Outpatient vision therapy aids brain injury recovery

After 12 weeks of treatment, this patient was able to return to work and driving.

Mild traumatic brain injury can result in visual, perceptual, oculomotor and oculo-vestibular dysfunctions, but a comprehensive outpatient vision/vestibular therapy program can help a patient resume important activities of daily living.

Case report

A 30-year-old man was rear-ended in a motor vehicle accident. He was the driver and was wearing a seat belt. He suffered a mild traumatic brain injury (mTBI)/concussion resulting in typical post-concussion symptoms: light sensitivity, headaches, difficulty with concentration and memory, and difficulty with reading. He stated, “Things are not the same as prior to the accident.”

He reported a short loss of consciousness right after the accident. MRI studies were negative, and he was diagnosed with mTBI/concussion. He wears glasses for myopia and is a high school educator. He had to avoid busy and crowed places and he had difficulty driving and working. Overall, his signs and symptoms are typical for mTBI, as described in our previous two articles, “ODs can play a role in rehab for mTBI,” February 2018, page 12, and “Test refraction, balance, contrast sensitivity in suspected mTBI,” January 2018, pages 1 and 8.

The patient was evaluated at a concussion center in Pennsylvania. After 8 weeks, his symptoms increased, and he was not responding to traditional medical therapies dispensed at the center, including traditional post-concussion supplements such as vitamin D, fish oil and magnesium taurate.

Jeffrey Becker

He was subsequently referred for a neuro-optometric visual/vestibular evaluation. His goals were to go back to work, drive and become independent, as he was prior to his accident.

Evaluation

The patient was seen at the Neurosensory Center in Kingston, Pa., where he was evaluated clinically and electrodiagnostically. He rated the severity of his symptoms affecting his activities of daily living as 9 out of 10 even though his visual acuities were 20/20 at distance and near. Ocular health and pupillary responses were normal. However, testing was significant for:

  • increased light sensitivity;
  • decreased depth perception to 400 seconds of arc (2 of 9 on the Randot Stereo Test by Precision Vision);
  • erratic eye movements with near point convergence at 10 inches to break point, followed by recovery of fusion at 14 inches – intermittent diplopia and suppression were reported during the test;
  • high exophoria at distance and near with variable and inconsistent compensating vergences;
  • end-point nystagmus on extreme peripheral gaze both horizontally and vertically; and
  • a reproducible and reliable bilateral midline shift.

Electrodiagnostics confirmed the above. Electronystagmography, vestibular autorotation test and computerized balance testing indicated a micronystagmus on both the horizontal and vertical meridians. Vestibulo-ocular reflex showed deficits horizontally and vertically and a bilateral midline shift. Balance testing indicated shifts laterally, right and left, with good reliability. ImPact testing (Immediate Post-concussion Assessment and Cognitive Test, ImPact Applications) yielded significant visual composite score deficit.

Treatment

The patient engaged in a comprehensive outpatient vision/vestibular therapy program – 1-hour sessions three times a week for 14 weeks. He was also given a home therapy program that would reinforce what was done in the outpatient clinic setting.

The therapy consisted of the use of a computer orthoptics program, yoked prisms were used, and the vestibular balance component of the program was incorporated into the exercises. We also added cognitive integration techniques in a computerized program to address his low ImPact scores affecting his memory and concentration. He was an ideal compliant patient and made significant gains in all areas.

Joseph Hallak

We started with simple therapy – Brock strings at home and easy eye movement exercises – for the first several weeks to ensure we did not make his symptoms worse. Outpatient therapy in the early stages consisted of first-, second- and third-degree targets, working our way to random dot stereograms, both base out and base in, making sure he was always “balanced” with vergences. This was completed with the VTS4 (Vision Therapy System v4, Vision Therapy Solutions), which he was able to achieve by the fourth week of treatment.

In the fifth to seventh weeks, balance skills were incorporated with the VTS4 balance program and balance beam and board. When the patient soon started to master these skills, the therapist began to add integration skills, or multitasking. These included audio/verbal tasks, such as counting backward, doing mental math and playing word games, and proprioception skills, such as finger pointing and catching a ball, with the patient performing them at the same time, requiring him to “balance” to keep his binocular skills sharp and accurate. Most of us without mTBI would take such tasks for granted.

Eight to 11 weeks later, yoked prisms were added. The patient had to continue all of the above skills donning yoked prisms glasses. At first the patient regressed for two sessions with the use of the prisms, but once the vision/vestibular system became accustomed to these intense demands, he was able to perform well with no symptoms present. It was at this point the patient felt, for the first time, that he was ready to go back to work and driving.

Finally, a program called Interactive Metronome was added. This program, along with the yoked prisms and binocular skills, addresses the cognitive and memory component so that the patient can work in a real environment where distractions are common.

The last several weeks focused on the patient’s endurance for his job and activities of daily living. All of the above activities were completed, but at a much faster pace and with reduced error scores. He was to do a home-based program for maintenance. These weeks were dedicated to preventing regressions and making sure his symptoms did not recur.

Outcomes

Repeat clinical and electrodiagnostic testing was done after 12 weeks of treatment. The patient reported that his symptoms had completely resolved. He rated a decrease in the severity of his symptoms that were affecting his daily activities to 1 out of 10. Electrodiagnostic testing was normal, and his clinical evaluation indicated his convergence was at 2 inches with a break point at 3 inches. His stereo depth improved to 9 of 9, corresponding to 40 seconds of arc, and the nystagmus was no longer present. Midline shift was also no longer present, and vergence ranges were excellent, easily and largely compensating for his exoposture.

The patient’s impact scores were all normal, and no deficits were noted. He was discharged from our care and referred to the concussion center so he could obtain final permission to return to work, drive and continue his normal activities of daily living without depending on others. This was a success story for all concerned.

Disclosure: Becker and Hallak report no relevant financial disclosures.

Mild traumatic brain injury can result in visual, perceptual, oculomotor and oculo-vestibular dysfunctions, but a comprehensive outpatient vision/vestibular therapy program can help a patient resume important activities of daily living.

Case report

A 30-year-old man was rear-ended in a motor vehicle accident. He was the driver and was wearing a seat belt. He suffered a mild traumatic brain injury (mTBI)/concussion resulting in typical post-concussion symptoms: light sensitivity, headaches, difficulty with concentration and memory, and difficulty with reading. He stated, “Things are not the same as prior to the accident.”

He reported a short loss of consciousness right after the accident. MRI studies were negative, and he was diagnosed with mTBI/concussion. He wears glasses for myopia and is a high school educator. He had to avoid busy and crowed places and he had difficulty driving and working. Overall, his signs and symptoms are typical for mTBI, as described in our previous two articles, “ODs can play a role in rehab for mTBI,” February 2018, page 12, and “Test refraction, balance, contrast sensitivity in suspected mTBI,” January 2018, pages 1 and 8.

The patient was evaluated at a concussion center in Pennsylvania. After 8 weeks, his symptoms increased, and he was not responding to traditional medical therapies dispensed at the center, including traditional post-concussion supplements such as vitamin D, fish oil and magnesium taurate.

Jeffrey Becker

He was subsequently referred for a neuro-optometric visual/vestibular evaluation. His goals were to go back to work, drive and become independent, as he was prior to his accident.

Evaluation

The patient was seen at the Neurosensory Center in Kingston, Pa., where he was evaluated clinically and electrodiagnostically. He rated the severity of his symptoms affecting his activities of daily living as 9 out of 10 even though his visual acuities were 20/20 at distance and near. Ocular health and pupillary responses were normal. However, testing was significant for:

  • increased light sensitivity;
  • decreased depth perception to 400 seconds of arc (2 of 9 on the Randot Stereo Test by Precision Vision);
  • erratic eye movements with near point convergence at 10 inches to break point, followed by recovery of fusion at 14 inches – intermittent diplopia and suppression were reported during the test;
  • high exophoria at distance and near with variable and inconsistent compensating vergences;
  • end-point nystagmus on extreme peripheral gaze both horizontally and vertically; and
  • a reproducible and reliable bilateral midline shift.

Electrodiagnostics confirmed the above. Electronystagmography, vestibular autorotation test and computerized balance testing indicated a micronystagmus on both the horizontal and vertical meridians. Vestibulo-ocular reflex showed deficits horizontally and vertically and a bilateral midline shift. Balance testing indicated shifts laterally, right and left, with good reliability. ImPact testing (Immediate Post-concussion Assessment and Cognitive Test, ImPact Applications) yielded significant visual composite score deficit.

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Treatment

The patient engaged in a comprehensive outpatient vision/vestibular therapy program – 1-hour sessions three times a week for 14 weeks. He was also given a home therapy program that would reinforce what was done in the outpatient clinic setting.

The therapy consisted of the use of a computer orthoptics program, yoked prisms were used, and the vestibular balance component of the program was incorporated into the exercises. We also added cognitive integration techniques in a computerized program to address his low ImPact scores affecting his memory and concentration. He was an ideal compliant patient and made significant gains in all areas.

Joseph Hallak

We started with simple therapy – Brock strings at home and easy eye movement exercises – for the first several weeks to ensure we did not make his symptoms worse. Outpatient therapy in the early stages consisted of first-, second- and third-degree targets, working our way to random dot stereograms, both base out and base in, making sure he was always “balanced” with vergences. This was completed with the VTS4 (Vision Therapy System v4, Vision Therapy Solutions), which he was able to achieve by the fourth week of treatment.

In the fifth to seventh weeks, balance skills were incorporated with the VTS4 balance program and balance beam and board. When the patient soon started to master these skills, the therapist began to add integration skills, or multitasking. These included audio/verbal tasks, such as counting backward, doing mental math and playing word games, and proprioception skills, such as finger pointing and catching a ball, with the patient performing them at the same time, requiring him to “balance” to keep his binocular skills sharp and accurate. Most of us without mTBI would take such tasks for granted.

Eight to 11 weeks later, yoked prisms were added. The patient had to continue all of the above skills donning yoked prisms glasses. At first the patient regressed for two sessions with the use of the prisms, but once the vision/vestibular system became accustomed to these intense demands, he was able to perform well with no symptoms present. It was at this point the patient felt, for the first time, that he was ready to go back to work and driving.

Finally, a program called Interactive Metronome was added. This program, along with the yoked prisms and binocular skills, addresses the cognitive and memory component so that the patient can work in a real environment where distractions are common.

PAGE BREAK

The last several weeks focused on the patient’s endurance for his job and activities of daily living. All of the above activities were completed, but at a much faster pace and with reduced error scores. He was to do a home-based program for maintenance. These weeks were dedicated to preventing regressions and making sure his symptoms did not recur.

Outcomes

Repeat clinical and electrodiagnostic testing was done after 12 weeks of treatment. The patient reported that his symptoms had completely resolved. He rated a decrease in the severity of his symptoms that were affecting his daily activities to 1 out of 10. Electrodiagnostic testing was normal, and his clinical evaluation indicated his convergence was at 2 inches with a break point at 3 inches. His stereo depth improved to 9 of 9, corresponding to 40 seconds of arc, and the nystagmus was no longer present. Midline shift was also no longer present, and vergence ranges were excellent, easily and largely compensating for his exoposture.

The patient’s impact scores were all normal, and no deficits were noted. He was discharged from our care and referred to the concussion center so he could obtain final permission to return to work, drive and continue his normal activities of daily living without depending on others. This was a success story for all concerned.

Disclosure: Becker and Hallak report no relevant financial disclosures.