Ocular motor disorders in children and adults with mTBI: a scoping review protocol.

INTRODUCTION: Ocular motor function is susceptible to neurological injury because it requires a large portion of brain circuitry including every lobe of the brain, brainstem, thalamus, basal ganglia, cerebellum, cranial nerves and visual tracts. While reports of a high frequency of ocular motor dysfunctions after mild traumatic brain injury (mTBI) span multidisciplinary journals, there is no scoping review of the signs, diagnostic assessments and criteria, and appropriate management of ocular motor disorders post-mTBI. Post-mTBI ocular motor dysfunction has been reported to respond to active treatment. The objective of this scoping review is to map the available evidence on the diagnostic assessment and treatment modalities currently used in the management of mTBI-related ocular motor disorders in children and adults. This scoping review also aims to identify gaps in the current literature and provide suggestions for future research. METHODS AND ANALYSIS: This review will include populations with reported concussion and/or mTBI without restrictions on age, race, sex or time since injury. The review will evaluate the reported symptoms related to ocular motor dysfunction, types of assessments and diagnostic criteria used, reported treatments, and the level of evidence supporting the reported treatments. This review will exclude literature on brain injury of non-traumatic aetiology and moderate/severe traumatic brain injury. Ocular motor dysfunction after mTBI appears in journals across multiple disciplines. Thus, multiple databases will be evaluated including Pubmed, Embase, PEDro, OVID, Clinical Key, Google Scholar and REHABDATA. Literature will be searched from inception to present day. Evidence sources will include experimental study designs including randomised controlled trials, non-randomised controlled trials and interrupted time-series. Additionally, analytical observational studies including prospective and retrospective cohort studies, case series, cross-sectional studies and clinical practice guidelines will be considered for inclusion. Data will be extracted on clinical presentation, frequency, assessment, diagnostic criteria management strategies and outcomes of concussion and mTBI-related ocular motor disorders. ETHICS AND DISSEMINATION: This scoping review will use data from existing publications and does not require ethical approval by an institutional review board. Results will be disseminated through publication in a peer-reviewed scientific journal and presented at relevant conferences and as part of future workshops with professionals involved with diagnosis and management of patients with mTBI.

Vestibulo-ocular dysfunction in mTBI: Utility of the VOMS for evaluation and management - A review.

BACKGROUND: Individuals who have suffered a concussion/mild traumatic brain injury (mTBI) frequently report symptoms associated with vestibular and/or oculomotor dysfunction (VOD) like dizziness, nausea, fatigue, brain fog, headache, gait and neurocognitive impairments which are associated with the development of chronic symptoms. The Vestibular/Ocular Motor Screening (VOMS) tool has been established as a reliable and clinically relevant complement to use alongside a battery of post-concussion tests to improve screening and referral for further evaluation and treatment of VOD. OBJECTIVES: This paper will review the pathoanatomy and symptomatology of common vestibular and oculomotor disorders after concussion, as well as the utility of the VOMS to assist in diagnosis, referral, and management. METHODS: Primary articles were identified using a search via PubMed, Google Scholar, OneSearch, and CINAHL. Search key terms were combinations of "mild traumatic brain injury" or "concussion" or "pursuit" or "accommodation" or "vergence" or "convergence insufficiency" or "saccades" or "vestibulo-ocular reflex" or "vestibular ocular motor screen" or "vestibular rehabilitation", or "vision rehabilitation" including adult and pediatric populations that were published in print or electronically from 1989 to 2021 in English. Classic papers on anatomy of eye movements, vestibular system and pathological changes in mTBI were also included, regardless of publication date. RESULTS: Objective impairments are commonly found during testing of smooth pursuit, saccades, vergence, accommodation, vestibular ocular reflex, and visual motion sensitivity after mTBI. These deficits can be actively treated with vestibular physical therapy and oculomotor/neuro-optometric vision therapy. VOMS is an efficient and reliable tool that can be used by all healthcare and rehabilitation providers to aid in diagnosis of post-concussion VOD, to help facilitate the decision to refer for further evaluation and treatment to expedite symptomatic post-concussion recovery. CONCLUSIONS: VOD is common after concussion in acute, post-acute, and chronic phases. Once areas of impairments are identified through proper assessment, clinicians can maximize recovery by referring to vestibular physical therapy and/or neuro-optometry to design a targeted treatment program to address individual deficits.

Differential diagnosis and theories of pathophysiology of post-traumatic photophobia: A review.

BACKGROUND: Photophobia is a common sensory symptom after traumatic brain injury (TBI) that may have a grave impact on a patient's functional independence, neurorehabilitation, and activities of daily living. Post-TBI photophobia can be difficult to treat and the majority of patients can suffer chronically up to and beyond one year after their injury. OBJECTIVES: This review evaluates the current theories of the pathophysiology of photophobia and the most-common co-morbid etiologies of light sensitivity in TBI to help guide the differential diagnosis and individualized management of post-TBI photophobia. METHODS: Primary articles were found via PubMed and Google Scholar search of key terms including "photophobia" "light sensitivity" "photosensitivity" "photo-oculodynia" "intrinsically photosensitive retinal ganglion cells" "ipRGC" and "concussion" "brain injury" "dry eye". Due to paucity of literature papers were reviewed from 1900 to present in English. RESULTS: Recent advances in understanding the pathophysiology of photophobia in dry eye and migraine and their connection to intrinsically photosensitive retinal ganglion cells (ipRGC) have revealed complex and multifaceted trigeminovascular and trigeminoautonomic pathways underlying photophobia. Patients who suffer a TBI often have co-morbidities like dry eye and migraine that may influence the patient's photophobia. CONCLUSION: Post-traumatic photophobia is a complex multi-disciplinary complaint that can severely impact a patient's quality of life. Exploration of underlying etiology may allow for improved treatment and symptomatic relief for these patients beyond tinted lenses alone.

Methods to Assess Ocular Motor Dysfunction in Multiple Sclerosis.

: BACKGROUND:: Multiple sclerosis (MS) is an inflammatory disease of the central nervous system causing the immune-mediated demyelination of the brain, optic nerve, and spinal cord and resulting in ultimate axonal loss and permanent neurological disability. Ocular motor dysfunction is commonly observed in MS but can be frequently overlooked or underappreciated by nonspecialists. Therefore, detailed and quantitative assessment of eye movement function has significant potential for optimization of patient care, especially for clinicians interested in treating visual symptoms or tracking disease progression. METHODS:: A brief history of eye tracking technology followed by a contextualized review of the methods that can be used to assess ocular motor dysfunction in MS-including a discussion of each method's strengths and limitations. We discuss the rationale for interest in this area and describe new tools capable of tracking eye movements as a possible means of monitoring disease. RESULTS/CONCLUSIONS:: This overview should inform clinicians working with patients with MS of how ocular motor deficits can best be assessed and monitored in this population. It also provides a rationale for interest in this field with insights regarding which techniques should be used for studying which classes of eye movements and related dysfunction in the disease.