by Vincent R. Vicci, OD, DPNAP, FNORA
Dr. DeAnn Fitzgerald recently blogged about the visual and vestibular symptoms associated with concussion and how optometrists can play a critical role in diagnosing and managing the condition.
I agree wholeheartedly with that statement. But after many years of managing multitudes of patients in northern New Jersey with serious concussions, I can say that quite often ODs may be steering patients in the wrong direction when it comes to treatment.
General medical practitioners will often advise rest and staying away from “screens,” but this will only help a fraction of first-time concussion patients. The leading recommendation by functionally oriented optometrists is traditional vision therapy. In some cases, these recommendations can be extraordinarily helpful. In others, however, a different approach may be needed.
Vision therapy is a wonderful tool that can be an ideal solution for patients who are having difficulties with headaches, double vision, skipping, loss of place and movement of words when reading. The emphasis, however, is often placed on focal processing and treating convergence insufficiency. This may be the wrong approach for certain types of concussions and can actually exacerbate the problems. That’s because many patients with concussion have problems with dizziness, spatial orientation and imbalance, implying the likelihood of an accompanying vestibular dysfunction.
The vestibular system allows us to move comfortably through our environment and allows our environment to move comfortably around us. It is the balance and orientation system. When the vestibular system has been affected, visual triggers may develop — representing a compromise of the ambient visual system.
The ambient visual system refers to the pre-conscious awareness of the space around us that is used for navigating through our world. It is what makes the commotion of crowds and surrounding stimuli difficult for these concussion patients. Becoming overly focal—which is often the goal of traditional vision therapy programs — can make the patient even less aware of their ambient space.
What does work? Prism lenses, including yoked and base-in prisms. These have to be customized for the patient by someone experienced in neuro-optometric rehabilitation. The glasses alone can often resolve as much as 80% of the symptoms. The rest can then be addressed by occupational and physical therapists working with the patient to increase peripheral awareness while they wear their prism lenses. We may also use tinted lenses or move a patient from spectacles into contact lenses to improve their peripheral visual processing. Only after a regimen designed to enhance ambient visual processing may we choose to utilize focal processing.
These are the solutions that truly work. They can help bring visual and vestibular inputs back into alignment with one another and greatly reduce the visual triggers that provoke symptoms in our concussion patients.
For more information:
Vincent R. Vicci, OD, DPNAP, FNORA, is a graduate of the Pennsylvania College of Optometry and is in private practice in Westfield, N.J. He is a cofounder of the vision clinic at the Kessler Institute for Rehabilitation and on staff at a number of hospitals and rehabilitation centers for patients with stroke, concussion and other traumatic brain injuries. He is a cofounder of the Neuro-Optometric Rehabilitation Association.
Disclosure: Vicci reports no relevant financial disclosures.