a concussion, it is common for children and adolescents to experience difficulties in the school setting. Cognitive difficulties, such as learning new tasks or remembering previously learned material, may pose challenges in the classroom. The school environment may also increase symptoms with exposure to bright lights and screens or noisy cafeterias and hallways. Unfortunately, because most children and adolescents look physically normal after a concussion, school officials often fail to recognize the need for academic or environmental adjustments. Appropriate guidance and recommendations from the pediatrician may ease the transition back to the school environment and facilitate the recovery of the child or adolescent. This report serves to provide a better understanding of possible factors that may contribute to difficulties in a school environment after a concussion and serves as a framework for the medical home, the educational home, and the family home to guide the student to a successful and safe return to learning. Pediatrics 2013;132:948-957.
Now updated and expanded to cover the latest technologies, this full-color text on clinical refraction uses an easy-to-read format to give optometry students and practitioners all the important information they need. Also covers a wide range of other aspects of the eye exam, including anterior and posterior segment evaluations, contact lens, ocular pharmacology, and visual field analysis. Four new chapters cover wavefront-guided refraction, optical correction with refractive surgeries, prosthetic devices, and patients with ocular pathology. Offer precise, step-by-step how-to's for performing all of the most effective refractive techniques. Presents individualized refractive approaches for the full range of patients, including special patient populations. Contriubtors are internationally recognized, leading authorities in the field. New full-color design with full-color images throughout. Completely updated and expanded to include current technologies. A new chapter on Optical Correction with Refractive Surgeries, including keratoplasty, traditional refractive surgeries (e.g. LASIK and PRK), crystalline lens extraction with and without pseudophakia, the new presbyopic surgery, etc. A new chapter on Wavefront Guided Refraction provides information on the advantages and limitations the Hartmann-Shack Method for objective refraction plus aberrometry and the refraction and the use of in the correction of the eye with spectacles, contact lenses, and refractive surgery. A new chapter on Patients with Ocular Pathology reflects the most current knowledge of patients with ocular pathologies. Provides information on Optical Correction with Prosthetic Devices, including corneal onlays, stromal implants, phakic intraocular lenses, etc. Includes new chapters and/or discussions on such topics as: Aberrations of the Eye, Refractive Consequences of Eye Pathology, Diagnosis and Treatment of Dry Eye, Diagnosis of Pathology of the Anterior Segment, Diagnosis of Glaucoma, and Diagnosis of Pathology of the Posterior Segment. Visual Acuity chapter expanded to include the effect of refractive error on visual acuity and statistics on how much of a change in visual acuity is significant. Objective Refraction, Corneal Topography, and Visual Field Analysis chapters include the addition of new electro-optical and computer techniques and equipment. Chapters on Multifocal Spectacle Lenses and Contact Lenses now cover newer progressive addition lenses and contact lenses that are now on the market. Electrodiagnosis chapter revised to take a more clinical approach.
Sports-related concussions (SRC) are common in all ages and occur in all sports. The diagnosis based on clinical suspicion after more serious injury is ruled out. Symptoms of concussion are due to a temporary and reversible neurometabolic cascade resulting in blood flow changes, neuronal excitotoxicity, ionic shifts, and mitochondrial changes. Symptoms are nonspecific, and commonly include headache, cognitive complaints, photophobia, and phonophobia. Loss of consciousness is rare in SRC and has limited influence on recovery and prognosis. Imaging has a limited role in the management of concussion and should be used to evaluate for more serious intracranial pathology. Treatment is based on symptoms and an understanding of the typical, rapid (7-10 days) recovery. No athlete should return to play until their symptoms have resolved and they have completed a supervised, step-wise return to play protocol. The article covers the most recent literature on the diagnosis and management of SRC, including evidence-based recommendations and expert-based consensus opinion. The article will also discuss issues regarding medical retirement, legislation, and future concepts in concussion diagnosis and management.