Article: Vision and Reading Deficits in Post-Concussion Patients: A Retrospective Analysis

Abstract

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).

Full text

Vision Development & Rehabilitation Volume 1, Issue 3 • October 2015
206
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
ABSTRACT
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 btannenod@aol.com. 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 http://www.covd.org.
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
2015;1(3):206-13.
Keywords: accommodation, abnormal
binocular vision, concussion, mild
traumatic brain injury (mTBI), optometry,
reading deficits, reading rate, vergence,
version, vision deficits

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Vision Development & Rehabilitation Volume 1, Issue 3 • October 2015
INTRODUCTION
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
targets.7,8
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

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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.
METHODS
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
evaluation.
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)
NRA (D)
PRA (D)
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)

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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).
RESULTS
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
Occurence
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
56%
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
8%
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
76%
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)

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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.
DISCUSSION
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
NEVER
RARELY
SOMETIMES
USUALLY
ALWAYS
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
Disorientation
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
Headaches
Easily distracted
Decreased attention span
Reduced concentration ability
Difficulty remembering what has been read
Loss of balance
Poor handwriting
Poor posture
Dizziness
Poor coordination/eye hand coordination
Clumsiness
Table 5: Statistically significant findings compared with
Morgan’s normative values23 (p<0.05).
Test N Morgan’s
Normative Data
(mean value)
Present
Findings
(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
Level
Visagraph
Reading Rate
(grade level
equivalent)
Visagraph
Grade Level
Efficiency*
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-

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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

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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.

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TENURE-TRACK FACULTY POSITION AVAILABLE
pacificu.edu/optometry
EQUAL OPPORTUNITY EMPLOYER
PACIFIC UNIVERSITY COLLEGE OF OPTOMETRY
ARTS & SCIENCES | OPTOMETRY | EDUCATION | HEALTH PROFESSIONS | BUSINESS
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
citekk1@pacificu.edu
The review of applications will begin January 29, 2016 and continue until the position is filled.