Concussion Featured in EyeNet


The cover story of the December 2016 issue of EyeNet, the magazine of the American Academy of Ophthalmology is entitled: Concussion Care: Moving Vision off the Sidelines, written by Annie Stuart.  She notes: “Although the visual system involves about half of the brain’s circuits—many of which are vulnerable to head injury—vision has long been sidelined in the world of concussion diagnosis and treatment. That is beginning to change.”

There is a section of the article devoted to the King-Devick Test, featuring two neuro-ophthalmologists, Dr. Laura J. Balcer and Dr. Steven L. Galetta.  As nonpaid consultants,

Drs. Balcer and Galetta were asked 7 years ago to explore the usefulness of the K-D test. The article notes parenthetically that this test was developed by a team of optometrists who test kids for dyslexia, gauging the amount of time it takes to read numbers with variable spacing on 3 test cards.

In 2015, a meta-analysis found the K-D test to be a sensitive candidate for a sideline test, effective with athletes of all ages, said Dr. Balcer. In fact, it has been shown to capture concussions that other types of sideline tests miss, in part, because athletes tend to underreport symptoms. “A robust set of data indicates that it can accurately assess concussion on the sidelines, is feasibly administered by parents and coaches in about a minute, and doesn’t require any special equipment,” she said. “We think it is close to prime time use.”


At NYU Langone’s Concussion Center, Margaret A. Waskiewicz, MS, OTR/L, specializes in vision rehabilitation, which links concussion treatment to functional performance such as the ability to work or go to the store.  Vision therapy is typically offered by optometrists or other specialists who have a certification in vision therapy.


A recent addition to the NYU team is Dr. Neera Kapoor, an Associate Clinical Professor at NYU Langone Medical Center’s Department of Rehabilitation Medicine. She was an Associate Clinical Professor at SUNY College of Optometry for 21 years and is the former Chief of Vision Rehabilitation Services at SUNY College of Optometry’s University Eye Center in New York City.

New Guidelines for Concussion Incorporating Vision Therapy

I have always loved the concept of a meme, which is why the subheading of the journal Neurosurgery (from Wolters Kluwer Health) “The Register Of The Neurosurgical Meme” intrigues me.


Along those lines, concussion guidelines are like nutritional recommendations:  If you think you have a handle on best practices, wait a year (in some cases a few months) and the guidelines will change.  Case in point, the latest “new” thinking on concussion treatment, as reported in yesterday’s Wall Street Journal, which includes the following statement:  “In a white paper summarizing the views of more than three dozen concussion experts, published online Friday in the journal Neurosurgery, the authors aim to clarify the role of rest and physical activity in concussion treatment. The paper says most that concussions are treatable and that active rehabilitation may improve symptoms more than strict rest.”



The white paper they refer to in the article is: “Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.”  If you click on the hyperlink it will give you the option of obtaining the full PDF.


Point 14 of the white paper, found on pages 11 and 12, will be of interest (I added the bold print for vision therapy):

“14. Matching targeted and active treatments to clinical profiles may improve recovery trajectories after concussion.

Although there are no clear evidence-based treatments for concussion, emerging clinical research and observations suggest that recovery after concussion may be facilitated when targeted, active interventions are matched to the patient’s clinical profile on the basis of presentation and history.  For example, patients who present with postconcussion vestibular impairment and symptoms (eg, dizziness, vertigo, impaired balance, visual motion sensitivity) may benefit from vestibular rehabilitation exercises that treat benign paroxysmal positional vertigo and improve balance, gaze stability, eye-head coordination, and gait.  Similarly, vision therapy was recently reported to be beneficial for patients with concussion and mTBI who exhibited common oculomotor issues such as reading difficulty, vergence, accommodation, saccade, or pursuit impairment.  Vision therapy (orthoptics) uses a variety of vision exercises and tools designed to improve oculomotor control, focusing, coordination, and teaming. In addition to vestibular rehabilitation and vision therapy, exercise prescribed as an adjunct to other therapies or medication may reduce symptoms of depression and anxiety. and may prevent or modify the intensity of migraines that often accompany concussion.”

Concussion and Your Vision

A succinct piece about mTBI and vision on the Wills Eye site from Debra Lehr, O.D. – a neuro-optometrist with Wills Eye Hospital at the Jefferson Comprehensive Concussion Center in Philadelphia.  A graduate of Lehigh University with a degree in Behavioral and Neural Biology, Dr. Lehr is a graduate of Salus University and a member of NORA as well as COVD.


How often is vision affected in concussion?

A recent study found that over 90% of outpatients with mTBI had one or more visual impairment, including difficulty with eye movements, focusing, and eye alignment. Basically, the eyes were not working well together during visual tasks, such as tracking a moving target, shifting eyes from target to target, or holding steady gaze on a target.

What are the most common visual symptoms?

The visual symptoms can be subtle and at times, fatigue or brain fog may be blamed. However, one of the most common visual issues in concussion is difficulty keeping the eyes pointed to the same position in space while focusing the eyes to that same point. That is why objects may appear to move, be seen as double, or blur in and out of focus. Sometimes the impairment is noticed when attempting to focus quickly from near to far or far to near. You may feel uncomfortable when making eye contact or you may not be able to tolerate complex visual environments, such as the grocery stores or patterned flooring.

Other visual problems include light sensitivity, headaches, double vision, fatigue, dizziness, difficulty reading, or loss of peripheral awareness. You may feel the need to wear sunglasses when inside, particularly if you are exposed to fluorescent lights. Visual tasks involving the computer or prolonged reading may require more time than usual, and tend to be more confusing and fatiguing. Another common complaint is eye pain and discomfort, which at times is caused by staring to maintain focus, which dries the surface of the eyes.

What tests are needed to detect these visual problems?

A comprehensive vision evaluation must evaluate the health of the eye, as well as the visual processing system. The examination must include oculomotor (eye movement), binocular vision (eye teaming and alignment), and accommodative (focusing) testing. In addition, it is important to evaluate how the brain is processing the visual information through visual perceptual testing.

What can be done to alleviate these issues?

Once the vision evaluation detects the visual problems, a course of treatment can be prescribed. Remediation of the visual system may require specific lenses or prisms in glasses, lubricating drops, training exercises, and/or tinted filters to reduce light sensitivity.

Return to Learn: School Re-Entry Post Concussion

Visual guidance and optometric vision therapy can play an important role in helping a child return to learn effectively after mTBI and even more severe TBI.  The Concussion Project initiative provides significant information to the public about this subject.  Optometric collaboration with the concussion specialty center at Children’s Hospital of Philadelphia (CHOP) has resulted in an important new article in Optometry & Vision Science on Nearpoint of Convergence After Concussion in Children.


From the article’s conclusion:

Concussion questionnaires may not be sensitive to detect vision symptoms in children, making an accurate assessment for convergence important in the evaluation of concussion. Some children with abnormal NPC will recover without any formal intervention after concussion; however, a subset of patients with persistent abnormal NPC after concussion may benefit from interventions including vestibular and/or vision therapy.

The Return to Learn Plan from CHOP is a very good one, and to that we can add consideration of visual factors in the recovery process.

Return to Learn Plan: Children’s Hospital of Philadelphia (CHOP)

Step 1

Immediately after a concussion, it is beneficial to take a break from cognitive (thinking, processing) activities for up to a few days.

This may mean no school, no homework, no computer, no texting, no video games and maybe no TV if it makes symptoms worse. In general, it is beneficial to minimize screen time.  As symptoms improve, slowly reintroduce light cognitive activity. Initial activities may include watching TV, listening to audio books, drawing and cooking, as long as they do not increase symptoms.

Step 2

Light cognitive activity is resumed once your child has had significant improvement in symptoms at rest.  Your child may do activities that do not cause symptoms to get worse.
Initially, your child may only tolerate five to 15 minutes of work at a time. Stop the activity when moderate symptoms develop.  Your child may increase the length of cognitive activity as long as symptoms do not worsen significantly or as long as symptoms improve within 30 minutes of taking a break.

Step 3

School-specific activity should be increased gradually: When feeling better, your child should try to do some schoolwork at home, increasing the duration as tolerated.  Your child should continue to participate in this activity in short bursts of time (up to 30 minutes) as tolerated and then work up to longer time periods.

Step 4

Follow these guidelines to determine when your child is ready to return to school:  When your child is able to do one hour of homework at home for one to two days, she may try to return to a modified school schedule. Examples of a modified schedule: A decreased number of classes, adjustments to decrease reading and note taking, and extra time to complete assignments and tests.  If symptoms develop while your child is at school, she should take a break in a quiet, supervised area until symptoms improve. When symptoms improve, she may return to class.  Your child may increase her time in school as tolerated.

Adding Vision to Concussion Testing

Hard to believe it’s only 10 days until the movie Concussion makes its debut.

Will Smith admitted that he was conflicted in taking the role of Dr. Bennet Omalu because he is a big football fan.  He loved the four years of bonding when his son played football, and having grown up in Philly he is still a big Eagles’ fan.  The story of an Eagles’ player is featured in the film – the late Andre Waters, a former Eagles’ safety in Buddy Ryan’s defensive schemes known for his ferocious hits during which both he and opposing players experienced cumulative TBI and ultimately died from CTE.  I confess being conflicted because I am still a football fan (and yes – like Will – an Eagles’ fan) yet am very concerned about the effects on young athletes who stay at it for a number of years.

For that reason, vision and concussion was my top story of the year for Elsevier’s Practice Update for Eyecare.

Expert Opinion / Commentary · December 14, 2015

2015 Top Stories in Eye Care: Adding Vision to Concussion Testing

Written by
Leonard J Press OD, FAAO, FCOVD

As increasing numbers of youth participate in organized athletics, particularly contact sports, the need to identify concussed athletes becomes paramount. Anyone who has participated in team sports knows that competitive athletes are reluctant to admit that their function has been compromised because they don’t want to be removed from play. These competitive juices make it difficult for the individual to maintain objectivity as to whether function has been impaired significantly enough to affect performance.


Research on Vision in Concussion: An Update

Recently there have been two published articles which show the relationship between concussion and vision deficits.  These articles both highlight the prevalence of vision problems after concussion and suggest recommendations for incorporating vision evaluation for the concussion protocol:

1. Vision and Reading Deficits in Post Concussion Patients: A Retrospective Analysis  (Tannen et. al)

In this paper, records of 25 patients with a medical diagnosis of concussion were reviewed.  Three primary categories of vision/reading deficits were found: convergence insufficiency (eye-teaming problem-56%), accommodative insufficiency (focusing problem-76%), and oculomotor-based reading dysfunctions (68-82%). The most common symptom was headaches (84%).

68% were categorized as reading at least 2 grade levels below their current school grade level for reading eye movements based on the objective eye movement recordings. The reduced reading speed and efficiency is important as it is the first report using objective eye movement recordings to document oculomotor reading deficits in this patient group.  This gives further credence  to the importance of vision and eye movement evaluation in the return to learn protocol.

2. Vision Diagnoses Are Common After Concussion In Adolescents (Masters et al.)

100 adolescents who were diagnosed with concussion underwent a comprehensive vision examination.  Overall, 69% had one or more of the following vision diagnoses: accommodative disorders (51%), convergence insufficiency (49%), and saccadic dysfunction (eye movement deficits-29%). In all, 46% of patients had more than one vision diagnosis.  These data indicate that a comprehensive visual examination may be helpful in the evaluation of a subset of adolescents with concussion. Academic accommodations for students with concussion returning to the classroom setting should account for these vision diagnoses.


RightEye Concussion Testing and Beyond …


As we’ve introduced to you through this blog, our colleagues have become increasingly involved with the impact of concussion on visual function, and the opportunities for improvement through vision therapy.  For a number of years we’ve successfully used infrared sensing technology for recording saccadic eye movements while reading, and we’ve also been using the K-D test which has surfaced as a player in helping to decide when an athlete should be removed from play.  I’ve been intrigued by the possibility of using infrared sensing technology to record pursuit eye movements in a user-friendly way in a more natural setting than sensors in goggles.

When the RightEye company approached me, my eyes widened.  They have introduced their first module called Neuro Vision as related to concussion.  “Neuro Vision” should not be confused with a program that was introduced about 10 years ago as a therapy tool for amblyopia, ultimately repacked as Revitalvision.  This technology is entirely different, and thus far has targeted objective eye movement recording as follows.

Smooth Pursuit

Measures the % of total test time spent in smooth pursuit of target. Smooth Pursuit Eye Movements are voluntary behaviors that become active when a moving target appears in the visual field.

Smooth Pursuit On Target

Measures the % of test time spent on target.

Eye/Target Velocity Error (Degrees)

Measures the error in smooth pursuit of target at target velocity error. The effect of working recall memory load, which requires time-to-attention, on eye tracking.

Horizontal Synchronization

Measures horizontal synchronization of eye movements with the target’s horizontal motion.

Vertical Synchronization

Measures vertical synchronization of eye movements with the target’s vertical motion.

Predictive Smooth Pursuit

Measures eye movements that jump ahead of the target. An indication that there is a phase lead, meaning same velocity range but directionally ahead.

Latent Smooth Pursuit

Measures eye movements that lag behind. An indication that there is a phase lag, meaning same velocity range but directionally behind.


I see opportunities for this technology to inform clinical assessment and monitoring of patient progress for a wide variety of conditions, including strabismus, amblyopia, and visual components of attention deficit.  Plans are in the works for metrics related to dynamic visual acuity and a variety of other performance measures.  By way of full disclosure, I have no financial interest in the company nor any formal relationship as a consultant.  You can view a brief interview about this technology on the Bright Ideas segment of the CNBC video below.  It occurs at the 21:20 mark, and runs for just under 5 minutes.

Combating Concussions with Vision Therapy

Post Concussion Syndrome Word Cloud Concept on a 3D BlackboardA concussion is a neurological event sometimes referred to as an mTBI that, for some, can have long term consequences. While most individuals who have suffered a concussion recover on their own within 3 months, those who still persist with Post Concussion Syndrome beyond 3 months should be referred for neuro optometric vision rehabilitation. Dr Press and I have written Vision and Concussion on VisionHelp Blog on this topic. Furthermore, to raise public and professional awareness, the VisionHelp Group has created the Concussion Initiative to provide a resources for better understanding.

Concussion Project

In addition, as we are heading into the football season, local Fox News affiliate out of Grand Rapids, Michigan came to our office to gather more information. Their story, Combating Concussion with Vision Therapy  ran today and gave an excellent overview of on the newest methods in neuro optometric vision rehabilitation to help return to play, return to the classroom and return to work following concussion.

Fox News Vision and Concussion

Click on the above photo or here is the link:


Dan L. Fortenbacher, O.D., FCOVD

The Sea of Confusion in Concussion

You know from our Vision Help Concussion Project that concussions or mTBI cause significant visual difficulties that can delay a student’s ability to return to learn.  One of the common symptoms is confusion, and from a cognitive standpoint this often involves difficulty in coordinating the two eyes, or visual con-fusion.  Many of the principles we use in optometric vision therapy programs are helpful in this form of physical therapy for the visual system with a cognitive bent, although the pace and components of the program must be highly individualized.

Barrell Card

We are in the midst of working with a teen athlete, Alexa, who had been struggling to read with any meaningful level of comprehension, and without experiencing intense headaches after a very short period of reading.   She has made slow but very steady progress, consistent with the rate of change ideally seen with this population.  Alexa’s mother is very pleased with the changes she has seen already, and we therefore had her fill out an interim report to share her feelings with you.

Alexa 1

Alexa 2