Concussion Dr Jennifer Kungle NeuroOptometrist The Center for Vision Development Coup ContraCoup Injury The Visual Pathway Key Visual SignsSymptoms Headache B lurry vision Photophobia ID: 591704
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Visual Consequences of Concussion
Dr. Jennifer Kungle
Neuro-Optometrist
The Center for Vision DevelopmentSlide2Slide3Slide4
Coup Contra-Coup InjurySlide5
The
Visual PathwaySlide6Slide7
Key Visual Signs/Symptoms
Headache
B
lurry vision
Photophobia
D
ouble vision
Reading problems
Decreased processing speed
Dizziness/motion sickness
Peripheral vision defects
Nearly
30% of concussed athletes report visual problems during the first week after the
injury
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Baseline Testing1. Cognitive Baselines
Standardized Assessment of Concussion (SAC)
ImPACT Testing
Sports
Concussion Assessment Tool,
SCAT-2
2. Balance Baseline
Computerized
Timed Tandem Gate Test
3. Visual Baseline/Remove from Play
King Devick Saccadic Test
VOMS
RightEye
Neuro Vision
Slide9
ImPACT
Immediate
Post-Concussion Assessment and Cognitive
Testing, developed by UPMC
Neuro-cognitive test that
evaluates multiple aspects of
memory, attention, brain processing speed, reaction time, and
post-concussion symptoms.
Designed for children above 8 years of age.
Baselines should be repeated every two years for >13
yo
Baselines mandated by NFL, NHL and many collegiate and high school teams.
Impacttest.com to find providersSlide10
King Devick Saccadic TestSlide11
King Devick Saccadic TestThe
K-D Test has been widely used through the years as a measure of saccade function primarily as related to
reading.
Measures
rapid eye movement, visual tracking and related cognitive
responses;
is a reliable indicator of cognitive problems.
If
an injured
athlete
reads the numbers more slowly after a head impact
as compared to
baseline testing, he or she is considered to have sustained a concussion.Slide12Slide13
September 10, 2015, in Concussion
1419 athletes;
86% specificity
detecting concussion
King-Devick times 4.8 seconds slower for concussed athletes vs. 1.9 seconds faster for non-concussed
Physical exertion sharpens visual processing, often causing non-concussed athletes to perform better than their baseline
Critique
: does not evaluate other areas of ocular motor function such as
pursuits,
convergence, or accommodation
Slide14
Vestibular Ocular Motor ScreeningVOMS – developed at UPMC
Assessments
in the following five domains:
1
)
smooth
pursuits
2) horizontal and vertical saccades
3) convergence
4) horizontal and vertical vestibular ocular reflex (VOR)
5) visual motion sensitivity (VMS)
Following
each VOMS assessment, patients rate on a scale of 0 (none) to 10 (severe) symptoms of: headache, dizziness, nausea and fogginess
Takes 5-10 mins to administer.
Slide15
Eye Tracking TechnologySlide16
Circular smooth pursuit
Horizontal
smooth
pursuit
Vertical
smooth
pursuit
Horizontal
volitional saccades
Vertical
volitional saccades
Sample_Neuro_Report_Feb_2017.pdfSlide17
The Duality of the Visual System
Focal Vision System
Ambient Vision System
What/How Pathway
High-resolution, central vision = identification of objects
Attention
Concentration
Detail-oriented
Conscious
Reactive
Where
Pathway
“
Peripheral Vision System”
Localizes our bodies in space
Balance, Movement, Coordination, Posture
Gravity-Specific
Pre-Conscious
Anticipatory
Stimulated by motionSlide18
Ambient Processing
In the midbrain visual inputs combine and organize sensory information with information from
Vestibular (VIII)
Proprioceptive
Tactile
Kinesthetic
After acquiring additional sensory input, nerves travel
in a feed-forward mechanistic process to the visual cortex.Slide19
Sensorimotor ConnectionAll sensory systems are integrated neurologically.
While initially separate, they all join together to integrate sensorimotor information in the brain.
Some patients note that when they take off their glasses they have difficulty hearing
Not only sensory system share information – also the motor process (efferent pathway) is critical in providing a background for the sensory system.
ex. Balancing on one foot – much more difficult when eyes are closed.Slide20
Ambient Processing
The ambient system is responsible for
grounding
our spatial world through sensorimotor matching.
When this system is damaged by injury, grounding is affected and there is a shift towards focalization.
=
Focal Binding
This causes the person to project movement onto stationary objects which are fixated, and they perceive objects to be moving.
i.e. print on the page may appear to moveSlide21
Ambient ProcessingWhen in busy, visually stimulating environments, this over focalization and isolation on detail will be overstimulating – causing confusion and spatial distortion.Slide22
What happens with TBI?
In a neurological event such as a TBI, MS, cerebral palsy, autism, CVA, etc., the balance between the ambient and focal visual processes is often affected.
M-cells have larger diameter axons and are more susceptible to damage. Damage can come from ischemia, space occupying lesions, etc.
mTBI – concussion – diffuse shearing of axons leads to release of neurotoxins – creates hyper excitability – throws off the ambient systemSlide23
AMBIENT PROCESSING BECOMES DECOUPLED FROM FOCAL PROCESSING = focal bindingunable to process peripheral
information
Exophoria/exotropia
Diplopia
Reduced depth perception/localization
Unable to match visual to proprioceptive, kinesthetic, vestibular information
Balance, coordination and movement are compromised
Are unable to suppress second imageSlide24
Post Traumatic Vision SyndromeCharacteristics:
Exotropia/High Exophoria
Convergence Insufficiency
Accommodative Deficiencies
Visual Spatial Distortions
Oculomotor Deficits
Unstable AMBIENT systemSlide25
Post Traumatic Vision S
yndrome
Symptoms
Diplopia, possible
Objects appear to move
Reduced concentration and attention
Poor visual memory
Glare sensitivity (photophobia)
Problems with
Balance
Coordination
P
ostureSlide26
Vision Rehabilitative TherapyBinocular Integration
Oculomotor control, speed, accuracy
Accommodative flexibility, stamina and endurance
Smooth and easy convergence/divergence
Peripheral Awareness
Visual Motor Coordination
Visual Perceptual Spatial KnowledgeSlide27Slide28Slide29Slide30Slide31Slide32
Multi-Matrix GameSlide33
Neuro-Optometric Treatment Options
Lenses
Avoid
Multifocals
Always consider two pairs of glasses
May require additional computer Rx or sun Rx
Polarized/Transition Lenses
TintsSlide34
Neuro-Optometric Treatment Options2. Compensatory Prisms
Fresnel Press-On Prisms (temporary
)
Can be ground into standard lensesSlide35
Fresnel PrismSlide36
Therapeutic Prism
Base In yoked prism helpful in decreasing visual
stress; aids divergence; decreases photophobia and eyestrain
Yoked
prism can be used to realign a patient’s center of gravity and improve overall balanceSlide37Slide38
4. Patches
Cling Patches (Bangerter Occlusion Foils) can vary from opaque (light perception) to varying degrees of translucency
Provide varying acuities, i.e. 20/50, 20/200, light perceptionSlide39Slide40
Occlusion OptionsPartial or spot patches can be used as immediate treatment for double vision.
Partial patches will allow the patient to maintain peripheral awareness and facilitates their overall coordination and balance.
Occlusion Therapy without an assessment is NOT recommended.Slide41
Superior OcclusionSlide42
Spot OcclusionSlide43
Binasal OccludersSlide44Slide45
THANK YOU!
marylandvisiontherapy.com
drkungle@marylandvisiontherapy.com
Nora.cc Neuro-Optometric Rehabilitation Association
COVD.org College of Optometrists in Vision Development
Oepf.org Optometric Education Foundation
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