BLOG: Neuro-ophthalmology perspective on concussion management
by Eric L. Singman, MD , PhD
Historically, neuro-ophthalmologists have not embraced the comprehensive management of patients with traumatic brain injury. Increasingly, however, that is changing.
Today, I am seeing more interest in the neuro-ophthalmology community in traumatic brain injury (TBI) and growing interest in research and clinical collaborations with other concussion care providers, including neuro-optometrists. I am encouraged by these developments.
There are three things that must happen, in my opinion.
Better post-TBI evaluations
I would like to see all primary eye care providers, whether MD or OD, do a better assessment of any patient with a history of concussion or head trauma. We know that deficits due to TBI are most likely to occur in the areas of vergence, accommodation, saccades, pursuits and peripheral awareness, none of which is routinely evaluated in a typical exam. Too many doctors assess visual acuity and visual fields and pronounce the patient “fine” when in fact they have real oculomotor dysfunction. Here are some very simple tests to improve the exam:
- Evaluate pursuits by asking the patient to follow a pendulum with their eyes.
- Evaluate saccades by asking the patient to look at three visual targets a foot apart from each other (choose easy targets that don’t stress them cognitively, like simple pictures or colored blocks).
- Evaluate convergence (without accommodation) at a fixed distance using a prism set.
If the patient has difficulty with any of these tasks or cannot do them without discomfort or nausea, they likely have visual-motor difficulties and would benefit from a referral to a neuro-rehabilitation specialist.
More published studies
The publication more than a decade ago of the Convergence Insufficiency Treatment Trial supported by the NEI made a big difference in how ophthalmologists viewed vision therapy and served to begin breaking down the silos between our fields. There was broad agreement that convergence insufficiency was a problem, and the study validated that it could be successfully treated with therapy.
I believe that our field would benefit from more well-conducted studies published in peer-reviewed journals on pursuit and saccade insufficiency and on the treatments that many neuro-optometrists are using successfully.
More collaboration for the patient’s benefit
Working with TBI patients truly does take a village. There is a natural overlap among neuro-ophthalmologists, neurologists, neuro-optometrists and neuro-otologists (as well as many types of therapists) in caring for these patients. We all need to get past any divisiveness over scope of practice, because the reality is that there are not enough of any of us in the neuro specialties to meet the current patient need. I am encouraged to see more ophthalmologists embracing optometrists in their practices and in comanagement relationships.
In my experience with TBI patients, the ideal situation is to be able to refer them to a neuro-optometrist who has a fellowship certification from the Neuro-Optometric Rehabilitation Association or the College of Optometrists in Vision Development (FNORA or FCOVD).
Sometimes this is not practical because of distance or lack of access.
I have also successfully partnered with optometrists who evaluate patients and supervise their participation in computerized training programs that can be done at home (or closer to home), such as Home Therapy Solutions, VizualEdge or RightEye EyeQ Trainer. These can be acceptable options for a patient who can’t tolerate longer therapy sessions and/or is unable to travel to see a neuro-rehabilitation specialist and/or who cannot financially afford office-based therapy.
Our patients will benefit from all of us working together to more efficiently treat post-concussion syndrome and from further collaborative efforts to establish the scientific evidence for this type of care.
Convergence Insufficiency Treatment Trial Study Group. Arch Ophthalmol. 2008;doi:10.1001/archopht.126.10.1336.
Padula WV, Singman EL, Vicci V, et al. Evaluating and treating visual dysfunction. In: Zasler N, Katz D, Zafonte R (eds). Brain Injury Medicine: Principles and Practice, 2nd ed. 2012;Demos Medical.
Singman E, Quaid P. Visual disorders in mild traumatic brain injury. In: Hoffer M, Balaban C (eds). Neurosensory Disorders in Mild Traumatic Brain Injury, 1st ed. 2019;Academic Press, Elsevier.
For more information:
Eric L. Singman, MD, PhD, is chief of the general eye service and associate professor of ophthalmology at Johns Hopkins University’s Wilmer Eye Institute. He founded the Wilmer Clinic for Vision Disorders After Brain Injury and is the author of many publications, including seminal book chapters on visual dysfunction and brain injury. Singman was a co-recipient of the 2019 Advancement of Neuro-Optometric Rehabilitation Award from NORA.
Disclosure: Singman has no relevant financial disclosures.
Disclaimer: The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of the Neuro-Optometric Rehabilitation Association unless otherwise noted. This blog is for informational purposes only and is not a substitute for the professional medical advice of a physician. NORA does not recommend or endorse any specific tests, physicians, products or procedures. For more on our website and online content, click here.