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

Dr. Fortenbacher’s Annual Lecture on Vision & Concussion

Dan FortenbacherOur VisionHelp colleague, Dr. Dan Fortenbacher, will be presenting his annual lecture to the students at the Michigan College of Optometry tomorrow.  The subject of the lecture will be Vision & Concussion, and remains a very timely one.  Last month, our VisionHelp colleague Dr. Barry Tannen blogged about the launch of the VisionHelp Concussion Project.

The faculty of the Michigan College of Optometry will be doing something innovative this year.  Students have been assigned to watch Dr. Fortenbacher’s presentation from last year prior to the classroom discussion.  The lecture will take the form of facilitated interaction, based on questions or comments about the video presentation.  We present here the lecture presentation in its entirety for your viewing pleasure.


The VisionHelp Concussion Initiative is Live!

In March I blogged about the upcoming  VisionHelp Concussion Initiative.  I am happy to tell you that as of this morning it is live! (VisionHelp Concussion Project).

Screen Shot 2015-06-23 at 11.05.35 PM

To review, VisionHelp is a group of developmental and rehabilitation optometrists who meet regularly to discuss the latest developments and best practices as well as to facilitate and develop initiatives to advocate for professional and public awareness of developmental vision and rehabilitation.

Over a year ago, I shared my dream of a website dedicated to highlight the extraordinary effects of concussion and post-concussion syndrome on the visual system to my colleagues at VisionHelp. With their support, and the talent and creativity of web designer Rebecca Sherry, the website has become a reality.

We are hopeful that this site serves as a repository of information to help both patients and professionals.  We see so many patients who suffer needlessly from visual symptoms after concussion such as  double vision, blurred vision, headaches after reading/computer work, along with more subtle visual symptoms as light sensitivity in fluorescent lighting, and difficulty navigating busy visual environments such as malls and supermarkets.  We have been able to help our patients through neuro-optometric rehabilitation but we know that there are so many more patients who could be helped.

We envision this as a website to share the growing body of information for patients, parents, and professionals on the visual effects of concussion.  Your comments and suggestions are welcome!

Barry Tannen, O.D., FCOVD

Post-Rotary Nystagmus and Concussion

You may be familiar with the concept of post-rotary nystagmus, in which spinning around in circles makes you dizzy from sloshing up your semicircular canals, and sets off a characteristic oscillating motion of your eyes when you stop spinning.  Here is a real-time recording of what the eyes of a normal child are doing during rotation and then immediately post-rotation, as projected onto a video monitor.

We know that visual fixation under normal viewing conditions serves to dampen post-rotary nystagmus and stabilize balance through visual-vestibular interaction.  Frenzel goggles are high power convex lenses that serve to magnify the subjects’ eyes making the post rotary nystagmus more visible to the examiner, and also to blur the visual field significantly to impair the dampening of post-rotary nystagmus.  Here is a video of a young adult’s eyes during post-rotary nystagmus, wearing Frenzel goggles.

In a search of the literature I was unable to find any publications on the effect of concussion on post-rotary nystagmus.  By way of this post I am theorizing that concussion impairs post-rotary nystagmus in a way similar to Frenzel goggles, rendering the individual as “being in a fog”, as occurs with the high plus lenses.  Specifically, impaired visual-vestibular interaction should inhibit the ability of the visual system to dampen post-rotary nystagmus.  This would increase the decay time of pos-rotary nystagmus, and would be measurable objectively.

One of the holy grails of concussion testing is an objective measure that does not require responses on the part of the individual suspected of being concussed, or interpretation of the individual’s responses.  I am proposing that post-rotary nystagmus can be measured objectively through a sensor, either in glasses or though a fixation target, and that a baseline measure can be established of the duration of post-rotary nystagmus (PRN).

When testing an athlete, I am proposing that concussion prolongs PRN time, and impedes stabilization of gaze than dampens PRN.  This has great potential to complement other tests used for both remove from play as well as return to play, or return to learn.  It is entirely independent of intellect, and requires limited if any instructional set, or interpretation of verbal responses.  Baseline data can be established for post-rotary nystagmus done in the standing or vertical position, as opposed to sitting in a chair, which would be more pertinent for athletes.  For return to learn or driving, being seated in a chair may be more pertinent.

The VisionHelp Concussion Initiative

VisionHelp Logo

The stated mission of the VisionHelp group is “to provide leadership and foster the development of public and professional awareness projects to help end the senseless struggle of those individuals, children and adults who suffer from developmental vision and rehabilitation problems.”

VisionHelp is a group of developmental and rehabilitation optometrists who meet regularly to discuss the latest developments and best practices as well as to facilitate and develop initiatives to advocate for professional and public awareness of developmental vision and rehabilitation.

As part of our annual meeting last year we decided to establish the VisionHelp Concussion Initiative.

VisionHelp Concussion Initiative

Numerous journal articles and blogs have pointed out the critical role that the visual system plays in the diagnosis and management of concussion and post concussion syndrome (e.g. Post concussion discussionConcussions and VOMIT).   Our goal was to create an interactive digital site to allow for the the exchange of information for patients who have visual consequences of concussions, as well as optometrists, and other professionals who work with concussion and post concussion patients.


We felt that there was no better time than “Brain Injury Awareness Month” to unveil our plans for the VisionHelp Concussion Initiative.  Look for more details to come soon in this VisionHelp Blog!