1. Vision and Brain Trauma:
Optometric management of vision disorders in the traumatic brain injury population
Juanita D. Collier, MS, OD, FCOVD
Leslie Diaz, Vision Therapist, Training coordinator
4D Vision Gym

2. LEARNING OBJECTIVES
Recognize symptoms and behaviors that may be associated with Persistent Post Traumatic Vision Syndrome and other concussion/TBI vision disorders
List the effects of TBIs on vision
Learn statistics on the prevalence of vision disorders in concussed athletes
List the visual skills that can be restored through vision rehab
Explain the diff treatment options available through Behavioral Optometry
Execute vision screenings to determine when evaluation by a Behavioral Optometrist is necessary
We hope that by the end of this discussion, you will be able to:
Recognize when someone may have certain vision disorders, such as Persistent Post Traumatic Vision Syndrome
Explain how TBIs affect visual functioning and 3) Know how prevalent these vision issues really are in the concussed athletic population
4) Explain the different treatment options available through Behavioral Optometry, such as Vision Therapy
5) Know how Vision Therapy can help restore visual skills and help the patient return to their activities of daily living
6) Perform your own vision screenings to determine when to refer to a Behavioral Optometrist

3. Behavioral Optometry A Behavioral Optometrist: A Vision Therapist
functioning to determine the cause of an individual’s symptoms
Creates a treatment plan for resolution of symptoms and rehabilitation of visual function
A Vision Therapist
Trained under a Fellow of the College of Optometry and Development
Carries out the treatment plan to create permanent change at the neurological level by retraining the brain through the use of optometric tools

4. ≠ What is Vision? What is it? (20/20 vision, accommodation)
Where is it? (oculomotor skills, depth)
Where am I? (knowledge of body in space)
What does it mean? (visual perception)
How do I react? (eye-hand-body coordination) ≠
It is commonly believed that 20/20 vision is “perfect vision”, when in actuality 20/20 refers only to eyesight and does not take into account how we use that eyesight in order to guide decision-making. To help us with this decision making, Vision answers the following 5 questions:

6. Vision Is More Than 20/20
The relationship between the eyes, brain, and body
How we derive meaning from our environment
A learned process
Interconnected with other neurological processes ≠

7. Vision is a Learned Process
Ocular Motility
Focusing on Objects Near & Far
Eye Teaming
Fusion & Depth Perception
Visual-Motor Integration
Visual Perception
A weak spot in any of these key visual areas can hinder learning and affect behavior

8. TRAUMATIC BRAIN INJURY (TBI)
Bump, blow, jolt to the head or a penetrating head injury that disrupts the normal functioning of the brain
Severity ranges from “mild” to “severe”

9. TRAUMATIC BRAIN INJURY (TBI)
The Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine defined a mild TBI:
1. any period of loss of consciousness;
2. any loss of memory for events immediately before or after the accident;
3. any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused);
4. focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following:
• loss of consciousness of approximately 30 minutes or less;
• after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13–15; and
• posttraumatic amnesia (PTA) not greater than 24 hours.

10. Concussions and Post-Concussion Disorders
“A complex pathophysiological process affecting the brain, induced by biomechanical forces.”

11. What Occurs During a Concussion?
Excessive force applied to head or body
Brain crashes into sides of skull
Functional disturbance, not structural
Loss of consciousness
Recovery is a sequential process
Onset of symptoms varies

12. Concussion-Related Symptoms
Physical
Fuzzy, blurry or double vision
Headaches
Nausea and vomiting
Dizziness
Sensitivity to light or sound
Balance or depth perception problems
Cognitive
Mental fog
Difficulty concentrating
Difficulty remembering new information
Confusion
Sleep/Fatigue
Sleeping more or less than usual
Drowsiness or fatigue
Difficulty falling asleep or staying asleep
Emotional
Easily upset or angered, irritable
Sad
Nervous, anxious, or agitated
More emotional than usual

13. Concussions and Post-Concussion Disorders
Post Concussion Syndrome
Prolonged recovery from initial symptoms
Persistent Post-Traumatic Vision Syndrome
Imbalance between two visual processes, ambient and focal

14. Persistent Post Traumatic Vision Syndrome Symptoms
Blurred vision
Double vision
Light sensitivity/photophobia
Textual Visual Aliasing
Dizziness
Headaches
Limited attention or concentration
Confusion in visually stimulating environments
Loss of place when reading
Reading problems/comprehension issues
Loss of peripheral vision
Reduced visual processing skills

15. The Visuo-Cognitive Effects of TBIs on Vision
Visual Perceptual Skills:
Visual Motor Integration
Visual Auditory Integration
Visual Memory/Sequential Memory
Visual Closure
Visual Discrimination
Visual Figure Ground Discrimination
Visual Spatial Relations/Organization

16. Prevalence of Vision Dysfunctions in TBI Patients
After a TBI:
Approximately 30% of concussed athletes report having vision problems
For veterans who have suffered TBIs from a warzone blast, the rate of CI ranges from 25% to 47%
In the pediatric athletic population, more than 25% of those with acute concussions and more than 60% of those with post-concussion syndrome were found to have vision issues
In a study of hockey players, those with visual issues were 10x more likely to have previously suffered from a concussion
In a study of a general TBI population, 90% of individuals suffered from at least one type of visual problem not related to acuity

17. Concussion/TBI Treatment Team
Rehabilitation programs:
Hospital, Long-term, Outpatient, Home-based
Rehabilitation specialists:
Physicians
Rehabilitation Nurses
Physical Therapists, Occupational Therapists, Speech-Language Pathologists
Social Workers, Psychologists
Athletic Trainers
Behavioral Optometrists, Vision Therapists

18. Diagnosing a Concussion
1. Thorough head examination
Trauma
Neck exam
Signs of cervical spinal cord damage
2. Comprehensive neurological examination
Cognitive functioning
Physical functioning
Visual functioning

19. Vestibular/Ocular Motor Screening
Developed at the University of Pittsburgh
90% accuracy in diagnosing a concussion
Areas tested:
Smooth Pursuits
Saccades
Vestibulo-Ocular Reflex
Visual Motion Sensitivity
Near Point of Convergence

20. A Word of Caution:
Structural evaluation of the eyes does not provide a complete screening or diagnostic assessment for a comprehensive understanding of the visual system.

21. Visual Signs During your Evaluation
Oculomotor Dysfunction
Smooth Pursuits
Saccades
Vestibulo-ocular Reflex
Visual Motion Sensitivity
Near Point of Convergence

22. Oculomotor Dysfunction
Example of Oculomotor Issues

23. Visual Signs During your Evaluation
Oculomotor Dysfunction
Smooth Pursuits
Saccades
Vestibulo-ocular Reflex
Visual Motion Sensitivity
Near Point of Convergence
Visual Signs During your Evaluation

24. VOR Impairment Reading text especially challenging:
Distortion produced by even the smallest head movements
Bouncing words and shifting letters require more effort to process
VOR Impairment

25. Visual Signs During your Evaluation
Oculomotor Dysfunction
Smooth Pursuits
Saccades
Vestibulo-ocular Reflex
Visual Motion Sensitivity
Near Point of Convergence

26. Visual Motion Sensitivity
Mismatch between visual, vestibular, and somatosensory system
Discrepancy between what stimuli is expected and what is received
Symptoms:
Episodic dizziness
Fatigue
Imbalance
Motion sickness
Vertigo
Nausea/vomiting

27. Visual Signs During your Evaluation
Oculomotor Dysfunction
Smooth Pursuits
Saccades
Vestibulo-ocular Reflex
Visual Motion Sensitivity
Near Point of Convergence

28. Convergence Issues

29. What is a Sensorimotor Evaluation?
Near Point of Convergence Test
Extra Ocular Motilities Test
Depth Perception Test
Cover Test

30. Treatment for Vision Disorders
Prismatic compensation:
expand peripheral vision
compensate for visual field loss
reduce visual stress
improve neglect and midline shift
improve balance, gait, and mobility
Vision Therapy

31. What Is Vision Therapy?
Vision therapy is an individualized treatment program prescribed to eliminate or improve conditions such as eye turns, tracking, focusing, eye teaming and learning related vision disorders through the utilization of lenses, prisms, and other optical equipment in a wide variety of activities.
Trains the visual system to
Input accurate information
Process visual information efficiently
Output an effective response or action

32. The Vision Therapy Difference
Because of our specialized training, we can go deeper into the visual system and improve the ability to:
See clearly when focusing, near and far
Move smoothly, accurately, and quickly from one point to another
Work together as a team
Interpret and use visual information efficiently

33. Vision Therapy In Action

34. Rehabilitation Strategies
Starts no later than 2 weeks after a concussion
Active, vestibular work
Reduces spatial orientation issues and motion sickness
Journaling for planning and pacing
Energy “diet”
Sub-symptom thresholds

35. Rehabilitation Strategies
Peripheral awareness
Floor: stabilization
Compression
Peripheral  Central  Peripheral
Use a pain/discomfort scale
Vestibular challenges
VOR training
Pursuits/Saccades Training

36. Case Study Presentation
17 yo white female student athlete
Sustained concussion on 10/09/13 during soccer game
Presented on 01/28/2014 with unresolved symptoms of:
Becoming easily tired when reading for more than 5 minutes
Headaches when reading for more than 5 minutes
Eyestrain
Short attention span
Balance inconsistencies
Blurry near vision
Incoming Diagnoses:
Convergence Insufficiency with Intermittent Exotropia
Accommodative Insufficiency
Persistent Post-Traumatic Vision Syndrome

37. Case Study, continued
Vision Therapy treatment plan consisted of activities designed to:
Improve her ability to coordinate both eyes together
Build appropriate accommodative flexibility
Improve her visual processing speed
After 20 VT sessions:
Could read for an unlimited amount of time without discomfort
No longer experienced headaches
No longer needed medication
Resolved all visual diagnoses
Graduated from Vision Therapy with:
A brighter future – she graduated senior year on time; accepted to and now attends Villanova University!
Self-confidence – pursued and passed lifeguard training!
More fun - the ability to go on roller coasters once again!

38. When I first started vision therapy, my eyes could not focus properly and I could not read for more than 5 minutes at a time. Now I can read for an unlimited amount of time! I was able to graduate (high school) on time and will go off to college in the fall.
- 4D Vision Gym Graduate, 17 years old
From her mother: “We were so happy to find Dr. Collier and the coaches. Their care and expertise really helped our daughter complete her senior year and be ready for college. Most concussion specialists are unaware that a concussion can create convergence issues with the eyes”

39. Conclusions
Neurological impairments such as TBIs, concussions, and strokes can be successfully treated with recovery of most abilities with active rehabilitation.
A multidisciplinary team is required to successfully treat all areas of dysfunction, with assigned contact people responsible for communicating with all members.
Visual issues are significantly prevalent in the post-concussion or post-TBI population, making it crucial for all healthcare providers to be aware of the signs of visual dysfunction and options for treatment

40. Dr. Juanita D. Collier, Optometric Physician
Contact Information
Dr. Juanita D. Collier, Optometric Physician
4D Vision Gym
Cromwell, CT 06416
(860) 632-UC4D

41. References 1. www.ATSNJ.org
2. Pediatric Strategies for Prolonged Recovery in Pediatric and Adolescence Care. Pediatric Annals 41:9, Vidal, Paul G., PT, MHSc, DPT, OCS, FAAOMPE; Goodman, Arlene, MD; Colin, Amy, MA, CCC-SLP; Leddy, John L., MD; Grady, Matthew, MD 3.
4. International Conference on Concussion in Sport Zurich, Switzerland, November 2008 and November 2012
5. Office Based Management of Pediatric and Adolescent Care. Pediatric Annals 41:9, September Master, Christina L., MD and Grady, Matthew F., MD

42. References
6. Importance of “Return to Learn” in Pediatric and Adolescent Care. Pediatric Annals 41:9, September Master, Christina L., MD; Cioia, Gerard A.; Leddy, John L.’ and Grady, Matthew F., MD
7. Post Concussion Syndrome: New Optometric Interventions. Merrill Bowan, OD. 2014
8. Concussions: Getting Your Head Out of the Game. American Medical Society for Sports Medicine. October 3, 2014.
9. Effect of Oculomotor Rehabilitation on Vergence Responsivity in Mild Traumatic Brain Injury. Journal of Rehabilitation Research and Development. Vol 50, number
10. Furman, et al. PITT, UPMC Researchers Create New Vestibular Test to Add to Comprehensive Concussion Screening. September 9, 2014.

43. References
11. Cook, et al. Cognitive gains from gist reasoning training in adolescents with Chronic-stage traumatic brain injury. Frontiers in Neurology. 11 June 2014.
12. Annette Theis, MSPT; Gaylord Specialty Healthcare. “Beyond the Diagnosis: Eyes, Balance and Gait.” Concussion Conference, 9/24/14, Quinnipiac University
13. DeAnn Fitzgerald, OD. “Sports Concussions Management and Treatment.” Northeast Congress of Optometry, 9/7/14, Westford MA
14. Vestibular Disorders Association. Vision Challenges with Visual Disorders.

44. References American Medical Association www.ama-assn.org
National Stroke Association
American Stroke Association
National Institute of Neurological Disorders and Stroke
Annette Theis, MSPT; Gaylord Specialty Healthcare. “Beyond the Diagnosis: Eyes, Balance and Gait.” Concussion Conference, 9/24/14, Quinnipiac University
DeAnn Fitzgerald, OD. “Sports Concussions Management and Treatment.” Northeast Congress of Optometry, 9/7/14, Westford MA
Centers for Disease Control and Prevention

45. References
22. Hellerstein LF, Freed S and Maples WC. Vision profile of patients with mild brain injury J Am Optom Assoc 1995;66:
23. Cockerham GC, et.al. Eye and visual function in traumatic brain injury. J Rehabil Res Dev 2009;46(6):
24. Chang A, Cohen AH and Kapoor N. Top-down visual framework for optometric vision therapy for those with traumatic brain injury. Optom Vis Perf 2013;1(2):48-53.
25. Suchoff IB, Gianutsos R. Rehabilitative optometric interventions for the adult with acquired brain injury. In: Grabois M, Garrison SJ, Hart KA, et al., eds. Physical medicine and rehabilitation: the complete approach. Malden, MA: Blackwell Science, 2000:

46. References
26. Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. The American journal of sports medicine. 2014;42(10): doi: /
27. Thiagarajan P, Ciuffreda KJ, Ludlam DP. Vergence dysfunction in mild traumatic brain injury (mTBI): A review. Ophthalmic Physiol Opt. 2011;31(5):456–68.
28. Galetta KM, Barrett J, Allen M, et.al. The King-Devick test as a determinant of head trauma concussion in boxers and MMA fighters. Neurology (17):

47. References Images and Animations:
Google Search. Google. Web. 07 October 2013.
Childrensvision.com