Q, and I’ll use only his first initial to preserve patient confidentiality, is a teenager with whom we’ve worked in vision therapy. He is a very talented high school baseball player who has serious upside as a pitcher. Our primary purpose in therapy was to enable him to develop better visual skills to support academic learning, but we also incorporated activities that would allow him to achieve at an even higher level for sports. He happens to attend the same high school from which Doug Glanville graduated, who was quite a scholar/athlete in his day and went on to get a degree in engineering from the University of Pennsylvania before fashioning a nice career as an outfielder in the major leagues. We saw Q for his final progress evaluation a few months ago, and both he and mom were very pleased with his outcome.
I was therefore surprised to get a phone call from his mother, with great concern in her voice, that Q had not been himself for a couple of days. He experienced dizziness and headaches in the morning upon awakening, that got a bit better as the day went on. But today was different. Q. called his mother from baseball practice, which had just started up again this year, and he was very distressed. His vision was all out of whack, and when it was his turn in the batting cage he couldn’t even see the ball well enough to hit it. We told her to get Q over to our office immediately, as it sounded like he was experiencing the sequelae of concussion. It was important to rule out anything deeper and even life-threatening that might be going on in the visual pathways.
My resident extraordinaire, Dr. Mike Montenare, did the work-up we typically do for urgencies and emergencies of this nature. Although Q. had alot of the positive symptoms of neurological damage, his visual acuity was 20/20 with each eye and he had no binocular vision disorder on a cover test. His pupil responses were normal, as was the automated visual field screening and optic nerve appearance in both eyes on dilated fundus examination. However on the field test he was noted to have a very fine fixation nystagmus. Dr. Montenare conducted motility testing and sure enough Q exhibited gaze-evoked nystagmus (GEN) with significant oscillation of his eyes when looking to the left. We had the benefit of knowing Qs previous visual and ocular history, and therefore knew that this was an acquired condition. This means that Q would need immediate further medical attention to pin down the source of the GEN. We don’t have a video of Q, but here is an example pulled from YouTube, in which a child is exhibiting GEN when looking to either side of his midline, beginning at about a 30 degree angle from the straight-ahead position.
Why was it that Q didn’t realize the severity of what was happening with his vision until he stepped in to bat? Because as a right-handed hitter when he adopts his batting stance his eyes are at an angle requiring extreme gaze toward his left side, and this was the angle that triggered intense nystagmus. When this form of eye oscillation is acquired, the patient perceives what is called oscillopsia, or a great degree of jumping of the visual image. It would be very similar to the image smear that you get when trying to take a single digital image off someone running at high speed. While Q probably knew over the last day or two that something was amiss, competitive athletes are very reluctant to turn themselves in. In fact, Q reassured his mother the previous day by reminding her that he was probably just dehydrated. He had to remind himself to drink more fluid when training full tilt and when he didn’t it wasn’t uncommon for him to feel queazy or light-headed. But this was very different, and alarming. As it was evening, we were unable to find a neurologist on call and therefore had Q’s mother take him directly to the ER of our local hospital, together with a copy of our findings and instructions to have an MRI obtained.
By Q’s mothers verbal report to me after they were discharged at 1:30 AM, the MRI showed signs of significant swelling in the frontal lobe. Although Q indicated only that he had been hit with a baseball on the helmet after a ricochet while in the batting cage, the extent of his post-concusion anatomical changes in terms of the GEN and the edema seem more extensive than one could attribute to the single incident that Q described. As Lovell notes in this excellent slide presentation, the damage that occurs to the brain in closed head injury is often greater within a few days of the injury than it is after impact, and is potentially greater with younger athletes than it is with adults. The rank order of symptoms in terms of percentage of positive responses reported by high school and college athletes within three days of injury is as follows:
# 1 Headache 71 %
# 2 Feeling slowed down 58 %
# 3 Difficulty concentrating 57 %
# 4 Dizziness 55 %
# 5 Fogginess 53 %
# 6 Fatigue 50 %
# 7 Visual Blurring/double vision 49 %
# 8 Light sensitvity 47 %
# 9 Memory dysfunction 43 %
#10 Balance dysfunction 43%
The key for Q. initially is going to be bed rest. He’ll be consulting with a neurologist on Tuesday. Although the hospital indicated to his mother that he needs considerable rest over the next 10 days, one of the most difficult things with athletes is insisting that they rest. There should be no thought of baseball now for at least a month, and Q will have to gradually build up his stamina for the cognitive load of the classroom. I’ll share an update as we follow him along. He’s an incredible kid, with whom both Dr. M and I feel a special connection.