Optometry’s role in Concussion diagnosis and …...• Used in therapy for Concussion, ABI, strabismus and other therapies • Gain can be changed by lenses and therapy •Low plus/minus

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CONCUSSIONWHERE DOES OPTOMETRY FIT IN? ‐2HRS

CE QUALITY LECTURE

OPTOMETRY’S ROLE IN CONCUSSIONDIAGNOSIS AND MANAGEMENT

• Keith Smithson, OD

• Northern Virginia Doctors of Optometry

• Director of Visual Performance Washington Nationals

• Team Optometrist Washington Redskins, Wizards, Mystics, Spirit, DC United

• Visual Performance Consultant Washington Capitals

• AOA Sports and Performance Vision Comm‐ Immed. Past Chair

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FINANCIAL DISCLOSURE

• Dr. Smithson is a consultant for VSP, RightEye, Neurotracker, Headstrong, Sensory Performance Technology, Johnson and Johnson Vision Care

CONCUSSIONS – A HOT TOPIC

• Concussions in the Military (IED)

• Concussions and TBI in the NFL, Concussion the movie

• Return to Play Law – all 50 states

• Rest vs. Exercise

• Primary vs. Secondary concussions

• Concussion Testing for youth coaches

• Concussion Centers actively looking for Optometry

• *Importance of vision in pretesting, evaluating and treating concussions

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WHAT THE WORLD THINKS CONCUSSION LOOKS LIKE

• It’s big news these days… everybody’s got one… or not?• How to assess true Concussion. Can be a challenge‐ pre‐existing conditions/ anxiety/ true concussion

• My opinion is to not be frontline ( removal/ return to play) but an integral part of the rehabilitation team focusing on the visual component of concussion

• Who is comfortable beginning the management of the visual symptoms of concussion?

CONCUSSION

•What does a concussion look like in your chair?

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WHAT IT LOOKS LIKE

CONCUSSIONWhat is a concussion?

• Generally accepted terms

• Concussion trajectories

• Concussion symptoms

• Visual symptoms of concussion

• Other symptoms of concussion

• What kind I find? and How can I help to fix it?

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WHAT IS A CONCUSSION/MTBI?

• Defined as an immediate acceleration and deceleration or stopping event, resulting in temporary or permanent damage to the “structures” of the head.

• 2.5 million TBI reported in 2010 (hospital)

• 75% were mTBI

• How many are not reported?

• 1 of 10 mTBI have persistent symptoms

CONCUSSION

• What is the role of the primary care optometrist?

• Understand how concussion effects visual function in our patients

• Understanding the other signs and symptoms of concussion

• Communicating information to other providers

• Understand the neurology in treatments of visual sequelae of concussions

• Providing care/referrals to those that can and do treat

• Provide a framework for evaluation that all practitioners could accomplish and then work up from there based on the technology/ experience and comfort level each practitioner

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CONCUSSION

• 6 current trajectories for symptoms of concussion• 1. Vestibular – This is vision…we’ll explain

• 2. Anxiety and mood – Aspects of vision

• 3. Ocular/visual – This is vision

• 4. Migraine – This can be affected by vision

• 5. Cognitive fatigue – This can be affected by vision

• 6. Cervical – This can be affected by vision

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WHAT DO YOU OBSERVE IN A CONCUSSION/MTBI?

• Physical aspects are overt• Slow to get up, disoriented, gait

• Speech/Cognitive aspects are overt• Speech is irregular, not oriented to self, place or time

• Some visual aspects are overt

• Dizziness

• Nausea due to visual/vestibular dysfunction• Reading problems


• Some visual aspects are covert

• Blurry Vision‐ Previously undiagnosed Refractive, Latent Hyper

• Photophobia

• Convergence/non‐Strabismic

• Accommodative function

• Visual/vestibular‐balance issues

• Visual Processing Delays

• Visual Reaction Speed delays

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Blurry Vision‐ Near or Far? End of day or upon waking? Doing specific things?

What is the first step?

Refract

Look for:

Previously uncorrected refractive error

Latent hyperopia

Anisometropia

Oblique Astigmatism

Small error can yield larger than expected gain. Trial frame and prescribe if needed

Powerful to give immediate benefit, even if other aspects still need to be addressed

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Photophobia

Difficult to quantify

Case history again important‐ What kind of light? Outdoor, computers, all?

Some discussion around managing photophobia, to do or not to do?

I am a believer in giving relief where you can as, other symptoms seem to resolve quicker then, and again can help manage the anxiety component from extended recoveries

Photophobia Interventions

Tints‐ Can trial in the room or in dispensary, glasses or contacts

Photochromic lenses‐ if constant indoor and out

Blue Blocking if induced more by digitaal light

Nutritional supplements

Some cases with all interventions in place will spontaneously resolve when rest of syndrome remediated

Some will not‐ Constant tints, tinted windshields, visors etc.

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There is a problem with Convergence?

Start with simple cover testing

Distance and near phorias

NPC‐ Normal 10cm

Base In/ Base Out vergence, I prefer prism bar for

observation

Can be CX/CI/ Hyper/ Verg Infacility

MAy be pre‐existing 15‐20% gen population

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What to do?

Basic VT, has already been lost to concussion centers/

PT/ ATC etc. ( Brock String, Barrel Cards,

Pencil push ups etc.)

Prism

Higher level VT, using stereopsis

Remember we are building vergence ranges to

compensate for a deficit,

not changing a pre‐existing phoria magnitude

Treat to your level of comfort‐ refer if necessary

Accommodative Function

FCC

NRA/PRA

Accommodative Amps

Think pre‐presbyopia or if latent hyperope

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What to do?

PAL lenses‐ Specs or Cls if patient resistant, prior emmetrope

NVO/ CVO specs

Accommodative VT ( Hart Chart etc.)

Think therapeutic monovision for this and vergenece concerns

Eye tracking‐ Pursuits and Saccades

Case history reveals difficulty when motion is present‐ patient, surroundings or both

Will discuss more later in relation to VOR and OKN

Evaluate in all directions of gaze

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Old School

ObservationalKDDEM Need Pic

New School

RightEye

Objectively quantifiable metrics in all directions of gazeValuable marker of recovery as well as helpful in communication with allied health professionals making the return to life/work and play decisions

Will discuss TX options at the end for the next couple topics, as may involve abit higher level Tx

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Vestibular/ Balance Concerns

• VOR – Vestibulo‐ocular reflex (latency 16 msec)

• Maintains fixation and stability by registering very short period of time

• Sub‐cortical response at birth – becomes cortically controlled with development

• Gain is the ratio of head to eye movement (visual motion if > or < 1.0)

• Two types ‐ rotational (semi‐circular canals) and translational (otolith organs)

• Sub‐cortical gain is 1.0 (no visual motion) at birth down to 0.6‐0.8 when affected by concussion, development and other cortical responses

• Used in therapy for Concussion, ABI, strabismus and other therapies

• Gain can be changed by lenses and therapy

• Low plus/minus

• Prism affects VOR gain in one plane

• BU, BD, BI, BO ‐ implications

OPTOMETRY’S ROLE IN CONCUSSIONDIAGNOSIS AND MANAGEMENT ‐ NEUROLOGY

• VOR• Testing

• DVA 2 hertz

• 2 line drop in binocular acuity is vestibular dysfunction

• Doll’s eye on infants

• ENG

• Patient complaints – dizziness, lack of coordination, vertigo, reading delays, hx of ear infection, and blur with motion (concussion)

• Almost always effected with ABI

• Sometimes causative in oculomotor deficiencies

• Primarily reflexive early on, cortical develops control later on a continuum

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• Vestibular system’s job

• Maintenance of balance through integration with proprioception and vision

• Maintenance of posture

• CONTROL OF EOMs

• Kinetic/transitory contractions of muscles for maintenance of equilibrium and EOM during movement ‐ phasic

• Maintains muscular tone of EOMs – tonic posture (think CI)

• Specifically a saccule function (vertical stimulation)

• First fully myelinated sensory system – fully myelinated at birth

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OPTOMETRY’S ROLE IN CONCUSSIONDIAGNOSIS AND MANAGEMENT ‐ NEUROLOGY• Vestibular system is fully myelinated at birth

• Sensory system for acceleration/deceleration

• 60% of compensatory eye movements

• Supplemented with OKR and smooth pursuits to provide stable eye movements

• Smooth pursuits overrides (integrates) VOR

• If SP is overriding mechanism, patients with poor SP ability can only marginally suppress VOR

• Summary

• Short or transient eye stabilization and movement that is suppressed or integrated by SP system

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• OKR‐ OptoKinetic Response (Latency 140 msec)

• Registers sustained stimulus through sub‐cortical with cortical integration (along with the continuum of development)

• Indirect in infants (sub‐cortical) and direct SP pathway in adult type movement (cortical)

• Stimulated by visual motion input on retina

• Involves optokinetic system, smooth pursuit, and saccades

• Testing ‐ OKN drum 60 degrees per second UP TO 180 degrees per second


• OKR• Motion tracking is “hard wired” with lateral to nasal tracking

• Development of nasal to lateral begins at 2‐3 months

• Can have asymmetry up to 6 months, but should be symmetric at 9 months

• Asymmetries are found in infantile strabismus and may be the cause of latent nystagmus

• VOR + OKR= stability of eye movements

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• In concussion the VOR gain may be disintegrated sub‐cortically or cortically and integration of motion processing may be affected, so what can we do?

• 1. We can change the VOR gain with lenses and prism

• 2. Decrease the overlap/confusion/ “noise” in the system with binasal occlusion

• 3. Visual/vestibular therapy


• 1. How is VOR Gain affected by lenses?

• Plus lenses have a base in effect in all directions from OC

• Magnification of visual space (tilt and rotation too)

• Makes better visual/vestibular motion match

• May/Not increase central blur allowing for peripheral processing speed to be normalized

• More peripheral speed sends information to balance

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• How is VOR Gain affected by prisms?

• Base in prism lenses effect in one plane from OC

• Magnification of visual space (tilt and rotation too) in one plane

• Makes better visual/vestibular motion match in horizontal plane

• More peripheral speed sends information to balance

• Muscle tone compensation for CI


• 2 ‐ How might bi‐nasal occlusion help with visual sequelae of concussion?

• Decreases overlap of binocular temporal retinal (non‐decussated tract) information

• Allows nasal retina (decussated tract) to process peripheral information

• Nasal retinal information is for motor fusion

• Temporal retinal information is for stereopsis information

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• 3 – Visual/Vestibular therapies can modify/adapt the VOR gain through the neural integrator

• Neural Integrator (cortical control)

• Prolongs/decreases signal from peripheral vestibular apparatus

• Signals from SCC/otoliths

• Velocity signal aligns eye to speed of rotation (VOR)

• Horizontal oculomotor – Nucleus Prepositus Hypoglossi (NPH)

• Vertical and torsional oculomotor – Interstitial Nucleus of Cajal (INC)

• Integrates information signals from VOR/OKN/SP to allow for normal eye movements

• Can be performed by OT, PT, Physiatrists, and Optometric Physicians


• What is bi‐nasal occlusion?

• Partial nasal opaque patching

• Used for more than concussion

• Think about strabismus

• Think about paresis

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Overlapping visual fields with binocular overlap shown

Overlapping visual fields with binocular overlap confusion removed by bi‐nasal occlusion shown

Visual Reaction Speed

How long does it take for the eyes to get from point A to point B to deliver stimulus to the train the process

Delay in visual input can cause a delay in overall reaction speed

Second injury risk

Univ of Cinn‐ Football study

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What to do about Visual Reaction Speed

Address any underlying foundational vision

deficiencies that could cause a delay in input

Then move patient into dynamic neurovisual

rehabilitation to create dynamic environments

in training to prepare them for dynamic environments in life

Visual Processing Speed

Delay in the decision making phase

Can also delay overall reaction time, as this plus visual

reaction speeds, makes up overall reaction time.

Can quantify all 3 in ms with RE

Mental “fogginess”, cognitive, memory concerns

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Multi‐sensory Integration

The breakdown in the compartmentalization of sensory input

Walls have broken down that divide the senses

Patient is overwhelmed, at school, in the mall, at a sporting event

Managed with neurological feedback loops using multisensory input and repetition

Neurovisual rehabilitation

Projected system with multiple modules focusing

on varying aspects visual reaction/

processing speed/ fixation/ multisensory integration

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Ocular Health Assessment

These patients have had acute head trauma

Need to evaluate ocular health back to

the retina

What to do with Visual Reaction/ Processing Speed

Dynamic VT options:

Neurotracker

Synaptec

RightEye

NVR

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OCULAR (VISUAL) TRAJECTORY, CONT’D. Diagnosis Codes

• May use binocular codes ( Exophoria etc.)

• Post Trauma Vision Syndrome has no ICD 10 Code –consider Post Concussion Syndrome(F07.81)


• What else can we do other than testing?

• More than you might think

• AOA ‐ Insurance, Vision Therapy, and Neuro‐Optometric Rehabilitation Coding and Billing Guidelines

• Advocating for our place at the table as part of the team

• But there’s no evidence… only if you don’t look

• Studies

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• Ancillary testing and treatment for concussion (with billing) is determined by each state’s board of Optometry and is different for each state.• Neuro‐muscular/sensory motor (92060) with a strabismus, paresis, palsy, CI, or other

neuro‐muscular problem

• K‐D and DEM (96111 or 96116) – with appropriate visual spatial sequelae diagnosis

• VEP (95930) associated visual spatial sequelae

• OKR

• VF (92082‐3) associated diagnosis

• ERG, EOG, OKN, PRN, Visagraph, and vestibular fxn Look these up

• ImPACT and/or other cognitive testing (96116) associated visual spatial sequelae

• Neuro‐rehabilitation (97XXX codes) associated neuro‐visual sequelae


Top 10 myths about vision therapy (Neuro‐rehabilitation and orthoptics) and concussion

• 1. It is unproven – WRONG‐ MDs want gold standard studies… what about surgery? We have more and better levels of studies. – CITT is the ONLY therapy study of all therapy

• 2. You can’t bill insurance – WRONG – See AOA Coding and Billing for Vision therapy

• and Neuro‐rehabilitation

• 3. Primary Care Optometrists can’t do anything – WRONG – see all the previous slides

• 4. There are not many concussions in my practice – WRONG – you don’t see it till you

• start asking

• 5. I can’t order or bill for ancillary testing – WRONG – check with your state board

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• Top 10 myths about vision therapy (Neuro‐rehabilitation and orthoptics) and concussion• 6. I have to be specialized to do this – WRONG – see all the previous slides

• 7. I can’t do neuro‐ WRONG – If I can do it, anyone can

• 8. There is no referrals to other ODs – WRONG – try AOA vision rehabilitation section (www.AOA.org) , COVD (www.COVD.org) , and NORA (www.NORA.cc)

• 9. It isn’t profitable – WRONG – ask me

• 10. I have to have special equipment – WRONG – just space if you are doing therapy, a RX pad, and some knowledge


• For a complete list of hundreds and hundreds of studies on visual function for neuro‐rehabilitation www.nora.cc or www.AOA.org

• sportsvisionpros.com

Documents

Optometry’s role in Concussion diagnosis and …...• Used in therapy for Concussion, ABI, strabismus and other therapies • Gain can be changed by lenses and therapy •Low plus/minus