Development of a mild traumatic brain injury-specific vision screening protocol: A Delphi study

INTRODUCTION Mild traumatic brain injury (mTBI) and concussion are interchangeable terms referring to mild brain injury arising from external forces [1]. By definition, mTBI is a form of neurotrauma. Traumatic brain injury (TBI) is diagnosed as mild, moderate, or severe based on the events that occur directly following the insult. These events include loss of consciousness (LOC), posttraumatic amnesia, disorientation, or other neurological problems. If an individual sustained head trauma without any of these accompanying signs or symptoms, the diagnosis of TBI would not be made. The diagnosis of mTBI usually requires one or more of the following: Glasgow Coma Scale score of 13 to 15, LOC lasting The symptoms used to diagnose TBI at the time of injury (e.g., LOC) are not the same as those that may occur a few days or more after the injury. Postconcussion syndrome (PCS) refers to the spectrum of symptoms that can arise after TBI and is a frequent reason for doctor visits [5-6]. The symptoms of PCS may persist for days, months, or years after the injury and often include fatigue, dizziness, headache, memory problems, and poor concentration. Unfortunately, many persons who have incurred TBI go on to have additional problems, including medical, psychological, and social problems; problems with academics and with alcohol abuse; and numerous others [7-8]. Among the many issues that can arise post-TBI, as part of PCS, are problems related to the eyes and vision [6]. Blurred vision, light sensitivity (photophobia), and diplopia have been reported [9-13]. These can occur subsequent to TBI from all causes, regardless of severity. Problems with binocular vision (BV), extraocular muscle function, and the accommodative system have also been found at relatively high frequencies [10-12]. These and other TBI-related vision problems have the potential to affect daily functioning in affected patients. For example, reading problems from convergence or accommodative deficiencies can negatively affect educational endeavors. In addition, sensitivity to light may cause discomfort or headaches. These examples illustrate the potential negative effect of TBI on vision and underscore the importance of correctly evaluating and treating these problems. The recent conflicts in Iraq and Afghanistan have brought increased awareness to TBI. It is estimated that since the beginning of hostilities, more than 262,065 service-members have sustained a TBI [14]. However, TBI is not exclusive to the military, and approximately 1.7 million persons from all professions and lifestyles incur TBI in the United States every year [15]. Many military service-members and veterans with moderate or severe TBI also have physical injuries and are seen in polytrauma treatment facilities in the Department of Veterans Affairs (VA) system of care. Polytrauma is defined as having injuries to multiple body parts and organs, one of which may be life threatening [16]. Patients with polytrauma usually have access to advanced eye care as part of their treatment plans. In fact, Veterans Health Administration (VHA) Directive 2008-065 requires that any patient who has been admitted to a Polytrauma Rehabilitation Center (PRC) with a definitive diagnosis of TBI be referred to optometry or ophthalmology for a comprehensive TBIspecific ocular health and visual functioning examination [17]. However, there may be over 180,000 Active Duty servicemembers and veterans with mTBI resulting from recent overseas conflicts that do not have polytrauma and therefore may not have formal access to eye care services. Some of these patients may be referred to optometry or ophthalmology if a visual or eye-related complaint is made to their primary care provider, but many of those who do not complain of vision problems may not be referred for eye care. …