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Sunday / March 3.
HomemifeaturePutting Concussion Into Perspective

Putting Concussion Into Perspective

Reading a book or watching a movie was a simple pleasure until law student Luke was concussed during a game of Australian Rules. Eighteen months later, and six months after commencing vision therapy for his visual issues with a behavioural optometrist, he regained enough focus to push himself through the pages of a light-weight novel. The work continues.

It was April 2015 when Luke was struck down while playing football. Having played at a high level while at high school he’d taken a break and was keen to get back into the game. The accident occurred during a pre-season marking contest. “I went up for a mark, came back down and as I did, a knee hit me in the head. My head hit the ground – one punch style – and I woke up moments after. I remember falling through the air and thinking I was in a bit of trouble, but when I woke up on the ground, I didn’t realise the severity of the situation. I hadn’t heard much about concussion so I didn’t know what to expect.”

Luke suffered a contrecoup injury – his brain hit both the front and back of his skull, affecting the brain stem and in doing so caused damage to his nerve supply as well as other organs and areas of his body.

As a result of his injury, he felt very unwell for the next few days, then disoriented for a week… and, much to his surprise, the repercussions continued. “Before the accident, I was athletic, studying at a high level, working two days a week and I really enjoyed making my own films. Suddenly every element of my life was taken from me. I missed one full year of university and I had to give up working, driving and film. With a lot of help from the State Head Injury Unit and the university, I’ve managed to get back to university but even getting through a couple of units is a struggle and work-wise, I can only manage one four hour shift a week. I am back driving but I can only drive for about 30 minutes before I need to take a rest. Maintaining focus and concentration is exhausting and leaves me feeling nauseous.”

There was no point in adding vision therapy into the mix until he was at a stage when he could cope with it physically, mentally and logistically

The Value of Vision Therapy

With the effects of concussion typically lasting anywhere between six weeks and three months, Luke said his recovery presented a challenge for his doctors.

“I had so many medical problems to manage following the concussion – I had whip lash, migraines, intense nausea and I developed an irregular heart-beat. But the main symptom was living in what I’d describe as a brain fog – I was unable to gain any clarity of thought.

“When the effects of the concussion lasted longer than three months, some of the doctors I was seeing suspected there was something else going on and so I was sent off for more tests… my vision didn’t become part of the thought process until much later.”

Liz Wason, a behavioural optometrist with Eyes on Oxford in Perth, who is now working with Luke said this scenario is not uncommon. “There were so many obvious concerns for Luke. Over 12 months he had been receiving medical care from his general practitioner, the State Head Injury Unit, a physiotherapist, occupational therapist, a neurologist, cardiologist and a psychologist. There was no point in adding vision therapy into the mix until he was at a stage when he could cope with it physically, mentally and logistically.

“When I saw Luke a year after his accident, many of his symptoms had still not improved. Reading and retaining data was difficult and made him extremely tired, he was glare sensitive inside and outdoors, and because his depth perception had suffered, he couldn’t drive. The concussion had affected his life dramatically.”

Testing and Therapy

As with all concussion patients, Ms. Wason undertook extensive testing to determine his eye movement, focus and convergence issues.

“We do very intensive eye movement checking to see how smoothly the patient can follow or track a moving target – from left to right and from top to bottom – we look at how much stress that causes and how smoothly the patient’s eyes work together. We also look at how easily they change focus from near to far and how well they can maintain focussing because following concussion, sometimes the focussing system can be quite poor. In terms of convergence, we’re looking to see whether the patient can converge their eyes and maintain keeping their eyes together no matter where they look – far, close, to the side, and when moving in the environment.

“Sometimes, depending on the location of their head injury, a patient can have subtle double vision problems when they look to the side – because of the damage that has occurred to the brain, eye muscles or the optic pathway.”

While convergence and focussing issues are not solely due to concussion, Ms. Wason said it is important to rule concussion in or out before deciding on a treatment strategy. “Some patients come in and during a regular screening I observe a subtle focussing problem and perhaps they complain of glare sensitivity even when they are inside. If we rule out the possibility of causes like medications, eye health changes, extensive close or computer work, we’ll start to probe into the patient’s history. Often we’ll discover that some years ago they had a head injury, even a minor one, and that may be central to the vision problem.

“We use vision therapy to make patients aware of what is happening to their vision and educate them as to how, by making simple adjustments, some of the issues they are experiencing can be improved. Guiding the patient on strategies on how to move and control their eyes again (which was an automatic skill pre-concussion) can promote better changes in eye movements and eye co-ordination). We also look at the refraction the patient has – sometimes a small distance prescription can make their world seem clearer and easier and more stable.”

Ms. Wason said in severe cases of double vision, a prism can be put into the patient’s glasses. If this problem is very subtle and limited to one side, a small partial occlusion on one of the lenses will block that part of the patient’s vision.

“Our goal is to desensitise the patient’s visual system while they are in a state of disorientation due to concussion – sometimes the brain repairs itself quite quickly, other times it can take years and in some cases the brain does not totally repair, but our goal is to help them get back on track visually.”

Overcoming Split Vision

In Luke’s case, Ms. Wason identified that each time he focussed on a target his vision would split, so he’d have to blink and try to focus on it again – his eyes weren’t working together efficiently.

A program of eight vision therapy sessions, with practice consultations once a fortnight and home exercises in between, has begun to show some signs of improvement.

Luke said the sessions are hard work. “Every week I’m given new tasks that work on my near and distance vision and the difficulty ramps up. When I reflect back, what seemed impossible to get through in week one seems easy now that I am working on tasks that are far more challenging and exhausting.

“What’s great is until now it’s been hard to measure any improvements – all the rehabilitation I’ve done post-concussion has been wishy washy – but this isn’t. Liz can give me clear measurements showing me how much I’ve improved… I would love to say I feel better day to day but I haven’t got to that point yet. However I am driving short distances and over Christmas, for the first time in almost two years, I was able to read a book – that was a real milestone – I read the book and I remembered it.”

Luke will begin his second vision therapy program shortly which will concentrate on improving his visual stamina. “Luke’s convergence and his eye movements are better and he’s more aware of how he uses his vision system. He has improved but he’s not where he wants to be. This next series of exercises we give him will help him maintain his eye movements, focusing and convergence for longer periods of time,” said Ms. Wason. “Our aim is to improve his visual function to get Luke back to full time study, to see him graduate, commence employment and enjoy a good quality of life.”

Initial Examination Findings

Elizabeth Wason

Initial examination of Luke confirmed myopia (R & L -1.00 sph), which he reported pre-head injury, but with a mild -0.25 increase from his previous spectacles.

Focusing skills for near tasks were poorly sustained with + 1.25 lag of accommodation unaided, he had difficulty changing focus, and a remote blur point for small print at near.

His binocular vision skills were unstable with moderate exophoria and low base out fusion ranges at near. Intermittent diplopia was reported in all areas of gaze when fixating a target for pursuits, displaying cog-wheeling and vergence break-down requiring effort and excessive attention to regain fusion.

All structures for both anterior and posterior eye were normal with no optic neuropathy. Pupil reactions were equal and reactive.

Visual fields results (24-2) displayed no significant field loss but showed scattered scotomata of reduced sensitivity for both eyes, and with a small superior defect left eye which may be directly related to head trauma location.

Treatment included near spectacles for reading and study with lenses, low power prism and light blue tinting. Discussion also centred around using his distance. Transition spectacles more often to improve acuity, reduce glare and eyestrain, stabilise spatial skills, and improve confidence in mobility.

Vision therapy was introduced for visual function skills and visual processing, and counselling and advice was offered.

Ten Tips for Managing Concussion

Elizabeth Wason

  1. Get a comprehensive medical history of your patient – ask lots of questions and if possible try to pinpoint an event: what treatment did the patient receive, are they on medications, what diagnosis have they been given?
  2. Undertake a thorough visual assessment – check the patient’s eye movements, focussing system, eye coordination system, their refraction, have a look at their eye health – make sure there’s no trauma to the optic nerve.
  3. Check the patient’s visual fields to identify whether your findings match the symptoms. If it doesn’t match, you need to investigate further or refer on to a neurologist or ophthalmologist, depending on the issue
  4. If your patient complains of glare sensitivity, prescribed a tinted lens o suit their needs
  5. If your patient needs glasses, give them single vision lenses and if necessary one pair for near and one for distance. Avoid blended or multi-focals lenses which will further exacerbate problems with balance and depth perception.
  6. Look for subtle double vision – then decide to take action or not depending on whether it is worrying the patient. A prism, partial occlusion or vision therapy may be the answer.
  7. Identify any subtle signs that indicate the patient’s eye co-ordination system is breaking down, for example their convergence system or problems coping with close work.
  8. Consider the effects that medications such as anti-depressants, anti-convulsants, anti-epilepsy and painkillers can have on vision, eg. dry eye, increased glare sensitivity convergence etc
  9. When appropriate recommend a referral for vision therapy
  10. Offer the patient and their carer(s) as much information as possible about what is happening with their vision system, what to expect, and how to manage day to day, eg. ensuring reading for short periods of time with rest in between; avoiding sport and long periods reading, driving or using a computer, get used to wearing new glasses by wearing them at home etc.

Liz Wason, Dip App Sc (Optom), FACBO, completed post-graduate studies to become a Fellow of the Australasian College of Behavioural Optometrists in 1996. Liz has extensive experience and distinct expertise in assessment of visual processing development in children with learning problems; vision problems of special needs children and adults; assessment and management of visual function and processing problems in people with acquired brain injuries, such as from stroke or head injury; and management of the ocular and visual effects of Parkinsons’ disease.