Optometric Management of a Post-Concussion Patient: A Case Report

A case report on the optometric vision therapy treatment of the visual symptoms of a concussion patient was published in the December 2016 issue of the journal, Vision Development & Rehabilitation. We treat many concussion patients in our vision therapy and rehabilitation practice in Vancouver and the results of this case report are consistent with the results that we see in our clinic.

Concussions are a mild injury to the brain which have been known to cause visual problems such as blur, double vision, reading problems, sensitivity to light, visual memory problems and other visual deficits like reductions in contrast perception. It is estimated that 15% of concussion patients experience a visual problem as a result of their concussion.

The patient that was the subject of the case report suffered several sports-related concussions that caused a variety of problems with the patient's visual system. The patient was diagnosed with with low myopic astigmatism, convergence insufficiency, fusional instability, oculomotor dysfunction, and photosensitivity. Treatment included tinted spectacle correction for full-time wear and conventional oculomotor-based vision therapy. 

When vision therapy concluded, the patient was free of symptoms. And this effect was still present at a three-year follow-up appointment. The results demonstrate the efficacy of a comprehensive optometric approach in concussion treatment. The results also demonstrate the ability of the visual system to heal when the proper therapy is used for treatment. 

Patching alone is not good enough for amblyopia treatment

This point, that was made in a study published in the September 2010 issue of the journal Optometry & Vision Science should be required reading for every amblyopia patient (or their parents):

amblyopia is an intrinsically binocular problem and not the monocular problem on which current patching treatment is predicated. Thought of in this way, the binocular problem involving suppression should be tackled at the very outset if one is to achieve a good binocular outcome as opposed to hoping binocular vision will be regained simply as a consequence of acuity recovery in the amblyopic eye, which is the current approach and which is often not found to be the case.

Developmental (behavioural) optometrists (which is what we are) treat amblyopia using the better approach. If you are looking for a developmental or behavioural optometrist, visit the website of the College of Optometrists in Vision Development.

For more information on amblyopia, including alternatives to patching, visit www.amblyopia.ca.

Brain injuries and vision problems - vision therapy and developmental optometry

Brain injuries Brain injuries can result from impacts during sports, car accidents or falls and they can also result from events like a stroke, aneurysm or due to degenerative diseases that affect the brain. A brain injury caused by an external trauma to the head is called a “traumatic brain injury” or “TBI”.

Brain injuries and vision

It is estimated that 20%-40% of people with brain injuries suffer vision related disorders.  

At our Vancouver developmental optometry clinic, we have treated patients with brain injuries resulting from car accidents, viral brain infections, sports related injuries such as concussions and more with vision therapy.

In many brain injury cases, eye muscles or the nerves controlling the eye muscles are damaged, resulting in problems with teaming, movement and focusing of the eyes. These disorders include binocular vision problems, visual information processing disorders, convergence insufficiency and accomodative insufficiency.

A number of published research studies support vision therapy as a and effective treatment for vision disorders caused by brain injuries.  One study presented  4 cases of pediatric brain injury patients aged 6-18 years who were examined at an optometry clinic of a local hospital.  The author found that the children suffered from a variety of ocular and visual disorders and three of them were having difficulties academically. Academic problems are no surprise since 80% of our learning happens through our visual system.  The patients benefited from vision therapy.

Symptoms of brain injury caused vision disorders

The most common vision related symptoms of brain injuries include the following:

• Double vision
• Poor eye tracking ability
• Difficulties with shifting gaze quickly from one point to another
• Focusing
• Loss of binocular vision (eye alignment)
• Eye strain
• Fatigue
• Glare, or light sensitivity
• Inability to maintain visual contact
• Headaches
• Blurred near vision
• The extent of the injury can also impact a person’s visual information processing ability.  This can cause the following symptoms:
• Spatial disorientation
• Shifts in ability to judge location of objects
• Difficulties with balance and posture
• Poor depth perception
• Memory loss
• Poor handwriting

Studies on the treatment of vision problems caused by brain injury

For more information on the treatment of vision problems caused by brain injuries, check out the following published scientific studies on the topic:

Brodak, M.I. Pediatric acquired brain injury. Optometry 2010 81: 516-527. DOWNLOAD.

Green, W., Ciuffreda, K.L., et al. Accomodation in mild traumatic brain injury. Journal of Rehabilitation Research & Development. 2010. 47: 183-200. DOWNLOAD.

Ciuffreda KJ, Ludlam DP, Kapoor N. Clinical oculomotor training in traumatic brain injury. Optom Vis Dev 2009;40(1):16-23. DOWNLOAD.

Cockerham, G.C., Goodrich, G.L., et al. Eye and visual function in traumatic brain injury. Journal of Rehabilitation Research & Development. 2009. 46: 811-818. DOWNLOAD.

Julie L., Julie, B-T, et al. Deficits in complex visual information processing after mild TBI: Electrophysiological markers and vocational outcome prognosis Brain Injury.March 2008; 22(3): 265–274. DOWNLOAD.

Stanley, Paul. Effects of computer assisted visual scanning training on visual neglect: three case studies. Physical & Occupational Therapy in Geriatrics,1996 Vol. 14(2) 33-44. DOWNLOAD.

Sharieff K. From braille to quilting: a neuro-optometric rehabilitation case report. Optom Vis Dev 2010;41(2):81-91. DOWNLOAD.

Schlageter, K. Gray, B. Incidence and treatment of visual dysfunctoin in traumatic brin injury. Brain Injury. 1993, 7:439-448. Download.

Brosseau-Lachaine, O. Gagnon, I. et al. Mild traumatic brain injury induces prolonged visual processing deficits in children. Brain Injury.August 2008; 22(9): 657–668. DOWNLOAD.

Leslie S. Myopia and accommodative insufficiency associated with moderate head trauma. Opt Vis Dev 2009;40(1):25-31.DOWNLOAD.

Gottlieb, D.D., Fuhr, A., et al. Neuro-optometric facilitation of vision recovery after acquired brain injury. NeuroRehabilitation. 1998. 11: 175-199. DOWNLOAD.

Mandese M. Oculo-visual evaluation of the patient with traumatic brain injury. Optom Vis Dev. 2009;40(1):37-44. DOWNLOAD.

Raymond, M.J., et al. Rehabilitation of visual processing deficits following brain injury. NeuroRehabilitation. 1996. 6: 229-240. DOWNLOAD.

Proctor A. Traumatic brain injury and binasal occlusion. Optom Vis Dev 2009;40(1):45-50.DOWNLOAD.

Tong D, Zink C. Vision dysfunctions secondary to motor vehicle accident: a case report. Optom Vis Dev 2010;41(3)158-168. DOWNLOAD.

Tassinari JT. Vision Therapy for sensory fusion disruption syndrome: two case reports. Optom Vis Dev 2010;41(4):215-221.DOWNLOAD.

Hellerstein L.F., Freed S., Maples, W.C., Vision profile of patients with mild brain injury. J Am Optom Assoc. 1995; 66: 634-39. DOWNLOAD.

Freed, S. Hellerstein, LF, Visual electrodiagnostic findings in mild traumatic brain injury, Brain Injury. 1997, VOL. 11, NO. 1, 25-36. DOWNLOAD.

Rowe, F. Visual perceptual consequences of stroke. Strabismus. 2009 Jan-Mar;17(1):24-8. DOWNLOAD.

Han, E., The role of the neuro-rehabilitation optometrist. DOWNLOAD.

Suchoff, I., Gianutosos, R., Rehabilitative optometric interventions for the adult with acquired brain injury. DOWNLOAD.

Visual function development: behaviors to watch out for in your children

Developmental optometry and ophthalmology

Dr. Lea Hyvarinen is one of the worlds few developmental ophthalmologists.  Usually, if you or your child has a developmental vision problem you will see a developmental optometrist like Dr. Randhawa  who is a member of the College of Optometrists in Vision Development (COVD).  Dr. Lea has just commenced a blog on children's vision development, which you can visit here and was a well-received speaker at the COVD annual meeting last weekend.

Dr. Lea Hyvarinen

In a recent post about infants with normal visual development, she provided the following table, which summarizes the development of visual functions that are easy to for parents and teachers to observe.  The table and the related post give an excellent indication of the quality of her new book called "What and how does this child see?" 

Visual information processing

The book covers many of the topics discussed on this blog, including as visual information processing, a topic that North American ophthalmologists tend not to be familiar with.  For example, see this 1996 study from the field of rehabilitation medicine published in the journal NeuroRehabilitation by Raymond et al., where the authors say that patients with potential visual information processing deficits "should be referred to a behavioral or neuro-optometrist" and noted that  "referrals made to an ophthalmologist may be insufficient, as they are primarily concerned with the health of the eye only."  Of course, Dr. Lea is an exception to this and would likely provide excellent assessments of her patient's visual information processing skills.

Visual development behaviors to watch for

Parents can refer to this table when trying to assess their child's visual development.  But understand that trained professionals should be consulted for reliable assessments and diagnoses.  As noted by Dr. Lea, the table "summarizes the main steps of the visual development. These milestones are used in many countries in the follow-up of normal development of visual functions and in detecting symptoms and signs of deviations from the norm."

Age (months)	Behavior
0–1	•       turns eyes and head to look at light   sources  •       horizontal eye tracking, tonic focusing
2–3	•       intense eye contact at 6-8 weeks  •       vertical and circular tracking •       interested in mobiles •       interested in lip movements
3–6	•       watches own hands  •       reaches toward, later grasps hanging objects •       observes toys falling and rolling away •       shifts fixation across mid-line •       visual sphere of attention widens gradually •       very active in visual interaction
7–10	•       notices small bread crumbs, touches them  •       adjusts the grasp to the size of the objects •       interested in pictures, also stereo images •       recognizes partially hidden objects •       recognizes family members by facial features
11–12	•       knows places at home  •       looks through window and recognizes people •       recognizes pictures, plays hide-and-seek •       can predict adult’s goals of motor actions

For more information of children's vision, eye care, and children's optometry, please visit www.kidsvision.ca.

Related articles:

Study proves that vision problems - visual information processing deficits -  interfere with learning to read and cause dyslexia

The former First Lady of the United States on her daughter's developmental vision problem and how vision therapy worked for her

Mom of struggling reader speaks out

Vision problems can have drastic effects on brain development and learning

How to choose a children's (pediatric) optometrist

Binocular vision dysfunctions ate my homework 

TED: ideas worth spreading - Dr. Susan Barry on vision therapy and depth perception

Patient story - Five year old girl sees her mom's face for the first time in our Vancouver eye clinic

The former First Lady of the United States on vision therapy

Lyndon B. Johnson was the 36th president of the United States and was married to First Lady, Lady Bird Johnson. Many of  Lady Bird's interviews are collected at the LBJ Presidential Library at the University of Texas.  In one interview she talks about her daughter's "eye problem" and how an optometrist who prescribed a program of eye exercises (vision therapy) cured her and allowed her to function to the limits of her intellectual abilities.

Here is an except of the interview (thanks to the Vision Help Blog for finding this gem) where "J:" stands for Lady Bird Johnson and "M" stands for the interviewer, Harry Middleton.  Janet Travail, who is mentioned a couple of times in the excerpt below, was the White House physician at the time.  Lady Bird begins this excerpt and we have reproduced it starting in mid-paragraph:

     "It was a great thing that happened in her life.  She had long had an eye condition, now the well-known name for it is dyslexia.  But there are many, many forms of that, where what you see doesn't get translated to the brain in quite the way it should.  It used to be a puzzle to her teachers and to us, that this child that we thought was so bright would not make good grades.  And the teachers would talk to me about it and I would take her to the best eye doctors that I could, according to what my peers, the wives of other congressmen and senators, told me was the best eye doctor they'd found.  And they'd say, "Nothing the matter."  Finally--no, this was even after this time--she fell into the hands of the doctor who finally discovered her ailment, was maybe after Lyndon became vice president.  So it may have been still a year in the future.  But it's something that I want to tell a little bit about, because that lady doctor who took care of Kennedy--

M:   Travail.  Was it Janet Travail, or something like that.

J:   Janet Travail directed her, I think, as I recall, to a doctor, and his name I will too remember in a few minutes, because he has remained our lifelong friend.  [He] figured out what it was, gave her a series of eye exercises that changed her whole life and personality, because she became an achiever up to her mental capacity, her very remarkable mental capacity, whereas before, because of this eye problem, she had just kind of been stunted, and frustrated, and angry.  It changed her personality, her rate of performance; it was a wonderful blessing. 

M:   Was it eye exercises only that changed it?

J:   Dr. [Robert] Kraskin.  I do not know what.  It was treatments; a large part of it were eye exercises, I think.  And whatever he did, it was a boon, principally to Luci, but just as much, almost, to her mother and the rest of the family.  And that is a digression.  But--

M:   Well, it's a good one. 

J:   --in our life it was an important one."  

Here is a link to what seems to be a piece written by President Johnson's daughter, Luci, on her treatment by Dr. Kraskin and how it impacted her life: http://visiontherapyofvermont.com/2011/02/.

The interview above and Luci's comments at the previous link resonate with what so many patients with developmental vision problems and eye coordination problems (as well as their families) experience every day.  Vision therapy's positive impact on the patient also has not changed since Lady Bird's time.

The sad thing is that the run around that some patients receive before they find the right doctor and the right treatment is the same today as it was in the 1960's when Lady Bird and her daughter experienced the frustration of a treatable condition that the "best doctors" could not figure out.

To learn more about vision therapy visit www.visiontherapy.ca and to learn about children's vision development visit www.kidsvision.ca.

The photographs in this post come from Wikipedia and are Lady Bird Johnson and President Lyndon B. Johnson.

The gold standard treatment for convergence insufficiency

Convergence insufficiency (CI) patients are unable to properly make their eyes move inward when doing near work like reading. Often, the intensity of symptoms in CI depends on the amount and type of near work a patient does.  Students obviously do lots of near work their symptoms may be severe and diminish their academic performance.

The problem of CI is serious enough that the National Eye Institute (one of the National Institutes of Health in the United States) funded a number of studies to determine the best treatment for CI.  These studies are known as the Convergence Insufficiency Treatment Trials (CITT).  Most of the CITT studies can be found here.  The treatments investigated by the CITT included office-based accommodative–vergence therapy with supplemental home therapy, placebo office-based vision therapy, home-based computerized vision therapy with pencil push-ups, and pencil push-ups. 

A major review of the CI research to date was published in the journal Optometry earlier in 2012.  You can read the entire review here.

Patients who participated in the CITT were assessed at the end of 12 weeks of  therapy. In-office vision therapy supplemented with home therapy was found to be the most effective treatment. Long-term effects were determined at 6 months and 12 months of follow-up and the beneficial effects of vision therapy were found to be lasting.

Vision therapy is the gold standard for treating CI.

Mom of Struggling Reader Finds Help and Speaks Out for College of Optometrists in Vision Development's National Children's Vision and Learning Month

This blog post reproduces the content of a press release issued by the College of Optometrists in Vision Development to commemorate National Children's Vision Learning Month. It is a story that is familiar in my office and the office of every developmental optometrist. Patients are told by doctor after doctor that their child's vision is fine so long as the child can read the letters on the chart and there is nothing wrong with the physiology of the eye. However,visual acuity the the health of the structures that make up the eye are only part of an eye examination.

Developmental optometrists also assess the functioning and movement of the eye, the ocular muscles and the workings of the visual system. The latter assessments can uncover binocular vision problems or deficiencies in visual informaiton processing, which have been shown to adversely impact learning and academic performance.

Here is the press release:

Despite being told by five different eye doctors that her 8-year-old daughter Shelby's vision was fine, Lynn DeVore of Yakima, Washington continued to search for reasons why her daughter continued to struggle with reading. The pediatrician said that since the eye doctors said Shelby's vision was fine that Lynn "was just being paranoid and that maybe Shelby was simply not very smart." She continued to search until she found the answer and now DeVore is stepping forward to help other parents by sharing their story for National Children's Vision and Learning Month.

"We knew there was a problem early on, but we were told she would read soon. We struggled and struggled and still reading was a fight. Shelby was very frustrated with reading and had very little confidence in all areas of her life," shares DeVore. Fortunately she saw an ad in a local magazine that listed all the things Shelby struggled with. The ad was for a developmental optometrist who provides an in-office program of optometric vision therapy.

The evaluation confirmed that Shelby did in fact have a vision problem. It was convergence insufficiency, an eye coordination problem that can make reading very difficult. After completing the prescribed program of vision therapy, Shelby went from reading at 1st grade level to reading on grade level.

How could so many eye doctors have missed this? A very good question! When parents suspect their children have a vision problem that is contributing to their learning difficulties they often go to the pediatrician or the pediatric ophthalmologist only to be told their child's vision is fine and they can see 20/20. States Dr. David Damari, President of the College of Optometrists in Vision Development, "It is important for parents to know that when it comes to the diagnosis and treatment of vision problems which interfere with reading and learning, a comprehensive vision exam is needed. These children need to see an optometrist who provides an in-office program of vision therapy and performsthe in-depth testing required to determine if the child has all the visual skills required for academic success,".

Despite volumes of evidence-based optometric research, many pediatricians and ophthalmologists continue to state that vision has nothing to do with learning, referring parents to psychologists, learning specialists, etc. However, the limitations caused by convergence insufficiency and similar visual disorders can be disabling during reading and computer use according to the definitions of disability in the Americans with Disability Act, but these disorders are all easily treatable with optometric vision therapy.

The five most common signs that a vision problem may be interfering with your student's ability to read and learn are:

1. Skips lines, rereads lines

2. Poor reading comprehension

3. Takes much longer doing homework than it should take

4. Reverses letters like "b" into "d" when reading

5. Has a short attention span with reading and schoolwork

Any one of these symptoms is a sign of a possible vision problem. A more in-depth symptoms checklist is available on COVD's website.

It is vital that parents take the time to learn all of the signs that a vision problem may be interfering with academic performance. When a child has a vision problem, they do not outgrow it, and despite extensive tutoring or special services at school, very little improvement occurs.

Shelby was lucky that her mother didn't take no for an answer. Take 5 minutes in honor of August being National Children's Vision and Learning Month and visit the website for the College of Optometrists in Vision Development; then spread the word and share the information: www.covd.org .