Treatment of TBI, concussions an underutilized focus in ophthalmology

Take-home message: Though given little attention during residency training, the area of visual performance should become the standard of care in patients with traumatic brain injury, explains Barry L. Seiller, MD, MBA.

By Barry L. Seiller, MD, MBA, Special to Ophthalmology Times

As one of the few ophthalmologists who specializes in the evaluation and training of visual skills and how those skills impact athletics, academics, and rehabilitation, I am constantly surprised by how many of my colleagues are unfamiliar with this area of the visual system.

While the area of visual performance is given little exposure during residency training, it has an impact on many functions of patients’ everyday lives.

I became interested in this field in the 1990s through an optometrist who received an education in the field of visual performance as part of his training. Visual performance services can generate more patient visits, and depending on the business model, the ophthalmologist or optometrist can charge “out of pocket” for the services.

Visual function areas

Four main areas of visual function include: visual acuity, visual field, oculomotor control, and central visual processing.

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One of the parts of the visual system-the visual-motor portion-comprises such components as tracking, convergence/divergence, visual recognition/memory, and depth perception. While interrelated, these components can be isolated, are measurable, and in many instances are trainable.

Students with reading issues may be born with reduced visual skills; athletes may want to enhance their existing visual skills to improve athletic performance; and civilians and/or athletes with traumatic brain injury (TBI) would like to restore them.

Next: Media exposure

Although there have always been large numbers of head injuries in both the civilian and military environments, the topic of TBI-particularly concussions-has recently received a great deal of media exposure and has created high visibility in the athletic arena.

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As mentioned in the Physical Medicine & Rehabilitation textbook chapter, which I authored, patients may experience a variety of visual impairments after TBI or post-concussion syndrome, which can result in both overt and insidious symptoms.

Impairment of ocular motor control is one of the most frequently associated with TBI. It is estimated that between 40% and 75% of patients with TBI experience some reduction of oculomotor control. A dysfunction in this area can lead to a spectrum of issues affecting athletic play and daily activities.

The severity or number of visual problems does not appear to relate to the severity of the brain injury. While moderate-to-severe brain injury can understandably cause significant problems, it is now postulated that even minor brain injuries can disrupt the overall speed, efficiency, and integration of mental and central nervous function.

These symptoms frequently do not correlate with the amount of pathology and are not found on radiologic imaging. There may be severe cognitive and behavioral impairments causing headaches, dizziness, photophobia, delay in return to play or work, inability to drive, emotional instability, and memory difficulties. Symptoms may be a combination of organic and psychological factors.

The impact of visual deï¬Âcits may be further complicated by the injured person not being aware of a change in vision. Without appreciation for the deficit, the injured person thereby fails to compensate for the deï¬Âcit.

Also, because visual perception is a subjective experience, the person may have difï¬Âculty articulating his or her difï¬Âculties and relating them to impairment in vision.

Conversely, the patient may also have developed a compensatory strategy as a result of the impairment that interferes with his or her ability to compensate in other areas of visual functioning and that may confuse both the person and the rehabilitation team.

However, if the visual impairment can be correctly and promptly diagnosed and provided appropriate therapeutic intervention, the patient's rehabilitation course may be improved and the medical outcome enhanced.

Next: Vision performance programs

In order for survivors of acquired brain injury to benefit during the acute phase of trauma, there may be a variety of disciplines available to them in the inpatient or outpatient setting. Most concussion programs do not include an ophthalmologist and only some include an optometrist.

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Unfortunately, for those patients in the subacute or chronic phase of concussions, the rehabilitation team has less to offer, while the patient/athlete frustratingly is waiting for the symptoms to dissipate and return to work or play. The patients, usually athletes, are frequently in the chronic phase and have continued symptoms years after the initial event.  Although they have seen numerous physicians, only rarely will these physicians have considered a compromised visual system as the basis of the dysfunctionality. Now the landscape is changing for these patients.

Vision performance programs

In 1989, I founded the Visual Fitness Institute to investigate and implement vision performance programs for athletes and head injuries. Up until recently, there were a multitude of visual devices that existed that attempted to measure the most important visual skills. A vast majority of these devices were produced by a variety of clinicians, but most had no credible basis especially for researchers looking to examine the validity of this ï¬Âeld.

As a result of the work performed at Visual Fitness, the Vizual Edge Performance Trainer (VEPT) was developed to address the issues inherent in these previous devices. This Web-based visual performance program allows for consistently reproducible results that are portable and to which users can gain easy, economical access to the technology.

The commercially available program reliably collects metrics that are used to measure the most important visual skills and create a database of scores for each user. The system offers valuable information to athletes, coaches, researchers, and now rehabilitation staff.

The program can be used by oneself or by a coach or trainer. On the clinical side it allows for a comparison of one user’s skills to another and also a method to monitor training progress.

Researchers have utilized the program for a variety of investigational studies in multiple sports. This has also lent new credibility to visual performance testing and vision training that now can be correlated to performance on-court, ï¬Âeld, or ice. Many high school, collegiate, Olympic, and professional athletes take advantage of the technology for athletic enhancement.

Next: Continuing to educate

Just as access to athletes has grown, so has the use of the program in determining the visual effects of a concussion and its remediation. The program can help determine affected visual skills and a method to rehabilitate them either at home on their own computer or in an office setting.

This includes a number of eye-care professionals’ offices, facilities, and hospitals in the United States and Canada. Utilizing the program can help to determine dysfunctions, such as convergence insufficiency, which is one of the most common problems post-trauma and the most overlooked.

Athletes are also being visually tested pre-injury similar to the popular ImPACT program that tests cognitive function for similar purposes.

We will continue to educate the eye-care practitioner in this seldom-considered area of the visual system. However, given the frequency of visual symptomatology that results from mild-to-moderate brain injury, the epidemic of concussions, readily available new technology such as the VEPT, ophthalmologists or optometrists should be integrated either as a member of an interdisciplinary concussion team or as a value-added service in the practice.

The visual performance program provides a new depth of understanding that should become the standard of care in patients with TBI.

Barry L. Seiller, MD, MBA

Dr. Seiller is the developer and owner of the Vizual Edge Performance Trainer and lead consultant of visual performance research in the newly opened Sport Performance Research Lab at Texas A&M University Corpus Christi.