Concussion and the ocular system have a close connection.

4. C O N C U S S I O N S
J O D Y A B R A M S , M D
HERE COMES THE BOOM

5. CONCUSSIONS
• This is a complex pathophysiological process
affecting the brain
• From rotational, acceleration or deceleration injury
to the head

6. CONCUSSIONS
• The forces on the brain causes an alteration in the
function of the brain function

7. 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

8. CONCUSSIONS
• CDC had around 3 million reported concussion in
2010
• Underestimated
• Lack of awareness
• 90% without LOC

9. 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

10. CONCUSSIONS
• Concussions at a younger age are more damaging
then when older
• Leads to dementia
• Depletes cerebral reserves

11. CONCUSSIONS
• Regulations for testing on athletes coming out
• No return to play until cleared
• Limit the long term affects

12. 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

13. CONCUSSIONS
Which one has the concussion?

14. CONCUSSIONS
Tensor Diffusion Imaging

15. 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

16. 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

17. CONCUSSIONS
• Most fall in mild range
• LOC often not present
• Amnesia brief

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. CONCUSSIONS
• Neuro-psych testing assess neurocognitive and
psychological effects
• Need a baseline test to compare any changes
• Helps track recovery

25. CONCUSSIONS
• Neuropsychological testing assesses the following
cognitive domains:
• Memory
• Speed of information processing
• Planning executive functioning
• Visual spatial abilities
• Visuomotor abilities
• Attention
• Reaction Time

26. CONCUSSIONS
• Memory and processing speed appear to be the
most susceptible

27. 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

29. CONCUSSIONS AND VISION

30. 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

31. 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

32. CONCUSSIONS AND VISION
• Accommodative-convergence insufficiency
• Very common with concussions
• Often overlooked
• Exact control area unkonwn

33. CONCUSSIONS AND VISION
• ACI patients complain of problems mostly at near
• Can have double vision
• Causes premature presbyopia
• Nothing on MRI

34. CONCUSSIONS AND VISION
• Good refraction at near and distance helps
• Could uncover latent refractive error

35. CONCUSSIONS AND VISION
• Convergence insufficiency
• With or with out accommodative insufficiency
• Problem mostly with near

36. CONCUSSIONS AND VISION
• Often complain of blurred vision, headaches and
even double vision
• Very common injury
• Check deviation distance
and near

37. CONCUSSIONS AND VISION
• Treat with near point exercises (PPU)
• Occasionally base in prism for reading

38. CONCUSSIONS AND VISION
• 6th nerve palsy
• Most common CN in
concussion
• Long intracranial
course

39. CONCUSSIONS AND VISION

40. CONCUSSIONS AND VISION
• Often recovers in 6 months
• Can use patching, prism, or botox
• Surgical repair if not better in 6 months

41. CONCUSSIONS AND VISION
• 4th nerve palsy
• Can occur with minor trauma
• Trauma could breakdown old phoria

42. CONCUSSIONS AND VISION
• Longest intracranial course
• Look at old photos for head tilt
• Measure vertical amplitude

43. CONCUSSIONS AND VISION
• Treat with patching or prism
• Wait 6 months to surgical fix
• Often do inferior
oblique myectomy
• Worry about bilateral
4th nerve

44. CONCUSSIONS AND VISION
• 3rd nerve palsy
• Mechanism is possible from downward displacment
of brainstem or from disruption of blood flow

45. CONCUSSIONS AND VISION
• Can be complete or partial
• Image to image for space occupying lesion from
the trauma
Heme

46. CONCUSSIONS AND VISION
• Can be hard to treat
• Often do not recover much
• Difficult prism or surgery
• Often must occlude

47. CONCUSSIONS AND VISION
• Traumatic Optic Neuropathy
• Variable presentation
• Minimal visual field defect to complete loss of vision

48. CONCUSSIONS AND VISION
• Can see decreased VA, change in VF, or color
vision changes
• Acutely nerve looks normal, 3-6 weeks atrophy can
appear

49. CONCUSSIONS AND VISION
• Most traumatic optic
neuropathy in males
• Often MVA or bicycle
accidents
• Helmets are important

50. 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

51. CONCUSSIONS AND VISION
• Swelling can occur in acute phase
• Further compromises blood supply
• Retinal ganglion cell loss

52. CONCUSSIONS AND VISION
• Document damage with VF and OCTs
• VEP can be useful
• If no response on flash VEP little chance for recovery

53. CONCUSSIONS AND VISION
• Get imaging to look for treatable problems

54. 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

55. 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