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Concussion–AnEvidence-BasedApproachtoOptometricManagement
JacquelineTheis,OD,FAAOOptoWest
FinancialDisclosures
-C.LightTechnologies• ClinicalResearchConsultant,NIHSBIR
ObjecOves• GiveabriefoverviewoftheevoluOonofthecurrentdefiniOonandpathophysiologyofconcussion
• Discusscurrentparadigms(orlackthereof)forvisionscreeningaXerconcussionbynon-optometricproviders
• GothroughthemostcommonvisualsignsandsymptomsseenaXeraconcussionandtheirOmelinesforresoluOon(acutevs.chronic–PCS)– AfferentVisualPathway(OcularHealth,ColorVision,VisualFields,Pupils,RefracOveError)
– EfferentVisualPathway(OcularmoOlity)– HigherOrderPathways(Visualprocessing)
• Current/Futureroleforvisioninconcussion
GlasgowComaScale(GCS)● MotorResponse
○ (4)WithdrawsfromnoxioussOmuli○ (1)NoResponse○ (2)ExtensorResponse○ (3)AbnormalFlexion○ (5)LocalizestonoxioussOmuli○ (6)Obeyscommandsfully
● VerbalResponse○ (1)Nosounds○ (2)IncomprehensibleSounds○ (3)Inappropriatewordsandjumbledphrases
○ (4)Confused,yetcoherentspeech○ (5)Alertandoriented
● EyeOpening○ (1)Noeyeopening○ (2)Eyesopentopain○ (3)Eyesopentospeech○ (4)Spontaneouseyeopening
• LevelofTBI– Mild(13-15)
• +/-lossofconsciousness<30min• Normalneuroimaging
– Moderate(9-12)• Lossofconsciousness>30min,<24hrs• Normal/abnormalneuroimaging
– Severe(3-8)• Coma• Normal/abnormalneuroimaging
– VegetaOve(<3)
TeasdaleG,JennehB.AssessmentofComaandImpairedConsciousness:ApracOcalscale.Lancet304,81-84.VossJ,ConnollyJ,SchwabK,ScherA.Updateontheepidemiologyofconcussion/mildtraumaOcbraininjury.CurrPainHeadacheReports.2015;19(7):32.
Concussion-Controversyovera“DefiniOon”
● McCroryP,MeeuwisseWH,AubryMetal.Consensusstatementonconcussioninsport:the4thInternaOonalConferenceonConcussioninSportheldinZurich,November2012.BrJSportsMed2013;47:250-8.
● HarmonKG,DreznerJA,GammonsM,etal.AmericanMedicalSocietyforSportsMedicineposiOonstatement:concussioninsport.BrJSportMed2013;47:15-26.
● KimparaH,IwamotoM.MildtraumaOcbraininjurypredictorsbasedonangularacceleraOonsduringimpacts.AnnBiomedEng2012;40:114-26.
● ZhangL,YangK,KingA.AproposedinjurythresholdformildtraumaOcbraininjury.JBiomechEng2004;126:226-36.● PReilly,RBullock.HeadInjury2ed:PathophysiologyandManagement,CRCPress2005TaylorandFrancis,Florida
TypeofmildtraumaOcbraininjury
ExternalforceorsuddenmovementcausesrapidacceleraOon/deceleraOonofthebrainOssuewithintheskull
Internallinear,translaOonal,androtaOonalforcesleadstoacomplexpathophysiologicalprocess
ResultsinafuncOonaldisturbanceinbrainfuncOon
Anever-changingdefiniOon• +/-Lossofconsciousness• +/-Directblowtothehead• Rapidonsetofshort-livedimpairmentofneurologicalfuncOonthatresolvesspontaneously– HOWEVER,signsandsymptomsmayevolveoverminutestohoursinsomecases
• AcuteclinicalsignsandsymptomslargelyreflectafuncOonaldisturbanceratherthanastructuralinjury– HOWEVER,itmayresultinneuropathologicalchanges
• ResoluOonofclinicalfeaturestypicallyfollowsasequenOalcourse– HOWEVER,insomecasesitmaybeprolonged
McCroryP,MeeuwisseW,DvorakJetal.Consensusstatementonconcussioninsport–the5thinternaOonalconferenceonconcussioninsportheldinBerlin,October2016.BrJSportsMed.2017;0:1010.
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TraumaOcBrainInjury-Pathophysiology
• PrimarytraumaOcbraindamage– Mechanicalforces→OssuedeformaOonATthemomentofinjury– Directdamagetobloodvessels,axons,neurons,glia,etc– Diffuseaxonalinjury(DAI)/vascularinjury(DVI)– FocalInjury
• Vascular(intracerebral,subdural,extradural,subarachnoidinjury)• Axonalinjury• Contusion• LaceraOon
• SecondarytraumaOcbraindamage– ComplicaOonofprimarydamage– Ischemicandhypoxicdamage,cerebralswelling,increasedintracranialpressure,infecOon,etc
ReillyP,BullockR.HeadInjury2ed:PathophysiologyandManagement,CRCPress2005TaylorandFrancis,Florida
Imagefrom:LienJ.PediatricConcussionandothertraumaOcbraininjuries.Medscape.com.AccessedApril15,2017.hhp://reference.medscape.com/features/slideshow/pediatric-concussion
TEAMApproachtoConcussion-2015• Mul$disciplinaryAssessment
– ReviewmechanismofInjury– Relevantmedicalhistory– SymptomChecklist– NeurocogniOveScreening/Neuropsychological
EvaluaOon– BalanceAssessment– VesObularScreening/ExaminaOon– OculomotorFuncOonScreening/ExaminaOon– NeurologicalEvaluaOon– CervicalSpineEvaluaOon– PsychologicalEvaluaOon– Neuroimagingprn
CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaOonandAcOveManagement(TEAM)ApproachestoTreaOngConcussionMeeOngHeldinPihsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.
PediatricConcussion-Whatwedoknow-
• ChildrenandadolescentshavelongerrecoveryOmesthanadults
• ExpectedduraOonofsymptomsassociatedwithsports-relatedconcussion<4weeks
• ProlongedrecoveryisdefinedassymptomaOcfor>4weeks
• MechanismforlongerrecoveryOmeisunknown– Proposedtobeduetodifferencesinresponsetoexcitotoxicinjurybydevelopingadolescentbrain
• DavisGA,AndersonV,BablFE,GioiaGA,GizaCC,etal.Whatisthedifferenceinconcussionmanagementinchildrenascomparedwithadults?AsystemaOcreview.BrJSportsMed2017;51:949-957.
• GradyM.Concussionintheadolescentathlete.CurrProblPediatrAdolescHealthCare.2010;40:154-169• EisenbergMA,MeehanWP,MannixR.DuraOonandcourseofpost-concussivesymptoms.Pediatrics.2014;133(6):999-1006• McDonaldJW,JohnstonMV.Physiologicalandpathophysiologicalrolesofexcitatoryaminoacidsduringcentralnervoussystem
development.BrainResRev.1990;15:41-70
PediatricConcussion–Whatwedon’tknow-
• Minimalclinicaltrialsinpediatricconcussion• Literaturedoesnotaddresshowtomanagedifferentagegroupsofchildrendifferentlyfromadults
EpidemiologyofConcussion• CDC2010-2.5millionpeoplewenttoERforTBIbasedonICD9data
– 75%mTBI– UnderesOmatesinceonlyincludes
thosewhopresentedtotheERandhadarelevantdiagnosOccode(Voss)
• PediatricpopulaOon– 173,285<19yononfatalconcussion
annually2001-2009– Increasefrom153,375to248,418
• Mostcommonmechanism–Falls• HighRiskPopulaOons
– Military– Athletes
• 1.6-3.8millionSRCsannually• 5.8%ofallcollegiateinjuries,
8.9%ofhighschoolinjuries
www.cdc.gov/traumaOcbraininjuryGesselLM,FieldsSK,CollinsCL,DickRW,ComstockRD.ConcussionsamongUnitedStateshighschoolandcollegiateathletes.JAthlTrain2007;42:495-503
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Epidemiology• USCentersforDiseaseControlandPrevenOon
– 173,285childrenandadolescents<19yearsoldtreatedforanonfatalrecreaOonandsport-relatedconcussioninERsannuallyfrom2001-2009
– Increasefrom153,375(2001)to248,418(2009)• 4millionchildrenpresentwithconcussiontoemergencyroomsannuallyworldwide– EsOmatedtorepresentonly12%ofchildrenwithconcussion– EsOmatedthat33millionchildrensustainaconcussionworldwide
• CentersforDiseaseControlandPrevenOon.NonfataltraumaOcbraininjuriesrelatedtosportsandrecreaOonacOviOesamongpersonsaged≤19years—UnitedStates,2001–2009.MMWR.2011;60(39):1337-1342
• PedenMMU.WorldHealthOrganizaOon.WorldreportonchildinjuryprevenOon.Geneva,SwitzerlandNewYork,NY:UNICEF,2008.
• CroweL,BablF,AndersonV,etal.Theepidemiologyofpaediatricheadinjuries:datafromareferralcentreinVictoria,Australia.JPaediatrChildHealth2009;45:346–50.
• LyhleMD,CroweL,OakleyE,etal.ComparingCATCH,CHALICEandPECARNclinicaldecisionrulesforpaediatricheadinjuries.EmergMedJ2012;29:785–94.
• ArbogastKB,CurryAE,PfeifferMR,etal.Pointofhealthcareentryforyouthwithconcussionwithinalargepediatriccarenetwork.JAMAPediatr2016;170:e160294.
CommonDiagnosOc/ScreeningTestsforConcussion
• Self-reportSymptomChecklists• BriefcogniOveassessment
– StandardizedAssessmentofConcussion(SAC)– SportConcussionAssessmentTool5(ChildSCAT5)
• Balance/GaitTests– TandemGaitTest(TGT)– BalanceErrorSymptomScore(BESS)
• ComputerBasedNeuropsychologicalTests– ImPACT– CogSport– Headminder
• OculomotorSidelineScreener– King-Devick
LimitaOons/DifficulOesinConcussionDiagnosisandManagement
• SubjecOvenatureofdiagnosis– SymptomScales– IntenOonallowbaselinescores
• Incompleteunderstandingofpathophysiology
• Lackofdata• Variabilityamongphysicians
• NostructuralinjuryonconvenOonalneuroimaging
• AdvancedneuroimagingcanshowfuncOonal/structuraldamageBUT$$andnotreadilyavailable
• Under/overreporOngofsymptoms
• Under/overdiagnosis• EvolvingdefiniOon
• McCroryP,MeeuwisseWH,DvorakJetal.Consensusstatementonconcussioninsport:the5thInternaOonalConferenceonConcussioninSportheldinBerlin,October2016.BrJSportsMed2017;51:838-847.
• HarmonKG,DreznerJA,GammonsM,etal.AmericanMedicalSocietyforSportsMedicineposiOonstatement:concussioninsport.BrJSportMed2013;47:15-26.
• KimparaH,IwamotoM.MildtraumaOcbraininjurypredictorsbasedonangularacceleraOonsduringimpacts.AnnBiomedEng2012;40:114-26.
• ZhangL,YangK,KingA.AproposedinjurythresholdformildtraumaOcbraininjury.JBiomechEng2004;126:226-36.• ReillyP,BullockR.HeadInjury2ed:PathophysiologyandManagement,CRCPress2005TaylorandFrancis,Florida
Whydoesdiagnosismaher?
hhp://www.bu.edu/cte/about/what-is-cte/
ChronicTraumaOcEncephalopathyRoleofEyesinConcussionDiagnosis
andManagement:
1)ObjecCvebiomarkerforbraindysfuncCon
2)Treatmentofconcussion
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VisualPathwaysintheBrain
Post-ConcussiveVisualSignsandSymptoms
• CurrentlyScreened– DoubleVision– BlurredVision– LightSensiOvity
• InAddiOon/Actuality– ReadingDifficulOes– Eyestrain/FaOgue– Eyefocusingproblems– EyeTrackingProblems– Vision-DerivedNausea– VisualInahenOon– VisualAnxiety/Crowding
LaukkanenH,ScheimanM,HayesJR.Braininjuryvisionsymptomsurvey(BIVSS)quesOonnaire.OptomVisSci.2016;94(1):43-50.
AfferentVisualPathway
Imagefrom-HannulaDe,SimonsDJ,CohenNJ.ImagingimplicitpercepOon:promiseandpizalls.NatureRevNeurosci.2005;6:247-255/
AfferentVisualPathway–CNII
BarnehBP,SingmanEL.VisionconcernsaXermildtraumaOcbraininjury.CurrTreatOpConsNeurol.2015;17:5(1-14).
Post-ConcussionVisualSigns
OcularHealth• TraumaOcIriOs• TraumaOcOpOcNeuropathy• ReOnalchanges• CommoOoReOnae• ReOnalTear/Detachment
PupilFindings• Afferent
– IncreasedaverageconstricOonlatency
• Efferent– ParasympatheOc
• SloweraverageconstricOonvelocity
– SympatheOc• Decreasedpupillarydiameter• SlowerpeakdilaOonvelocity
• Anisocoria?
ThiagarajanP,CiuffredaK.Pupillaryresponsestolightinchronicnon-blast-inducedmTBI.BrainInjury.2015;29(12):1420-1425
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Photophobia-LightSensiOvity
E$ology??–Photophobiapathway?
• OcularPhotophobia– IriOs
• Flashlighttest• Asymmetric
– Pupilproblems– DryEye
• NeurologicalPhotophobia– TBI– Migraines
• Pharmacologic
Management• SunglassesoutsideOKAY• Sunglassesinside–TRYTOAVOID
– WearingdarkglassesindoorsàdarkadaptaOonofthereOnaàaggravaOonoflightsensiOvity
• Visors/Hats• MildTints
– Wavelengthmahers
KatzBJ,DigreKB.Diagnosis,pathophysiology,andtreatmentofphotophobia.SurvOphth.2016;61:466-477
VisualSignsitmaybeMOREthanaConcussion
• Pupils– Dilated/Fixed– APD– Anisocoria
• ReducedBCVA• VisualFieldDefects• CranialNervePalsy• OcularHealthProblem
– OpOcnerveedema,pallor,etc
EfferentVisualPathwayCNIII,IV,VI,ParasympatheOc,SympatheOc
-EyeMovements
Imagefromhhp://what-when-how.com/neuroscience/the-cranial-nerves-organizaOon-of-the-central-nervous-system-part-4/
VesObulo-oculardysfuncOoninpediatricsport-relatedconcussion(SRC)
• RetrospecOvereviewofallpaOentswithacuteSRC(presenOng30daysorlesspostinjury)andPCS(3ormoresymptomsforatleast1month)referredtoamulOdisciplinarypediatricconcussionprogramfrom9/2013-7/2014
• Methods-ClinicalHx,Physical,PCSS,VOD– VODComplaint(dizziness,blurredvision,etc)+Sign(Abnormal
pursuits,saccades,VOR)• Results-n=101,age14.2+/-2.3years,76.2%withacuteSRC(n=77)and
23.8%withPCS(n=24)– MeanduraOonofSxwas40daysforptsw/acuteSRCandVODvs.21
daysforacuteSRCwithoutVOD.• Conclusions:EvidenceofVODinacuteSRCandPCS.
– VODwasasignificantriskfactorfordevelopmentofPCS
EllisMJ,CordingleyD,VisS,ReimerK,LeiterJ,RussellK.VesObulo-oculardysfuncOoninpediatricsports-relatedconcussion.JNeurosurgPediatr2015:16:248-255
WhatDeterminesConcussionResoluOon?
• BalanceRecovery<7days• SymptomScores5-14days• CogniOveRecovery7-21days• OculomotorRecovery21-28days
OtherFactors
LiOgaOonWorker’sCompensaOonIndividualMoOvaOon(Athlete,Military)AgeGenderConcussionHistoryPremorbidFactorsInjurySeverityType/TimingofTreatment
CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaOonandAcOveManagement(TEAM)ApproachestoTreaOngConcussionMeeOngHeldinPihsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.
RoleofEyesinConcussionDiagnosis:VOMS(VesCbular/OcularMotorScreening)
AssessmentVesCbular/OcularDomainsAssessed
1. SmoothPursuit2. HorizontalandVerOcalSaccades3. Convergence4. HorizontalandVerOcalVOR5. VisualMoOonSensiOvity
• 61%ofadolescentconcussedathletesreportedsymptomprovocaOonaXeratleast1VOMSitem
• AllVOMSitemswereposiOvelycorrelatedtothePCSS(PostConcussionSymptomScale)totalsymptomscore
• VOMSwasnearly90%accurateinidenOfyingpaOentswithconcussionfromcontrols
MuchaA,CollinsMW,ElbinRJ,etal.AbriefvesObular/ocularmotorscreening(VOMS)assessmenttoevaluateconcussions:preliminaryfindings.AmJSportsMed2014;42:2479-86.
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VOMSConOnued…• WomenhavehigherVOMSscoresthenmales(Sufrinko2017)• SymptomprovocaOon/clinicalabnormalityassociatedwithalldomains(except
convergenceandaccommodaOon)candelayrecoveryOmeaXerSRCinyouthandadolescents(Anzalone2017)
• VOMSdoesNOTprovokevesObularsymptomsinhealthyadolescents(Yorke2017)• VOMSmeasuresuniqueaspectsofvesObular-ocularfuncOonotherthanthose
measuredintheBESS(BalanceErrorScoringSystem)orKD(King-DevickTest)withgoodreliability(Yorke2017)
• Incollegiateathletes,VOMShadahighinternalconsistencywithan11%false-posiOverateatbaseline–mostlyfemaleorhistoryofmoOonsickness(Kontos2016).
AnzaloneAJ,BlueihD,CaseT,McGuffinT,PollardK,GarrisonJC,JonesMT,PavurR,TurnerS,OliverJM.AposiOveVesObular/OcularMotorScreening(VOMS)isassociatedwithincreasedrecovertyOmeaXersports-relatedconcussioninyouthandadolescentathletes.AJSM2017;45(2)474-479KontosAP,SufrinjoA,ElbinRJ,PuskarA,CollinsMW.ReliabilityandassociatedriskfactorsforperformanceontheVesObular/OcularMotorScreening(VOMS)toolinhealthycollegiateathletes.AJSM2016;44(6):1400-1406SufrinkoAM,MuchaA,CovassinT,Marche~G,ElbinRJ,CollinsMW,KontosAP.SexdifferencesinvesObular/ocularandneurocogniOveoutcomesaXersport-relatedconcussion.ClinJSportMed2017;27:133-138.YorkeAM,SmithL,BabcockM,AlsalaheenB.ValidityandreliabilityoftheVesObular/OcularMotorScreeningandassociaOonswithcommonconcussionscreeningtools.SportsHealth.2017;9(2):174-180.
YorkeAM,SmithL,BabcockM,AlsalaheenB.ValidityandreliabilityoftheVesObular/OcularMotorScreeningandassociaOonswithcommonconcussionscreeningtools.SportsHealth.2017;9(2):174-180.
Pursuits
Saccades
Imagefrom:KrauzlisRJ.RecasOngtheSmoothPursuitEyeMovementSystem,JNeurophysiology.2004;91(2):591-603
NormalSmoothPursuits
• VIDEO
AbnormalPursuits(i.e.SaccadicIntrusions)
Symptoms:DifficulOesreading,nauseawithvisualmoOon,difficulOesscrollingonascreen
VIDEO
NormalSaccades
• VIDEO
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AbnormalSaccades–Hypometric/Hypermetric
Symptoms:DifficulOesreading,difficulOes“tracking”,losingplacewhilereading,re-reading
• VIDEO
VisualConsequencesofConcussioninSport
Calhasreallygreatathletes.Theyare
smartandenjoygoingtoclassandto
pracOce.Whentheyarenotonthe
fieldtheyareinthelibrary.
Calhasreallygreatathletes.Theyare
smartandenjoygoingtoclassandto
pracOce.Whentheyarenotonthe
fieldtheyareinthelibrary.
King-Devick
• n=9,7dayspost-concussion• n=9,age,sexmatchnormal
volunteers• FixaOon,Reflexivesaccades,anO-
saccades,memoryguidedsaccades,self-pacedsaccades
• fMRI-widespreadincreasedacOvaOonofmulOplebrainareasfollowingconcussioninresponsetooculomotortasks
– LongerlatencyOme,worseposiOonerrors,fewernumberofself-pacedsaccades
JohnsonB,ZhangK,HallehM,SlobounovS.FuncOonalneuroimagingofacuteoculomotordeficitsinconcussedathletes.BrainImagingBehav2015;9:564-73
fMRIofAcuteOculomotorDeficitsinConcussedAthletes
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AccommodaOon• WhentheeyechangesrefracOvepowerbyalteringtheshapeof
thelenstofocusonobjectsatdifferentdistances• ie–Howtheeyefocusesonthings
AccommodaOvePathway
Imagefromhhp://what-when-how.com/neuroscience/the-cranial-nerves-organizaOon-of-the-central-nervous-system-part-4/
AccommodaOveInsufficiency AccommodaOveInfacility
AccommodaOveSpasmConvergence/Divergence
Distance Near
Divergence
Convergence
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NPC(NearPointofConvergence)
• VIDEO
VergencePathway
GamlinP.NeuralMechanismsfortheControlofVergenceEyeMovements.AnnNYAcadSci.2002Apr;856:264-72
ConvergenceInsufficiencyVergenceDysfuncOon
ConvergenceInsufficiencySigns• TrueCI(basedonthe
ConvergenceInsufficiencyTreatmentTrial)1. DecreasedNPC>6cm2. Exophoriaatleast4pd
greateratnearthandistance3. Decreasedfusional
convergenceatnear• “Gross”CI
– ReducedNPCDevelopmentalCIiscommoninthegeneralpopulaCon~2.5-13%
Symptoms• Headache• Eyestrain• Doublevision• Blurryvision• Lossofplacewhilereading/
wordsmovingonthepage• ExcessiveOrednesswhen
reading• Closinganeye• ShortahenOonspanfor
readingScheimanM,MitchellGL,CoherS,etal.Theconvergenceinsufficiencytreatmenttrial(CITT)studygroup.Arandomizedclinicaltrialoftreatmentsforconvergenceinsufficiencyinchildren.ArchOphthalmol.2005;123:14-24.RouseMW,BorsOngE,HymanL,etal.FrequencyofconvergenceinsufficiencyamongfiXhandsixthgraders.OptomVisSci.1999;76(9):643-9.LetourneauJE,DucicS.Prevalenceofconvergenceinsufficiencyamongelementaryschoolchildren.CanJOptom.1988;50:194-7.McGregorML.Convergenceinsufficiencyandvisiontherapy.PediatrClinNAm.2014;61:621-630
ConvergenceInsufficiencyTreatmentTrialCITTStudyGroup
• RandomizedclinicaltrialslookingatthedifferenttreatmentmethodscomparedtoplaceboforconvergenceinsufficiencyandaccommodaOvedysfuncOon– Home-basedpencilpushups– Home-basedcomputervergence/
accommodaOvetherapyandpencilpushups
– Office-basedvergence/accommodaOvetherapywithhomereinforcement
– Office-basedplacebotherapy– BIprismreaders
• Conclusion– MosteffecOvewasoffice-
basedvergence/accommodaOvetherapy
– StaOsOcallydifferentfromoffice-basedplacebotherapy
– Home-basedremediesnotaseffecOveasoffice-based
– Prismglassesdidnottreatsymptoms/signsbeherthanplacebo
ScheimanM,CoherS,RouseM,etal.RandomizedclinicaltrialoftheeffecOvenessofbase-inprismreadingglassesversusplaceboreadingglassesforsymptomaOcconvergenceinsufficiencyinchildren.BrJOphthalmol.2005;89:1318-1323CITTStudyGroup.RandomizedclinicaltrialoftreatmentsforsymptomaOcconvergenceinsufficiencyinchildren.ArchOphthalmol.2008;126(10:1336-1349ScheimanM,MitchellGL,CoherS,etal.Arandomizedclinicaltrialofvisiontherapy/orthopOcsversuspencilpushupsforthetreatmentofconvergenceinsufficiencyinyoungadults.OptomVisSci.2005;82(7):E583-E595ScheimanM,CoherS,KulpMT,etal.TreatmentofaccommodaOvedysfuncOoninchildren:resultsfromarandomizedclinicaltrial.OptomVisSci.2011;88(11):1343-1352
ConvergenceInsufficiency
TreatmentOp$onsPassive• ObservaOon• Prism/Readingglasses
– Helpwithsymptoms– DonotactuallytreatCI
AcOve• OrthopOcsVisionTherapy
– Home-based– Office-based
SecondaryCausesofCI• OculomotorPalsy/
RestricOon– CNIV– CNIII– DuaneSyndrome
• NeurologicalDisease– Pseudotumorcerebri– TBI/concussion– BehavioralmedicaOons– Parkinson’sDisease– LymeDisease
SignificantReduc$on:5cmbreak,7cmrecovery
MaplesWC,HoenesR.NearPointofConvergenceNormsMeasuredinElementarySchoolChildren.OptomVisSci.2007;84(3):224-228McGregorML.Convergenceinsufficiencyandvisiontherapy.PediatrClinNAm.2014;61:621-630
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NPCinConcussionNPCaYerconcussioninchildren
• N=275pediatricpaOentsaged5-18presenOngtoterOarycarechildren’shospitalsubspecialtyconcussionprogramatChildren’sHospitalofPhiladelphia
• 67(24%)hadabnormalNPC– 26(46%)recoveredwithstandard
clinicalcareovermedianof4.5weeks– 23(41%)recoveredamedianof11
weekspostinjuryaXerreferralforformalvesibulartherapy
– 7(13%)withpersistentabnormalNPCnecessitatedreferralforformalOBVT,withrecoveryof23weekspost-injury,medianof16weeksaXerreferraltoVT
NPCaYerSRC–rela$onshiptoneurocogni$veimpairment• N=78athletes,meanage14years• Seen~5daysaXerSRCand
comparedNPCtoIMPACTandsymptomassessments
• CIwascommon~42%• PaOentswithCIperformedworse
on– Verbalmemory– Visualmotorspeed– ReacOonOme– Symptomscores
StoreyEP,MasterSR,LockyerJE,etal.NearpointofconvergenceaXerconcussioninchildren.OptomVisSci.94(1):96-100
PearceKL,SufrinkoA,LauBC,etal.NearpointofconvergenceaXerasport-relatedconcussion:measurementreliabilityandrelaOonshiptoneurocogniOveimpairmentandsymptoms.AmerJSportsMed.2015.XX(X)
OculomotorProblemsinTBI
• 100post-concussionadolescentsaged11-17years– 51%accommodaOvedisorders– 49%convergenceinsufficiency– 29%saccadicdysfuncOon– 46%morethanoneofpreviouslymenOonedvision-relateddiagnoses
Arewejustfindingpre-exis$ngcondi$onswedidn’tlookforbefore?
MasterCL,ScheimanM,GallawayM,etal.VisiondiagnosesarecommonaXerconcussioninadolescents.ClinPediatr(Phila).2016;55(3):260-267.
VesObular-OcularReflexVesObular-OculomotorVisualMoOonSensiOvity
andEyeMovements(Saccades/Pursuits)
Visual-EvokedNausea
VisualMoOoninDailyLife Visual-VesObularMoOoninSport
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HigherOrderVisualProcessing
Spa$alProcessing-LocaOon-Movement-SpaOaltransformaOons-SpaOalRelaOons
ObjectProcessing-Color-Texture-Pictorialdetail-Shape-Size
VisualAhenOonandVisualProcessing
GilbertC,LiW.Top-downinfluencesonvisualprocessing.NatureRevNeurosci.2013;14:350-363RaffoneA,SrinivasanN,vanLeeuwenC.TheinterplayofahenOonandconsciousnessinvisualsearch,ahenOonalblinkandworkingmemoryconsolidaOon.PhilTransRSocB.2014:369.
VisualCrowding(Simultanagnosia) VisualCrowdinginDailyLife
ConcussionManagement
CurrentApproachtoTx• NosamedayReturn-to-Play
(RTP)• Needtobeclearedby
PhysicianforRTP• Prescribedphysical/cogniOve
restunOlasymptomaOc• AccommodaOonsatschool/
work• Progressivesymptom-based
aerobicexerOon-basedRTP
Limita$ons• LimitedguidanceonacOve
treatment• Limitedevidencefor
effecOvenessofprescribedrest– Norandomizedcontrolled
trials• LackofdefiniOonof“rest”• Recoveryisinfluencedby
severityofinjury,typeandOmingoftreatment
Wait–soRestisGood…orisit??Pros
• RestdecreasesexposuretoaddiOonalimpacts
• PhysicalandcogniOveacOvityexacerbatesymptomsposOnjury,prolongingrecovery
• 1-weekperiodofrestdecreasedSxandincreasedcogniOvescoresin60%ofpaOents– Evenwhenusedseveralweeks/
monthsaXerinjury• IniOalbriefrestmaybebeneficial
Cons• Youcanavoidcontactwithoutavoiding
allacOvity• PhysicalandcogniOveacOvitydonot
worsenpathophysiologicalinjuryorcauseaddiOonalharm
• NoassociaOonbetweenprescribedrestanddecreaseorSxorrecoveryOme
• PaOentswithhighestandlowestlevelsofacOvityhadworseoutcomes– Toolihleortoomuchrestmaydelay
recovery• Whattype,howlong–sOllTBD• Prolongedrestcanleadtosocial
isolaOon,anxiety,lossofacademic/workstanding
CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaOonandAcOveManagement(TEAM)ApproachestoTreaOngConcussionMeeOngHeldinPihsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.
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HowLongShouldChildrenRest?• NovalidateddatademonstraOng
theappropriateduraOonofcogniOveorphysicalrestinchildrenwithSRC
• ThomasetalRCTassessingpost-SRCin11-22yo–showednosignificantdifferenceinprescribedrestandthosereceivingusualcare– Thosereceivingstrictrest
reportedmoresymptomsandlongersymptomduraOon
• Exerciseatmildorself-selectedlevelsdoesnotappeartoprolongsymptomsandmayshortensymptomduraOonandmaybeparOcularlybeneficialforadolescentathletes(103)
• Restinfirstfewdaysmaybebeneficial,prolongedrestmaydelayrecovery(bothphysicalandcogniOverest)
• ThomasDG,AppsJN,HoffmannRG,etal.BenefitsofstrictrestaXeracuteconcussion:arandomizedcontrolledtrial.Pediatrics2015;135:213–23
• LeddyJ,HindsA,SiricaD,etal.Theroleofcontrolledexerciseinconcussionmanagement.PMR2016;8(Suppl 3):S91–S100• BrownNJ,MannixRC,O’BrienMJ,etal.EffectofcogniOveacOvitylevelonduraOonofpost-concussionsymptoms.Pediatrics
2014;133:e299–304.• ThomasDG,AppsJN,HoffmannRG,etal.BenefitsofstrictrestaXeracuteconcussion:arandomizedcontrolledtrial.Pediatrics
2015;135:213–23.• HowellDR,MannixRC,QuinnB,etal.PhysicalacOvitylevelandsymptomduraOonarenotassociatedaXerconcussion.AmJ
SportsMed2016;44:1040–6
TEAMApproachtoConcussion-2015
• Concussionsareatreatableinjury– MoreacOve/targetapproachesarebeherthanprescribedrestalone
• AcOveRehabilitaOon– VesObularTherapy– Oculomotor/VisionTherapy– BehavioralTherapy
CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaOonandAcOveManagement(TEAM)ApproachestoTreaOngConcussionMeeOngHeldinPihsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.
RoleforVisionTherapy?• n=220individualswithTBI(n=160)orCVA
(n=60)• ComputerbasedqueryinclinicalpopulaOon
2000-2003,selectedthosewhocompletedoptometricVTprogramTBI(n=33),CVA(n=7)
• Results:90%ofTBIand100%withCVIhadtreatmentsuccess
– Marked/totalimprovementinatleast1primarysymptomandatleast1primarysign
– ImprovementsremainedstableatretesOng2-3monthslater
CiuffredaKJ,RutnerD,KapoorN,SuchoffI,CraidS,HanME.VisiontherapyforoculomotordysfuncOonsinacquiredbraininjury:AretrospecOveanalysis.Optom2008:79:18-22.
Post-ConcussionVisionExam• AfferentVisualPathway
– VisualAcuity• Crowded/Isolated• VORacuity(DynamicAcuity)
– Pupils– ConfrontaOonVFs
• Eyemovements– FixaOon– Saccades– Pursuits– VOR– NumberReadingTest(KD,
DEM)• OcularPosture–CoverTest• EOMs
• AccommodaOon– MonocularNPA– MonocularFlippers– MonocularMEM
• Vergences– NPC– VergenceRanges– VergenceFacility
• OcularHealth– Adnexa/OrbitalExam
• Exophthalmometry– AnteriorSegment– PosteriorSegment
Optometry’sRole?
• PressingneedforobjecOvediagnosOctoolsforconcussionassessmentthatarestraighzorwardtoadminister
• CurrentresearchinusingeyemovementsandoculomotorfuncOonforsensiOveandobjecOvebiomarkersofcerebraldysfuncOon– Canwetrackconcussionwiththevisualsystem??
• ManagementofPost-Concussion/HeadInjuryVisionProblems
HeitgerMH,JonesRD,MacLeoda.D,SnellDL,FramptonCM,AndersonTJ.Impairedeyemovementsinpost-concussionsyndromeindicatesubopOmalbrainfuncOonbeyondtheinfluenceofdepression,malingeringorintellectualability.Brain2009;132:2850-70.JohnsonB,ZhangK,HallehM,SlobounovS.FuncOonalneuroimagingofacuteoculomotordeficitsinconcussedathletes.BrainImagingBehav2015;9:564-73.
OptometricManagementPrimaryCare
• Vergence(Ranges,NPC,Facility)• AccommodaOon(NPA,Facility)• DEM• Crowding(crowdedacuitysymbols)• Rx
– Focusing/vergenceissues– Sunglasses
• Reassurance
Ter$aryCare-PCS• ComprehensiveBinocularVisionAssessment
• VisualPerceptualSkillsAssessment
• VisionTherapy• VesObulo-OculomotorTherapy
AcOveparOcipaOoninmulOdisciplinarycare!
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PrescribedAccommodaOons/AdvocaOons
• VisualMoOonSensiOvity/VisualCrowding– Removalfromgym/danceclass,band/orchestra,schoolassemblies
– Doublespacedtext,increasedfontsize,lineguides• OculomotorDysfuncOon
– Delaytests/quizes– Reduceamountofhomework– IncreaseOmeontests/assignments
• Plannedbreaks– Notetaker
• TEMPORARYMODIFICATIONS
ClinicalPearls
• Thevisualsystemiscommonlyaffectedinconcussion
• Themajorityofvisualproblemsself-resolveaXerconcussionin3-4weeks,butsomepaOentsmayneedacOvetherapyforfullrecovery
• OptometryhasaroletofillinthemulO-disciplinarymanagementofconcussion
• Whenindoubtrefertoacolleague!
Thankyou!QuesOons?
References• AnzaloneAJ,BlueihD,CaseT,McGuffinT,PollardK,GarrisonJC,JonesMT,PavurR,TurnerS,OliverJM.AposiOveVesObular/Ocular
MotorScreening(VOMS)isassociatedwithincreasedrecovertyOmeaXersports-relatedconcussioninyouthandadolescentathletes.AJSM2017;45(2)474-479
• ArbogastKB,CurryAE,PfeifferMR,etal.Pointofhealthcareentryforyouthwithconcussionwithinalargepediatriccarenetwork.JAMAPediatr2016;170:e160294.
• BrownNJ,MannixRC,O’BrienMJ,etal.EffectofcogniOveacOvitylevelonduraOonofpost-concussionsymptoms.Pediatrics2014;133:e299–304.
• CentersforDiseaseControlandPrevenOon.NonfataltraumaOcbraininjuriesrelatedtosportsandrecreaOonacOviOesamongpersonsaged≤19years—UnitedStates,2001–2009.MMWR.2011;60(39):1337-1342
• CITTStudyGroup.RandomizedclinicaltrialoftreatmentsforsymptomaOcconvergenceinsufficiencyinchildren.ArchOphthalmol.2008;126(10:1336-1349
• CiuffredaKJ,RutnerD,KapoorN,SuchoffI,CraidS,HanME.VisiontherapyforoculomotordysfuncOonsinacquiredbraininjury:AretrospecOveanalysis.Optom2008:79:18-22.
• CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaOonandAcOveManagement(TEAM)ApproachestoTreaOngConcussionMeeOngHeldinPihsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.
• CroweL,BablF,AndersonV,etal.Theepidemiologyofpaediatricheadinjuries:datafromareferralcentreinVictoria,Australia.JPaediatrChildHealth2009;45:346–50
• DavisGA,AndersonV,BablFE,GioiaGA,GizaCC,etal.Whatisthedifferenceinconcussionmanagementinchildrenascomparedwithadults?AsystemaOcreview.BrJSportsMed2017;51:949-957.
• EisenbergMA,MeehanWP,MannixR.DuraOonandcourseofpost-concussivesymptoms.Pediatrics.2014;133(6):999-1006• EllisMJ,CordingleyD,VisS,ReimerK,LeiterJ,RussellK.VesObulo-oculardysfuncOoninpediatricsports-relatedconcussion.JNeurosurg
Pediatr2015:16:248-255• GesselLM,FieldsSK,CollinsCL,DickRW,ComstockRD.ConcussionsamongUnitedStateshighschoolandcollegiateathletes.JAthl
Train2007;42:495-503• GilbertC,LiW.Top-downinfluencesonvisualprocessing.NatureRevNeurosci.2013;14:350-363• GradyM.Concussionintheadolescentathlete.CurrProblPediatrAdolescHealthCare.2010;40:154-169• HarmonKG,DreznerJA,GammonsM,etal.AmericanMedicalSocietyforSportsMedicineposiOonstatement:concussioninsport.BrJ
SportMed2013;47:15-26.• HeitgerMH,JonesRD,MacLeoda.D,SnellDL,FramptonCM,AndersonTJ.Impairedeyemovementsinpost-concussionsyndrome
indicatesubopOmalbrainfuncOonbeyondtheinfluenceofdepression,malingeringorintellectualability.Brain2009;132:2850-70.
References• HowellDR,MannixRC,QuinnB,etal.PhysicalacOvitylevelandsymptomduraOonarenotassociatedaXerconcussion.AmJSportsMed
2016;44:1040–6• JohnsonB,ZhangK,HallehM,SlobounovS.FuncOonalneuroimagingofacuteoculomotordeficitsinconcussedathletes.BrainImaging
Behav2015;9:564-73• KatzBJ,DigreKB.Diagnosis,pathophysiology,andtreatmentofphotophobia.SurvOphth.2016;61:466-477• KimparaH,IwamotoM.MildtraumaOcbraininjurypredictorsbasedonangularacceleraOonsduringimpacts.AnnBiomedEng
2012;40:114-26.• KontosAP,SufrinjoA,ElbinRJ,PuskarA,CollinsMW.ReliabilityandassociatedriskfactorsforperformanceontheVesObular/Ocular
MotorScreening(VOMS)toolinhealthycollegiateathletes.AJSM2016;44(6):1400-1406• LaukkanenH,ScheimanM,HayesJR.Braininjuryvisionsymptomsurvey(BIVSS)quesOonnaire.OptomVisSci.2016;94(1):43-50.• LeddyJ,HindsA,SiricaD,etal.Theroleofcontrolledexerciseinconcussionmanagement.PMR2016;8(Suppl3):S91–S100• LetourneauJE,DucicS.Prevalenceofconvergenceinsufficiencyamongelementaryschoolchildren.CanJOptom.1988;50:194-7.• LyhleMD,CroweL,OakleyE,etal.ComparingCATCH,CHALICEandPECARNclinicaldecisionrulesforpaediatricheadinjuries.EmergMed
J2012;29:785–94.• MaplesWC,HoenesR.NearPointofConvergenceNormsMeasuredinElementarySchoolChildren.OptomVisSci.2007;84(3):224-228• MasterCL,ScheimanM,GallawayM,etal.VisiondiagnosesarecommonaXerconcussioninadolescents.ClinPediatr(Phila).2016;55(3):
260-267.• McCroryP,MeeuwisseWH,AubryMetal.Consensusstatementonconcussioninsport:the4thInternaOonalConferenceonConcussionin
SportheldinZurich,November2012.BrJSportsMed2013;47:250-8.• McCroryP,MeeuwisseW,DvorakJetal.Consensusstatementonconcussioninsport–the5thinternaOonalconferenceonconcussionin
sportheldinBerlin,October2016.BrJSportsMed.2017;0:1010• McDonaldJW,JohnstonMV.Physiologicalandpathophysiologicalrolesofexcitatoryaminoacidsduringcentralnervoussystem
development.BrainResRev.1990;15:41-70• McGregorML.Convergenceinsufficiencyandvisiontherapy.PediatrClinNAm.2014;61:621-630• MuchaA,CollinsMW,ElbinRJ,etal.AbriefvesObular/ocularmotorscreening(VOMS)assessmenttoevaluateconcussions:preliminary
findings.AmJSportsMed2014;42:2479-86.• PearceKL,SufrinkoA,LauBC,etal.NearpointofconvergenceaXerasport-relatedconcussion:measurementreliabilityandrelaOonship
toneurocogniOveimpairmentandsymptoms.AmerJSportsMed.2015.XX(X)• PedenMMU.WorldHealthOrganizaOon.WorldreportonchildinjuryprevenOon.Geneva,SwitzerlandNewYork,NY:UNICEF,2008.• RaffoneA,SrinivasanN,vanLeeuwenC.TheinterplayofahenOonandconsciousnessinvisualsearch,ahenOonalblinkandworking
memoryconsolidaOon.PhilTransRSocB.2014:369.
References• ReillyP,BullockR.HeadInjury2ed:PathophysiologyandManagement,CRCPress2005TaylorandFrancis,Florida• RouseMW,BorsOngE,HymanL,etal.FrequencyofconvergenceinsufficiencyamongfiXhandsixthgraders.OptomVisSci.1999;76(9):
643-9.• ScheimanM,MitchellGL,CoherS,etal.Theconvergenceinsufficiencytreatmenttrial(CITT)studygroup.Arandomizedclinicaltrialof
treatmentsforconvergenceinsufficiencyinchildren.ArchOphthalmol.2005;123:14-24.• ScheimanM,CoherS,RouseM,etal.RandomizedclinicaltrialoftheeffecOvenessofbase-inprismreadingglassesversusplacebo
readingglassesforsymptomaOcconvergenceinsufficiencyinchildren.BrJOphthalmol.2005;89:1318-1323• ScheimanM,MitchellGL,CoherS,etal.Arandomizedclinicaltrialofvisiontherapy/orthopOcsversuspencilpushupsforthetreatment
ofconvergenceinsufficiencyinyoungadults.OptomVisSci.2005;82(7):E583-E595• ScheimanM,CoherS,KulpMT,etal.TreatmentofaccommodaOvedysfuncOoninchildren:resultsfromarandomizedclinicaltrial.
OptomVisSci.2011;88(11):1343-1352• StoreyEP,MasterSR,LockyerJE,etal.NearpointofconvergenceaXerconcussioninchildren.OptomVisSci.94(1):96-100• SufrinkoAM,MuchaA,CovassinT,Marche~G,ElbinRJ,CollinsMW,KontosAP.SexdifferencesinvesObular/ocularandneurocogniOve
outcomesaXersport-relatedconcussion.ClinJSportMed2017;27:133-138.• TeasdaleG,JennehB.AssessmentofComaandImpairedConsciousness:ApracOcalscale.Lancet304,81-84.• ThiagarajanP,CiuffredaK.Pupillaryresponsestolightinchronicnon-blast-inducedmTBI.BrainInjury.2015;29(12):1420-1425• ThomasDG,AppsJN,HoffmannRG,etal.BenefitsofstrictrestaXeracuteconcussion:arandomizedcontrolledtrial.Pediatrics
2015;135:213–23• VossJ,ConnollyJ,SchwabK,ScherA.Updateontheepidemiologyofconcussion/mildtraumaOcbraininjury.CurrPainHeadache
Reports.2015;19(7):32.• YorkeAM,SmithL,BabcockM,AlsalaheenB.ValidityandreliabilityoftheVesObular/OcularMotorScreeningandassociaOonswith
commonconcussionscreeningtools.SportsHealth.2017;9(2):174-180.• ZhangL,YangK,KingA.AproposedinjurythresholdformildtraumaOcbraininjury.JBiomechEng2004;126:226-36.
11/26/17
14
PhotoReferences• Slide8-LienJ.PediatricConcussionandothertraumaOcbraininjuries.Medscape.com.AccessedApril15,2017.
hhp://reference.medscape.com/features/slideshow/pediatric-concussion• Slide17-hhp://www.bu.edu/cte/about/what-is-cte/• Slide22-HannulaDe,SimonsDJ,CohenNJ.ImagingimplicitpercepOon:promiseandpizalls.NatureRevNeurosci.
2005;6:247-255/• Slide23–-hhp://www.mcleishoptometrists.com/wp-content/uploads/2012/02/600anisocoria-e1330256999354.jpg
– hhp://ishiharatest.blogspot.com/2011/03/ishihara-color-blindness-test.html• Slide27-hhp://what-when-how.com/neuroscience/the-cranial-nerves-organizaOon-of-the-central-nervous-system-part-4/• Slide33-KrauzlisRJ.RecasOngtheSmoothPursuitEyeMovementSystem,JNeurophysiology.2004;91(2):591-603• Slide43–hhp://1degreebio.org/common/files/blogs/6303-1370955226-1degreebio_blog_focus.jpg• Slide44-=hhps://s-media-cache-ak0.pinimg.com/736x/45/30/c9/4530c95dfc4e1275ac6a3d780�dcbb9.jpg• Slide45,47,51,63–-hhp://4.bp.blogspot.com/-RGWwz6egcpU/UIs7JrSwy8I/AAAAAAAACes/7vDzCovB37U/s1600/
blurry.jpg• Slide46-h\p://cdn2.hubspot.net/hubfs/437097/DTC/09.blog/Note-taking-tumblr_-REVISEORDIE.jpg
– h\p://www.firehow.com/images/stories/users/683/aids_class_lepowsky06_1113.jpg• Slide48-h\ps://classconnec$on.s3.amazonaws.com/857/flashcards/527857/jpg/accomoda$on1305250857880.jpg• Slide50-GamlinP.NeuralMechanismsfortheControlofVergenceEyeMovements.AnnNYAcadSci.2002Apr;
856:264-72• Slide58–hhps://img.gadgethacks.com/img/14/45/63598590230051/0/scroll-beher-android-using-these-gestures.
1280x600.jpg• Slide59–hhps://www.nvcofny.com/wp-content/uploads/2016/04/Eye-Care-1.jpg• Slide60–-hhps://s-media-cache-ak0.pinimg.com/originals/e8/bd/6b/e8bd6bb333309ba4bf365feeb7f5b854.jp• Slide62-GilbertC,LiW.Top-downinfluencesonvisualprocessing.NatureRevNeurosci.2013;14:350-363
– RaffoneA,SrinivasanN,vanLeeuwenC.TheinterplayofahenOonandconsciousnessinvisualsearch,ahenOonalblinkandworkingmemoryconsolidaOon.PhilTransRSocB.2014:369.
• Slide64-hhps://i.yOmg.com/vi/v8O0xzD6Ax0/hqdefault.jpg