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Vision Development & Rehabilitation Volume 2, Issue 4 • December 2016
ARTICLE
236
Optometric Management
of a Post-Concussion Patient:
A Case Report
Noah Tannen, OD
Pediatric and Vision Therapy
Resident, Salus University,
Philadelphia, Pennsylvania
Barry Tannen, OD, FCOVD
Eyecare Professionals, P.C. Hamilton
Township, New Jersey; SUNY/
College of Optometry, New York,
New York
Kenneth J. Ciuffreda, OD, PhD,
FCOVD-A
SUNY/College of Optometry, New
York, New York
Correspondence regarding this article should be emailed
to Barry Tannen, OD, at btannenod@aol.com. All state-
ments are the authors’ personal opinion and may not
reflect the opinions of the College of Optometrists in
Vision Development, Vision Development & Rehabili-
tation or any institu tion or organization to which the
authors may be affiliated. Permission to use reprints of
this article must be obtained from the editor. Copyright
2016 College of Optometrists in Vision Development.
VDR is indexed in the Directory of Open Access Journals.
Online access is available at www.covd.org.
Tannen NM, Tannen B, Ciuffreda KJ. Optometric manage-
ment of a post-concussion patient: a case report. Vision
Dev & Rehab 2016;2(4):236-41.
Keywords: concussion, mild traumatic
brain injury, optometry, photosensitivity,
therapeutic tint, vision,
vision rehabilitation, vision therapy
with low myopic astigmatism, convergence
insufficiency, fusional instability, oculomotor
dysfunction, and photosensitivity. Treatment
included tinted spectacle correction for full-
time wear and conventional oculomotor-
based vision therapy. At the cessation of the
vision therapy, as well as three years later,
he was effectively asymptomatic with normal
clinical findings. These results demonstrate
the efficacy of a comprehensive optometric
approach in concussion, with evidence
suggestive of considerable residual visual
system plasticity.
INTRODUCTION
The diagnosis and treatment of “concussion”,
a form of mild traumatic brain injury (mTBI), is
one of the relatively new frontiers in optometric
care1. It has been made more visible and
relevant due to the increased prevalence of
mTBI in our recent military encounters,2 as
well as its increased recognition in contact
sports, such as football.3 It is believed to have
two phases:4 first, the initial biomechanical
phase due to the rapid, coup-contrecoup
motion of the gelatinous brain within the rigid
cranium at the time of injury, thus resulting in
shearing, stretching, and twisting of the brain
and its delicate fibrous tracts (e.g., diffuse
axonal injury); and second, the biochemical/
physiological phase occurring days and weeks
later with the release of neurotoxins in a
cascade of events, thus resulting in neuronal
death and further disruption/distortion of
neural signal transmission.
The occurrence of a concussion may
produce a constellation of non-visual and visual
sequelae.4,5 The former may include general
headaches, dizziness, nausea, sleep difficulties,
hyperacusis, and cognitive problems, as well
as many others. Presence of any one or more
of the above can have their own independent
effects and adverse influences on the
patient and their overall well-being, as well
as interact with and negatively affect those
ABSTRACT
Over the past decade, there has been
increased emphasis on the diagnosis and
treatment of concussion, especially in the
military and in sports. In this case report, the
optometric management of a post-concussion,
young-adult is described. He was diagnosed
237
Vision Development & Rehabilitation Volume 2, Issue 4 • December 2016
at the second author’s private optometric
practice. He was referred by a medical
concussion specialist based on a detailed
case history, physical examination, and related
symptoms. At the time of presentation, he had
suffered six medically-documented sports-
related concussions, all involving hockey, over
the past six years, with the most recent one
occurring four months prior to the current vision
evaluation. The patient indicated that he had
fully recovered from the first five concussions.
His symptoms now included daily headaches, as
well as photosensitivity especially to fluorescent
illumination. He also experienced general
asthenopia, intermittent horizontal diplopia,
and loss of place while reading. Presence
of these phenomena caused difficulty with
reading in general, reading comprehension,
computer work, and completing class
assignments. In fact, these symptoms became
so severe that he was subsequently forced to
take a one semester leave of absence during
his junior year at college. We had performed
our vision evaluation in the summer between
his sophomore and junior year at college.
A summary of the relevant vision findings is
presented in Table 1.
problems dealing directly with vision and
visual information processing. These latter
may include oculomotor deficits (e.g., blur,
diplopia) and related reading problems (e.g.,
skipping lines of text, rereading lines of text),
photosensitivity, visual memory problems, and
subtle visual field defects (e.g., local reductions
in contrast perception), as well as many others.
In fact, it is estimated that 15% of individuals
having experienced a single concussion will
manifest some type of visual disturbance.6
Related to this, a retrospectively-based study
in an academic, clinical setting revealed
that 90% of visually-symptomatic (n=160),
acquired brain injury patients exhibited an
oculomotor-based problem of some type (e.g.,
accommodative insufficiency, convergence
insufficiency, intermittent strabismus).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.
A detailed case report of a young-adult
having sustained several sports-related
concussions is presented. Its unique aspects
are: the severity of the consequences follow-
ing these concussions; the
detailed and successfully
employed diagnostic pro-
tocol and therapeutic
program of combined
con ven tional optometric
vision therapy, spectacle
correction, and spectral
tint; and the long-term,
follow-up period.
CASE SUMMARY
The patient was a
20-year-old, male, col-
lege student who pre sent-
ed for a “visual efficiency
and visual information
processing” evaluation
Table 1. Summary of initial visual findings.
Test Vision Exam Result Normal Range Interpretation
Best corrected visual
acuity (Snellen)
OD 20/20
OS 20/20
20/20 Normal
Refractive Status
(dry manifest)
OD Plano-0.50x105
OS Plano-0.75x072
N/A OD Astigmatism
OS Astigmatism
Distance Phoria (von Graefe) Orthophoria 0-2 exophoria Normal
Near Phoria (von Graefe) 5 exophoria 0-6 exophoria Normal
Nearpoint of Convergence
(accommodative target)
6” break/10”recovery 1-3” break/3-5”
recovery
Convergence
Insufficiency
Near Convergence
Range (von Graefe)
X/10/6 17/21/11 Convergence
Insufficiency
Near Divergence
Range (von Graefe)
8/16/12 13/21/13 Fusional
Instability
Vergence Facility
(3pd BI/12pd BO)
10 cpm (fails BO) 15 cpm Convergence
Insufficiency
Accommodative
Facility (+/- 2.00D)
OD 12 cpm
OS 12 cpm
12 cpm Normal
Stereopsis (Wirt circles) 20 seconds 20 seconds Normal
Visagraph Reading Eye
Movement Test (Level 10)
5.0 grade level
efficiency
12.0 or greater
grade level
Oculomotor
Dysfunction
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Vision Development & Rehabilitation Volume 2, Issue 4 • December 2016
DIAGNOSES
There were multiple visual
diagnoses (Table 1). First,
despite his unaided visual
acuity of 20/20 in each eye,
he exhibited a low amount
of symptomatic, uncorrected,
astigmatism bilaterally based
on a non-cycloplegic refraction.
Second, he had a reduced
near point of convergence
(with repetition), as well as
reduced positive and negative
relative, horizontal, vergence
ranges at near. Third, based
on the Visagraph Reading Eye
Movement Test (level 10), his
grade-level efficiency placed him
at the fifth-grade level. Fourth,
he exhibited disequilibrium
(visual vertigo) when stimu lated
with a peripheral optokinetic
drum.9 And, lastly, he reported
photosensitivity, especially
with fluorescent illumination.
Based on these findings,
he was diagnosed with low
myopic astigmatism, convergence insufficiency,
fusional instability, oculomotor dysfunction, and
photosensitivity.
TREATMENT PLAN
The basic treatment plan was as follows.
He was prescribed a spectacle correction for
his astigmatism, as well as his subjectively-
preferred bluish-purple tint (BPI Omega)
to alleviate the photosensitivity. He was
also prescribed a regimen of conventional
optometric vision therapy. This included 2
sessions per week of in-office vision therapy (45
minutes each session) for 12 weeks. No home
vision therapy was performed during this time.
The goal was to improve accommodation,
vergence, and versional eye movements,
as well as higher-level visual processing
skills, selective and sustained attention (e.g.,
computerized visual scan and tachistoscope),
and visual-vestibular interaction (e.g., walking
with a hand-held stereoscope).
More specifically, the vision therapy was
divided into three phases, each with a specific
goal.10 See Table 2 for some of the primary
techniques incorporated during each phase of
vision therapy.
Phase 1: Visual Stabilization: Initial therapy
began with procedures to develop monocular
oculomotor and accommodative ability. The
therapy procedures also served to stabilize the
vergence system at both distance and near.
The eventual goal with these procedures was
to normalize positive and negative, relative,
horizontal vergence ranges, as well as the
accommodative amplitude and its dynamic
facility, without any fatigue effects.
Table 2. Examples of vision therapy techniques used in each phase of treatment.
Visual Stabilization Binocular Vision
Integration
Visual Automaticity
Brock string Brock string with prism
flippers, +/- lenses
Neuro-vision Rehabilitator
(NVR) with multi-
sensory integration
Pointer in straw Binocular accommodative
rock with red/
green bar reader
Phase 2 activities
incorporating VOR, balance
board, and metronome
Clown vectogram BOP/BIM with quoits/
clown double vectograms
Computer RDS Dynamic reader/
visual search and
scan with prism and
accommodative flippers
Monocular
accommodative rock
Aperture rule with
look away
Alternating BI and
BO Aperture Rule
Monocular near-far
Hart chart
RDS jump ductions
(near, intermediate,
distance projected)
MFBF tracking/scan Stereoscope cards
Red rock anti-
suppression technique
Red Rock with +/- lenses
Hart chart saccades
Michigan tracking
Michigan tracking with
+/- lenses, prism flippers
Michigan tracking with
+/- lenses, prism flippers,
and added metronome
Marsden ball
pursuit activities
Marsden Ball with split
pupil accommodative rock
Marsden Ball with
balance board
PTS II Visual
Search and Scan
With Red-Blue glasses Faster speeds, adding
to the number of stimuli
and distractors
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Vision Development & Rehabilitation Volume 2, Issue 4 • December 2016
Phase 2: Binocular Visual Integration:
Treatment emphasized binocular accommo-
dative and oculomotor tasks. The procedures
served to improve vergence speed and accuracy.
As these tasks were improved and refined, new
and more difficult tasks were added requiring
the patient to respond to non-congruent
(i.e., unequal) vergence and accommodative
demands,11 such as with BOP/BIM.
Phase 3: Visual Automaticity: This final
phase served to refine the visual skills as well as
to increase response automaticity. To achieve
this goal, multi-sensory integration across
modalities was incorporated. Such techniques
required integration of the vergence,
accommodative, vestibular, tactile, and
auditory systems, with the goal of increasing
the speed, accuracy, and automaticity of visual
and visuomotor responses.
OUTCOMES
The patient manifested a wide range of
vision improvements at the cessation of the
office-based vision therapy.
(Table 3). He exhibited
total reduction in his visual
symptoms, with full-time
wear of his tinted, spectacle
refractive correction. He no
longer experienced either
headaches or asthenopia
while reading; he was now
able to read and study
comfortably for longer
periods of time (i.e., 60
minutes versus 5 minutes).
His visual efficiency based
on the objective Visagraph
results improved from the
fifth to the twelfth grade-
level. There was a significant
reduction in photosensitivity
and disequilibrium as well.
Lastly, his near point of
convergence, horizontal ver-
g ence ranges, and dynamic
vergence flipper facility all normalized, and
most importantly, remained so at his three-
year follow-up vision examination.
DISCUSSION
The role of the optometrist as a key member
of the multi-disciplinary, rehabilitative team
is essential to improve the overall quality-of-
life in patients experiencing residual, post-
concussion visual symptoms. In the present case
report, this is exemplified by the combined use
of prescription lenses, tints, and conventional
vision therapy in a successful, multi-pronged,
optometric approach. Furthermore, there was
long-term persistence (3 years) of the initial
positive remediation effects, which to the best
of our knowledge is being reported for the
first time in the literature.
Many individuals with concussion/
mTBI exhibit increased sensitivity to small,
uncorrected refractive errors.4,12 Therefore, it
is essential to correct even modest amounts
of astigmatism, as done in the present case,
Table 3. Summary of visual findings pre-vision therapy, post- vision therapy, and 3
year’s post-vision therapy.
Test Pre-Vision
Therapy
Post-Vision
Therapy
3 years
Post-Vision
Therapy
Best corrected visual
acuity (Snellen)
OD 20/20
OS 20/20
OD 20/20
OS 20/20
OD 20/20
OS 20/20
Refractive Status
(dry manifest)
OD Plano-0.50x105
OS Plano-0.75x072
No change OD -0.25-0.50x100
OS -0.25-0.50x70
Distance Phoria
(von Graefe)
1pd exophoria 1 pd exophoria Orthophoria
Near Phoria (von Graefe) 5 pd exophoria 5 pd exophoria 7 pd exophoria
Nearpoint of
Convergence
(accommodative target)
6” break/
10”recovery
2” break/3”
recovery
2” break/3”
recovery
Near Convergence
Range (von Graefe)
X/10/6 X/30/18 18/30/26
Near Divergence
Range (von Graefe)
8/16/12 X/26/24 14/26/20
Vergence Facility
(3pd BI/12pd BO)
10 cpm (fails BO) 14 cpm 15 cpm
Accommodative
Facility (+/- 2.00)
OD 12 cpm
OS 12 cpm
OD 12 cpm
OS 12 cpm
OD 13 cpm
OS 14 cpm
Stereopsis (Wirt circles) 20 seconds 20 seconds 20 seconds
Visagraph Reading Eye
Movement Test (Level 10)
5.0 grade level
efficiency
12.0 grade
level efficiency
Not performed
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Vision Development & Rehabilitation Volume 2, Issue 4 • December 2016
as well as more generally for low amounts of
myopia, but especially for hyperopia. In the
latter case, due to the frequently manifested
reduced accommodative ability in this
population,13 the patient may no longer be
able to compensate fully and comfortably for
any uncorrected hyperopia. Moreover, use of
the full refractive correction provides increased
clarity of vision in those with impaired contrast
perception (e.g., reduced contrast sensitivity),
10
and furthermore it balances the interaction
between accommodation and vergence at
near,4 thus resulting in improved binocularity.
The use of a therapeutic tint is frequently
another critical component in the manage ment
of those patients reporting photosensitivity.1 2 ,14 ,1 5
More than 50% of concussion/mTBI patients
report the perceptual phenomenon of photo-
sensitivity persisting longer than six months
following their injury.14 ,15 In the author’s
practice, the bluish-purple, BPI-Omega
tint (www.colorlenses.com) has been found
to be particularly beneficial in reducing
photosensitivity, especially for the typically
problematic fluorescent illumination, as was
true for this patient. It has been speculated
that spectral filters function to reduce hyper-
excitability of the visual cortex,16 while both
spectral and non-spectral filters (e.g., grey
neutral density) may act to reduce the luminous
intensity of the offensive visual stimuli.1, 4,12
Additionally, standard brown and grey
polarized filters may also be helpful in reducing
photosensitivity and glare while outdoors,
especially in very bright sunlight or with highly-
reflective surfaces (e.g., a white concrete
surface, sandy beach). Recent evidence has
suggested that the least amount of tint density
that helps the patient should be prescribed to
promote possible long-term, visual adaptation
to this aberrant hypersensitivity (i.e. reduced
photosensitivity).15
Lastly, there is growing evidence, both from
the clinic4,17,18 and the research laboratory using
objective recording techniques,4,5 that vision
therapy serves to improves and even normalizes
oculomotor system responsivity,4 , 5 ,13 with
correlated reduction in visual symptoms,4, 5 ,13
improved reading ability,19, 20 and enhanced
visual attention21 in these patients. Within the
context of vision therapy, which embodies the
tenets of perceptual and motor learning22 and
Hebbian neural network principles,23 there is
a conventional, multi-phase approach typically
used,10 as described earlier. First, one stabilizes
the monocular aspects of oculomotor control
at distance and near. Second, one employs
both integration and mismatch of binocular
accommodative and vergence/versional, ocu-
lo motor aspects to increase the speed and
accuracy of the binocular response. Third,
one continues to practice the aforementioned
visual skills/abilities, so that they become
fully habituated with response automaticity/
reflexivity, in particular incorporating multi-
sensory modality tasks (i.e., vision, balance,
taction, and audition) with progressively higher
task demands (i.e., “task-loading”).
This case report serves to provide a useful
optometric-based, vision remediation protocol
and model.1,1 0,12 , 2 4 It also provides detailed,
quantitative, clinical evidence for the presence
of considerable visual system plasticity, even
in the damaged, young-adult brain. This is
consistent with several other recent reports
in this area in both younger and older adults
with concussion/mTBI.4,25 The visual sequelae
in the concussion patient can be reduced,
and even eliminated, following a careful
and comprehensive neuro-optometric vision
rehabilitative approach, so these individuals
can once again become independent and
productive members of our society.
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CORRESPONDING
AUTHOR BIOGRAPHY:
Barry Tannen, OD, FCOVD, FAAO
Hamilton Square, New Jersey
1978, Colgate University, Biology
1982, Pennsylvania College of Optometry
Private Practice, Hamilton Square,
New Jersey
Associate Clinical Professor,
SUNY College of Optometry
Program Supervisor, Vision Therapy and Neuro-Optometric
Rehabilitation Residency (Southern College of Optometry)
... This is a binocular visual search test and identification task, which assesses sequential saccadic tracking. 19 The subject was presented with seven rows of randomized letters of the alphabet. The task was to search for the 26 letters in alphabetical order in a left-to-right direction and to cross off each letter in turn. ...
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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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In our earlier published studies, oculomotor therapy (OMT) was performed in 15 individuals with mild traumatic brain injury (mTBI) and over 90% of the clinical oculomotor parameters abnormal at baseline significantly improved immediately following the OMT. There was no placebo (P) effect on any of the parameters. The purpose of the present pilot study was to assess the short-term persistence of the previously obtained positive OMT findings. Upon completion of the OMT, clinical oculomotor parameters were re-assessed at 3-month and 6-month periods. No subsequent training was performed during this 6-month period. Clinical measures were repeated in eight of the 15 subjects who subsequently completed both the 3-month and 6-month follow-up assessments. All measures were assessed using conventional clinical testing methods. Eight of the 13 (62%) clinical oculomotor parameters exhibited either persistence of, or delayed, improvement at the 3 and 6 month follow-up intervals. Findings demonstrate both the presence and persistence of oculomotor-based changes, suggestive of neural plasticity even in the adult, compromised brain. Further studies are warranted to confirm and extend the present pilot findings.
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Purpose: To quantify visual attention objectively using the visual-evoked potential (VEP) in those having mild traumatic brain injury (mTBI) with and without a self-reported attentional deficit. Research design and methods: Subjects were comprised of 16 adults with mTBI: 11 with an attentional deficit and five without. Three test conditions were used to assess the visual attentional state to quantify objectively the VEP alpha band attenuation ratio (AR) related to attention: (1) pattern VEP; (2) eyes-closed; and (3) eyes-closed number counting. The AR was calculated for both the individual and combined alpha frequencies (8-13 Hz). The objective results were compared to two subjective tests of visual and general attention (i.e. the VSAT and ASRS, respectively). Results: The AR for both the individual and combined alpha frequencies was found to be abnormal in those with mTBI having an attentional deficit. In contrast, the AR was normal in those with mTBI but without an attentional deficit. The AR correlated with the ASRS, but not with the VSAT, test scores. Conclusions: The objective and subjective tests were able to differentiate between those having mTBI with and without an attentional deficit. The proposed VEP protocol can be used in the clinic to detect and assess objectively and reliably a visual attentional deficit in the mTBI population.