Traumatic Brain Injury in Children: Do the Eyes Have It? The Orthoptic Evaluation of Traumatic Brain Injury

Because the neuropathological changes caused by mild traumatic brain injury (mTBI) more often manifest as functional impairments than structural abnormalities, the clinical diagnosis of mTBI may rely too heavily on a combination of history and self-reported symptoms. The mechanism of injury in mild traumatic brain injury (mTBI) predicts that supranuclear pathways controlling eye movement systems would be vulnerable to damage, and diagnostic tests of these systems would be high-yield. In fact, tests of oculomotor function have proven to be highly sensitive in detecting neurological soft signs, but may require expensive, specialized equipment. Fortunately, Certified Orthoptists (COs) are skilled at the evaluation of accommodative dysfunction, abnormalities of saccades, smooth pursuit, and vestibular eye movements, and vergence errors using standard ophthalmic equipment. Because COs are accustomed to adapting the sensorimotor exam to infants and pre-verbal children, they are able to modify or design objective methods, the results of which may be difficult for the patient with a functional overlay to decipher and deceive. When the patient with a history of mTBI presents to the ophthalmologist with visual symptoms and a normal routine eye exam, it is important to order a sensorimotor examination by a CO to confirm the diagnosis.