Focusing on the role of eye care in concussion - OHSU
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12/16/2019
Focusing on the role of eye care in
concussion
Fraser C. Horn, OD, FAAO
Interim Dean – Pacific University College of Optometry
Disclosures
• Co-Founder of www.sportsvisionpros.com and
https://performancevision.academy
• Nike Vision
• Sanofi-Genzyme
– No financial support, direct or indirect, is received based off of
this presentation
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12/16/2019
What is Sports Vision?
3
The Truth
• Sports Vision is meeting the demanding visual needs of all
persons in your community, young and old, recreational and
professional, that would like to perform their sport of choice at
their peak!
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12/16/2019
Why is Sports vision critical?
• Injury prevention
• Injury management
• Concussion management
• Vision Enhancement
Today
• Quick discussion on…
– Role of vision in…
• Interprofessional collaboration
• Vision Basics
• Concussion assessment
• Concussion prevention
• Concussion Rehab
• and more…if time :)
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12/16/2019
Sports Vision
• Interprofessional Team
– We work closely with…
• Athletic Trainers
• Sports Medicine MDs
• Neuro
• Ophthalmology
• Chiropractor
• OT & PT
• Pharmacy
• Strength & Conditioning
• And more
Vision
• Estimated that ~80% of our perception, cognition, and
activities are modulated by vision
• Complex activity that takes place in the brain
Ripley DL, Politzer T. Visual Disturbance after TBI. NeuroRehabilitation 27 (2010) 215–
216
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Vision
• When the visual system works well, we are able to…
– See clearly and single
• Visual Acuity, Contrast Sensitivity,
Eye Alignment, Fixation
– Judge depth and speed
• Alignment, Versions, Retinal properties
– Read
• Accommodation, Fixation, saccades,
saccadic suppression
https://emedicine.medscape.c
om/article/1189759-overview
Vision
• When the visual system works well, we are able to…
– Awareness of periphery
• Retinal function, lateral inhibition
– Maintain Balance
• Peripheral awareness, Vestibular integration
– Plan movement
– So much more
https://emedicine.medscape.c
om/article/1189759-overview
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12/16/2019
Baseline Assessment
Pacific Sports Medicine
• Vision Check-in
– Not much time
– Foundational functions
– Assessing for success on field, in classroom, and baseline for
concussion
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12/16/2019
Pacific Sports Medicine
• Vision Check-in Components
– Case History
• Include Concussion hx
• Glasses and Contact Lens wear
• Last Eye Exam
Pacific Sports Medicine
• Vision Check-in Components
– Visual Acuity
• Right eye, left eye, and both eyes
• With whatever correction they use for sport
– Gross Peripheral Vision – Confrontational Visual Field
– Ocular Alignment – Cover Test at distance and near
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12/16/2019
Pacific Sports Medicine
• Vision Check-in Components
– Extra-Ocular motilities – pursuits (VOMS)
– NPC (VOMS)
– Pupils
– Consult with doc
VOMS
• Vestibular/Ocular Motor Screening (VOMS): University of
Pittsburgh Medical Center: (Am J Sports Med. 2014 Oct;
42(10): 2479-2486)
– Pursuits: Horizontal & Vertical
– Saccades: Horizontal & Vertical “A combination of VOR, VMS &
NPC scores resulted in a
– NPC (x3) positive prediction rate of 0.89
– Vestibular Ocular Reflex: H&V for identifying concussions”
– Visual Motion Sensitivity
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Baseline Assessment
• Comprehensive Vision Exam
– Additional tests to a standard exam
• History
– Prior concussions?
– Anxiety / Depression
• Entrance skills
– Contrast Sensitivity
• Binocular function
– Horizontal and vertical
• And more
Courtesy of Todd
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Daniels, ATC
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Other Evaluation Tools
• King-Devick Test
– Subjective, physical method of
evaluating visual tracking and
saccadic eye movements.
– Based on the time to perform rapid
number naming
http://kingdevicktest.com/about/
Other Evaulation Tools
• Right Eye System
– Objective
– Eye Tracking
https://righteye.com/product-
overview/
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After Baseline
• Inclusion of Vision Training
• 2016 Consensus Statement:
– There is minimal evidence to support individual injury-
prevention strategies addressing intrinsic risk factors for SRC in
sport. However, there is some promise that vision training in
collegiate American football players may reduce SRC.
McCrory P, Meeuwisse W, Dvorak J, et al. Br J Sports
https://bjsm.bmj.com/content/bjsports/early/2017/04/27/bjsports-2017-097699.full.pdf
Vision and Concussion
• University of Cincinnati Studies
– Utilized D2, Strobes, and tracking drills
– Training cohort 1.4 concussions per 100 player seasons
– No training cohort 9.2 concussions per 100 player seasons
– Reduction of concussion rate with team-wide sports vision
training
Clark JF, Graman P, Ellis J, et al. An exploratory Study of the potential effects of vision
training on concussion incidence in Football. Optometry & Visual Perofrmance 2015. 3(2).
116 - 125
1112/16/2019
Post-Concussion
Most common vision related signs and symptoms
Including, but not limited to:
–Blur –EOMs
–Asthenopia »Saccades
–Photophobia »Pursuits
–Accommodation –Pupils
»Spasm –Visual Fields
»Infacility –Possible traumatic
–Vergence effects on the eye
1212/16/2019
A Typical Post-Concussion exam may
include…
• Seen within 7 days post concussion
• Case History
– Include discussion on…
• Headaches
• Fogginess
• Overwhelmed in crowded environments
• photophobia
• Mental health
• And more
A Typical Post-Concussion exam may
include…
• Entrance Skills
– VA
– Contrast Sensitivity
– Cover Test – distance and near
• Versus fixation disparity
– Confrontational fields
1312/16/2019
A Typical Post-Concussion exam may
include…
• Entrance Skills
– EOMs (extended time)
• Pursuits
• Saccades – horizontal and vertical (diagonal?)
– NPC x 3
– Pupils
– Stereo acuity?
A Typical Post-Concussion exam may
include…
• Refraction
– Pay attention to small amounts of cylinder and axis
– Cycloplegic
• Binocular work-up
– Distance and near
– Phorias, ranges, accommodation ability, etc.
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A Typical Post-Concussion exam may
include…
• Slit lamp exam
• Dilated exam
Post-Concussion Intervention
• Glasses / Contact lenses
– Distance
– Reading
– Prism?
– Bi-Nasal Occlusion?
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Post-Concussion Intervention
• Vision Training
• Keep a training log
– Near-Far Rock
• Initially
– Large letters
– Primary Gaze
– Brock String
From Dr. Graham Erickson
https://www.pinterest.com/p
in/38702878023101011/
Post-Concussion
• Hat for photophobia
• Turn down screen brightness and slowly increase
• VMS
– With consistent background
– Increase distraction with movement
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Post-Concussion
• More in-depth
– Refer for vision therapy, especially vision rehab or Neuro-
optom
Post-Concussion
• More in-depth
– “Light the Candle”
– Working on depth and localization.
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Post-Concussion
• More in-depth
– Working on visual motion sensitivity
Courtesy of Katherine Green, OD, FAAO
Opportunity
• Vision is critical to what we all do
• Most patients will have some sort of visual related
symptom post-concussion
• Opportunity to help our patients through interprofessional
collaboration
1812/16/2019
Thank you
• hornfc@pacificu.edu
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