Comprehensive eye exams for PI clients

Head and neck injury victims may have subtle visual complaints to warrant examination

2014 August

Clients involved in motor-vehicle collisions are routinely referred to orthopedic surgeons and chiropractors to document the extent of injury and need for treatment. Neurologists are often the next specialists involved if these individuals have headaches or a variety of other more subtle neurological complaints. These referrals are routine after initial consultation with a personal-injury attorney, and are central to the appropriate medical care of injured clients.

Are you aware that routine eye exams should be included in most cases? It is obvious that patients with direct eye injuries need an ophthalmologist’s evaluation, but even in the case where there is no direct globe trauma, a dilated eye exam by an ophthalmologist should be performed to rule out any possible peripheral retinal tears resulting from the trauma. Symptoms such as “floaters and flashes” can indicate retinal issues that could result in a subsequent retinal detachment. But what about individuals with more subtle complaints and findings?

The academic evidence speaks for itself. Historically, researchers in the academic community have not been interested in the visual impact of motor-vehicle accidents and head/neck injuries. However over the last 10 years there has been a lot of interest in returning veterans from Iraq and Afghanistan with any form of head injury, even relatively mild head injury. The results are surprising but very informative.

In volume 46, number 6, of the Journal of Rehabilitation Research & Development (November 2009) Glenn C. Cockerham, M.D. the national program director of the Veteran’s Administration (VA) ophthalmology service in Stanford, California, describes symptoms of outpatients who live independently after only a mild traumatic brain injury.

“In patients who had no significant visual complaints before their injury, 75 percent had post-accident visual complaints and 63 percent had difficulty reading. Objective findings in these patients with normal visual acuity include almost 50 percent with accommodative insufficiency and convergence insufficiency which are bilateral visual functions that can only be detected by a detailed neuro-ophthalmological exam.” In laymen’s terms, issues with accommodative and convergence insufficiency affect binocular vision and can affect activities of daily living as well as job performance.

In another publication from the Journal of Rehabilitation Research & Development (2007, Vol. 44, no. 7), Gregory L. Goodrich, PhD, also of the VA Health System, notes that even in veterans with non-blast-related injuries, including motor-vehicle accidents, 60 percent had difficulty reading and again a high percentage had objective findings of bilateral neuro-ophthalmologic dysfunction, with a full 12 percent having double vision. In the overall study of trauma patients, 24 percent had visual field defects, a problem that can only be assessed in a comprehensive ophthalmological evaluation.

Finally, in the June, 2011, issue of the New England Journal of Medicine, a letter to the editor by Dr. Cockerham concluded, “We recommend comprehensive ocular evaluation by an ophthalmologist including gonioscopy and dilated retinal examination with scleral depression, for any veteran with a diagnosis of TBI (traumatic brain injury) of any severity level from blast exposure, including veterans with normal visual acuity.”

Civilians deserve the same high level of care recommended for our veterans. Many accident victims have ocular complaints, if asked, and these ocular issues can have real economic and personal consequences.