Eric L. Singman
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.