optom concussion testing
TRANSCRIPT
CONCUSSIONS
• This is a complex pathophysiological process affecting the brain
• From rotational, acceleration or deceleration injury to the head
CONCUSSIONS
• Most of the media focus on sports• Football and hockey
highest rates
• Multiple lawsuits for this now
• Our field also sees a lot from MVAs
CONCUSSIONS
• CDC had around 3 million reported concussion in 2010
• Underestimated
• Lack of awareness
• 90% without LOC
CONCUSSIONS
• Football has the highest rate
• 1/3 of all concussions occur during practice
• 1 in 5 school athletes will sustain a concussion during the season
CONCUSSIONS
• Concussions at a younger age are more damaging then when older
• Leads to dementia
• Depletes cerebral reserves
CONCUSSIONS
• Regulations for testing on athletes coming out
• No return to play until cleared
• Limit the long term affects
CONCUSSIONS
• During the trauma to the brain the neurons are stretched and strained
• This disruption of the cells alignment and configuration cause dysfunction
• A concussion does not usually cause large structural damage but more a functional problem
CONCUSSIONS
• Simple Concussions• Signs and symptoms resolve within 7-10 days,
with no residual deficits
• Complex Concussions • Persistent symptoms without exertion lasting for
more than 10 days• Prolonged loss of consciousness (>1 min)• History of multiple concussions• Neuropsychological testing and referral to a
neuropsychologist or neurologist recommended
CONCUSSIONS
• Individuals with complex concussion are 18 times more likely to have unusually low scores on neuropsychological tests
• Within 72 hours of the concussion, individuals with
complex concussion perform significantly worse than individuals with simple concussion
CONCUSSIONS
• Previously concussed athletes are 4-6 times more likely to experience a second concussion, even if the second head injury is relatively mild
• Those who experience LOC are 6 times more likely to sustain another concussion than those who have never lost consciousness
CONCUSSIONS
• Secondary Impact Syndrome
• Sustaining another concussion while recovering from another magnifies effect
• Auto regulation is disrupted and increases ICP
• Can cause brain swelling and possible death
CONCUSSIONS
• This is what has happened in the case of Nathan Stiles
• Even after 3 weeks the brain was not healed
• He died at halftime of his return game
CONCUSSIONS
• Signs of a Concussions• Loss of Consciousness (LOC)• Amnesia, retrograde or anterograde• Disorientation• Appearing dazed • Forgetting game rules or play assignments• Inability to recall score or opponent • Inappropriate emotionality • Poor physical coordination• Imbalance• Seizure• Slow verbal responses• Personality changes
CONCUSSIONS
• Post Concussions symptoms• Headache• Dizziness• Nausea and/or vomiting• Difficulty balancing• Visual changes• Photophobia• Phonophobia• Feeling “out of it”• Difficulty with concentration• Tinnitus• Drowsiness• Sadness• Hallucinations
CONCUSSIONS
• At present, there are a number of ways in which concussion is assessed including:• Clinical Examination• Symptom Checklist• Concussion Graded Scale• Standard Assessment of Concussion • Player self-report of current functioning• Neuropsychological testing• Imaging
CONCUSSIONS
• Neuro-psych testing assess neurocognitive and psychological effects
• Need a baseline test to compare any changes
• Helps track recovery
CONCUSSIONS
• Neuropsychological testing assesses the following cognitive domains:• Memory • Speed of information processing• Planning executive functioning • Visual spatial abilities• Visuomotor abilities• Attention • Reaction Time
CONCUSSIONS
• Advantages of computerized testing: • Ease of administration • Short administration time • Easy and widespread access• On-site immediate assessment • Ideal for mass administration • Cost Effectiveness• Automated data collection, storage, analysis and
interpretation
CONCUSSIONS AND VISION
• Can be subtle (CI) or obvious (blindness)
• Is important to ask about any recent head traumas or motor vehicle accidents
• Often injury is downplayed
CONCUSSIONS AND VISION
• Work up should include • VA• Motility measurements (distance and near)• Formal visual fields • Pupillary response• Optic nerve evaluation (oct, vep, ect)• Peripheral retinal exam
CONCUSSIONS AND VISION
• Accommodative-convergence insufficiency
• Very common with concussions
• Often overlooked
• Exact control area unkonwn
CONCUSSIONS AND VISION
• ACI patients complain of problems mostly at near
• Can have double vision
• Causes premature presbyopia
• Nothing on MRI
CONCUSSIONS AND VISION
• Good refraction at near and distance helps
• Could uncover latent refractive error
CONCUSSIONS AND VISION
• Convergence insufficiency
• With or with out accommodative insufficiency
• Problem mostly with near
CONCUSSIONS AND VISION
• Often complain of blurred vision, headaches and even double vision
• Very common injury
• Check deviation distance and near
CONCUSSIONS AND VISION
• Treat with near point exercises (PPU)
• Occasionally base in prism for reading
CONCUSSIONS AND VISION
• Often recovers in 6 months
• Can use patching, prism, or botox
• Surgical repair if not better in 6 months
CONCUSSIONS AND VISION
• 4th nerve palsy
• Can occur with minor trauma
• Trauma could breakdown old phoria
CONCUSSIONS AND VISION
• Longest intracranial course
• Look at old photos for head tilt
• Measure vertical amplitude
CONCUSSIONS AND VISION
• Treat with patching or prism
• Wait 6 months to surgical fix
• Often do inferior oblique myectomy
• Worry about bilateral 4th nerve
CONCUSSIONS AND VISION
• 3rd nerve palsy
• Mechanism is possible from downward displacment of brainstem or from disruption of blood flow
CONCUSSIONS AND VISION
• Can be complete or partial
• Image to image for space occupying lesion from the trauma
Heme
CONCUSSIONS AND VISION
• Can be hard to treat
• Often do not recover much
• Difficult prism or surgery
• Often must occlude
CONCUSSIONS AND VISION
• Traumatic Optic Neuropathy
• Variable presentation
• Minimal visual field defect to complete loss of vision
CONCUSSIONS AND VISION
• Can see decreased VA, change in VF, or color vision changes
• Acutely nerve looks normal, 3-6 weeks atrophy can appear
CONCUSSIONS AND VISION
• Most traumatic optic neuropathy in males
• Often MVA or bicycle accidents
• Helmets are important
CONCUSSIONS AND VISION
• Traumatic optic neuropathy felt to be from shearing force to the nerve or vascular supply
• The tight fit in the optic canal contributes to damage
CONCUSSIONS AND VISION
• Swelling can occur in acute phase
• Further compromises blood supply
• Retinal ganglion cell loss
CONCUSSIONS AND VISION
• Document damage with VF and OCTs
• VEP can be useful• If no response on flash VEP little chance for recovery
CONCUSSIONS AND VISION
• Treatment is debated
• Steroids make us feel better
• Alphagan- makes us still feel better
• Optic canal decompression
• No good study showing what works
CONCUSSIONS
• Suspected concussions need formal workup
• Outside of the visual complications the treatment is rest
• Warn patient about risk of damage with subsequent injury
• The eyes truly are the window to the problem