Eye on head injuries: Can football pass the eye test?

Excerpted from page 42 of the September 2016 edition of AOA Focus.

It's kickoff time again. Time for the pageantry, the crowds, the tailgating, the athleticism—and the rekindled discussion surrounding head injuries in football.

Now, as pundits decide whether the National Football League's (NFL's) newly implemented concussion protocols can pass the smell test, optometry will get a spot under the stadium lights as football elsewhere sees whether its players can pass an eye test.

This season, the Canadian Football League (CFL) is testing a number of player health and safety initiatives, including injury spotters and continued research, and use of the King-Devick Test (K-D Test), a sideline concussion test developed by Steve Devick, O.D., and Alan King, O.D.

Last year, the CFL's BC Lions, Edmonton Eskimos, Calgary Stampeders and Winnipeg Blue Bombers partnered with the NFL to use the K-D Test during games and practices, in addition to current CFL education and protocols. This year, all nine CFL teams will use the K-D Test.

"Our test is a simple but effective tool for validating a lot of things that doctors of optometry have done for years," Dr. Devick says.

And in March, the NFL reversed field and conceded—after years of denials—that there was "certainly" a link between repeated hits to players' heads and chronic traumatic encephalopathy.

"I think there's a lot more awareness," says Keith Smithson, O.D., who practices in Alexandria and Reston, Virginia, and serves as the director of visual performance for the Washington Nationals and team optometrist for several professional teams including the Washington Wizards (basketball), Washington Mystics (women's basketball), DC United (soccer) and Washington Spirits (women's soccer). He's also a consultant for the Washington Redskins (football) and the Washington Capitals (hockey) and a member of the AOA's Sports Vision Section.

"I'm involved with teams from the preseason assessments standpoint and when we see the teams in spring training," Dr. Smithson says. "And in preseason, there's a lot of baseline concussion testing that is now done. Every league has its own protocols. They are all a little bit different in what they require. But there is some level of baseline testing in pretty much every league at this point."

However, Dr. Smithson says he'd like to see improved detection and testing devices, both on the sidelines and off. He says more standardization of diagnosing, treating and rehabilitating TBI patients is needed, too.

"Concussions are real," he adds.

An opportunity for doctors of optometry

"Optometry understands vision better than any other profession, and because of this, has the tools to give patients with brain injury the best care possible," says Chrystyna Rakoczy, O.D., chair of AOA's Brain Injury Committee who practices at the James A. Haley Veterans' Hospital in Tampa, Florida. The Brain Injury Committee was formed under the AOA's Vision Rehabilitation Section (VRS).

"It's critical that primary-care optometrists learn how to identify, assess and treat patients with vision problems for brain injury, or these people will continue to suffer believing that they will never get better," Dr. Rakoczy adds.

The VRS has produced the Brain Injury Electronic Resource Manual ( BIERM) to help guide AOA-member doctors in properly diagnosing and managing TBI. While the BIERM Volume 1A: Traumatic Brain Injury Visual Dysfunction Diagnosis, addresses optometry's overall involvement in management and rehabilitation of patients with traumatic brain injury, the most recent addendum, Volume 1B: Traumatic Brain Injury Visual Dysfunction: Optometric Management and Advanced Topics, provides an overview of high-yield optometric management protocols that are important to incorporate into the care of patients with visual sequelae of closed head trauma.

Seventy percent of all sensory information comes through the eyes. When a person suffers a TBI, the brain and eyes no longer process information together. Dr. Rakoczy calls the dysfunction "garbage in, garbage out."

"The manual was developed because doctors of optometry are really in a very good position to treat these patients," says Brenda Heinke Montecalvo, O.D., immediate past chair of the VRS and one of the manual's authors. "As doctors of optometry, we have a unique ability to make sure the information coming into the eye is as accurate as possible because we know how to measure visual function. No other profession can provide the cutting-edge, high-level visual care that optometry does."

Dr. Smithson agrees. "Optometry should be on the forefront of providing vision care for people with postconcussion vision syndrome. There's a huge opportunity for our profession. If we miss it, shame on us."

He adds, "This is something that is right there waiting for us. People are looking for us. The referrals I get every day are not for someone who had a concussion yesterday. It's for people who had a concussion, went and got the right testing, went to a pediatrician or the concussion center or a neurologist and had it confirmed. And now they have vision symptoms that are lingering post-concussion, and they refer them to me for therapy. We should be an integral part of the rehabilitation team."

Read more about optometry's role in TBI management in the September 2016 edition of AOA Focus.