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Vision and Concussion

Vision and Concussion

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Concussion Info

eye brown twinkle close upConcussion is defined by a bump, blow, or jolt to the head, face, neck, or
elsewhere on the body that causes the head and brain to move rapidly back
and forth, causing mechanical stretching of nerve axons (diffuse axonal
injury) and disruptive biochemical changes. It is classified as a Minor
Traumatic Brain Injury (mTBI), although the effects are certainly not
minor. According to the Ontario Neurotrauma Foundation, 150,000 Ontarians
are diagnosed with concussion each year, of which 40,000 are children and
youth under 18. According to the Canadian Institute for Health
Information, sports and recreational activities were the third leading
cause of TBI admissions in Canadian hospitals in 2003-2004. Up to 3.6
million concussions occur annually, as estimated by the Centers for Disease
Control and Prevention.

There are typically no structural brain abnormalities seen on neuroimaging
studies such as CAT scan or standard MRI. According to The Centre for
Disease Control (CDC), up to 15% of patients diagnosed with mTBI may have
persistent disabling problems. When symptoms such as dizziness, headaches,
fatigue, cognitive impairment, trouble sleeping, and vision problems
persist beyond the typical recovery period of three months, the term
post-concussion syndrome or disorder is applied. Symptoms may occur
immediately or may not occur for days or weeks after the injury, and can be
a different presentation with each individual.

Vision and Concussion


70% of our brain is dedicated to vision and vision processing, and 80% of
all sensory processing in the entire body is directly affected by
information coming in from the eyes. Thus, it is not surprising that a
concussion affects the visual system in some way. 90% of people with TBI
(traumatic brain injury) experience 1 or more oculomotor dysfunctions
(tracking, scanning), and 40% have visual dysfunctions (eye teaming,
focusing, and scanning or eye movements) persisting beyond 3 months.

Vision is not just about seeing 20 20. There are two aspects of vision that
interact in harmony in a typical individual;
1) central or focal vision: seeing fine details
2) peripheral or spatial vision: information about our surroundings, where
we are in space, where objects are relative to us, and how we would like to
move through space. This information is established by an interplay of
vision, proprioception (body position), posture, and the vestibular or
balance system.
People suffering from Post-Trauma Vision Syndrome (PTVS) typically
experience an imbalance in these two kinds of vision, where they are
embedded in the focal central vision without the grounding, stabilizing
spatial vision. This is why standard optometric testing can reveal 20/20
vision, but yet the person can experience debilitating problems with
peripheral vision, not knowing where they are in space, and discomfort in
busy environments (too many details to process without the grounding vision
to orient them, like watching a snow storm through the windshield with high
beams on).

Symptoms of PTVS

When vision doesn’t work, it interferes.

tired_eyes-backgroundPost-Trauma Vision Syndrome (PTVS) can impact daily function, including work, social, and recreational activities. Symptoms can vary from individual to individual, and can include any of or a combination of the following:

  • dizziness
  • headaches
  • difficulty with reading, computer work, and/or scrolling on a phone (can also include losing one’s place or re-reading the same line)
  • blurry vision
  • double vision
  • balance and depth perception issues
  • light sensitivity
  • motion sensitivity
  • discomfort in crowded or busy areas; bothered by busy patterns
  • reduced sense of where body is in space and reduced confidence navigating through space
  • impaired ability to process visual information
  • memory issues: difficulty recalling what was read, or seen

Assessment

A standard examination does not reveal enough information about the
complexities of visual dysfunction associated with a concussive injury.
However, it is important to do the standard examination after the injury,
which includes testing visual acuity, measuring a vision prescription if
present, and conducting a thorough eye health examination. A visual field,
or peripheral vision test, is advised on that visit.

A Neuro-Optometric Assessment is then required to further investigate
symptoms associated with PTVS. This specialized examination entails:

  • Eye alignment and eye teaming (the ability of the two eyes to
    work together at distance, near, and in various positions of gaze, as well
    as whether the coordination of the eyes is stressful or effortless under
    stress.
  • Scanning and tracking ability
  • Gaze stability
  • Focusing ability, stamina, and flexibility
  • Peripheral awareness analysis
  • Visual-vestibular function
  • Visual-spatial function and visual midline shift testing (sense
    of position in space)
  • Visual-verbal automaticity
  • Visual perception or processing skills

Treatment Strategies

*"It is a fact that the brain and body reliably turn conscious effort into
unconcscious action that allows us to move from learning to mastery"*

*"Long-term neuroplastic change occurs more readily when a person pays
close attention while learning." Dr. Norman Doidge, The Brain’s Way of
Healing*

The Ontario Neurotrauma Foundation supports evaluation and treatment of
post-concussion vision disorders by an optometrist specializing in
neuro-optometric rehabilitation. Optometric treatment strategies for PTVS
include the following:

  1.  Specialized glasses with coloured tints, partial lens occlusion,
    stress-relieving near-point prescriptions, and prism lenses which can help
    improve spatial vision, visual comfort and visual stability.
  2. A vision rehabilitation program to re-automatize visual functions
    that were once effortless and have become more difficult post-injury,
    requiring conscious effort and exhaustive energy to achieve. The program
    consists of activities designed in a hierarchal way and customized to the
    individual to improve visual skills and processing function. Results are
    best achieved with regular in-clinic visits to reinforce and challenge
    skills, supported with daily 15-minute home sessions. Duration can vary
    depending on the case, but a program can typically take 6-12 months. The
    best results are seen with patients who are motivated, dedicated,
    compliant, and persistent. Therapy is not done ‘to’ the patient passively,
    but requires active participation by the patient using the tools provided
    by the therapist.

Multi-disciplinary care:

*It takes a village…*

Vision is closely connected to our sense of body position in space,
posture, and the vestibular or balance system. For this reason, concurrent
treatment with other professionals such as Physiotherapists, Chiropractors,
and Osteopaths can enhance visual recovery. Occupational Therapists and
Speech-Language Pathologists among others, can also play a vital role in
co-managed care.

Appointment Booking Info

Prior to the neuro-optometric assessment, a full eye examination is
required on a separate day. If a full eye exam has been performed within a
year and after the injury, we will require the details of the exam by fax
prior to the neuro-optometric assessment. If a full exam was not performed
after the injury, a full exam will be required due to possibility of
prescription changes and importance of a thorough eye health evaluation.

The regular eye examination, 45 minutes in duration, will require the
instillation of pupil-dilating eye drops in order to thoroughly examine the
retina at the back of the eye. These drops typically last 2-3 hours and
cause light sensitivity and reduced near vision clarity. Sunglasses should
be brought to the appointment.

The neuro-optometric assessment is conducted on a separate day, 1.5 hrs
in duration. This visit can cause fatigue and provocation of symptoms for
the duration of the day in some cases.

Insurance Coverage

Vision assessments and therapy may be included in some insurance plans,
however this depends on the individual's policy.
We complete and submit OCF-18 forms for cases of MVA (motor vehicle
accident). We are not currently set up for direct billing and require
payment for all visits.