Delayed Diplopia After Sports-Related Concussion: A Multidisciplinary Approach to Evaluation and Management

Abstract

ObjectiveTo highlight a multidisciplinary approach to the diagnosis and management of unilateral abducens palsy after a sports-related concussion.BackgroundMild traumatic brain injury (TBI) often leads to disruptions in visual functioning, affecting convergence, saccades, smooth pursuit, and accommodation. More severe TBI injuries may result in structural injuries to the ocular muscles, nerves, or the brain itself.Design/MethodsNA.ResultsCase: We present the case of a 33-year-old male with unilateral abducens nerve palsy after a sports-related concussion with loss of consciousness and multiple hemorrhagic contusions. The patient's visual symptoms manifested several days after the injury. With a multi-disciplinary evaluation involving specialists representing neurosurgery, endovascular neurology and neuro-ophthamology, unenhanced magnetic resonance imaging revealed multiple foci of intraparenchymal microhemorrhages and siderosis consistent with diffuse axonal injury (DAI), and an incidental parasagittal cavernoma. The delayed development of a sixth nerve palsy raised our suspicion for secondary axotomy, as has been described following TBI. While the probability of recovery is high, close follow up is imperative to address evolution of the patient's symptoms. In this case, the patient developed imbalance and headaches in association with his visual symptoms. For the imbalance we use physical therapy with therapists trained in vestibular therapy and for the visual symptoms we use vision therapy with trained optometrists.ConclusionsDelayed post-traumatic abducens palsy is concerning for DAI and secondary axotomy. Multidisciplinary assessment imparts the ability to evaluate for all possible causes and provide additional specialized care for recovery.

Post-Traumatic Craniocervical Disorders From a Postural Control Perspective: A Narrative Review

“…Visual symptoms may arise from primary vision deficit, eye movement disorders, and more complex vision-associated functions. Symptoms such as diplopia, visual acuity loss, blurred vision, photophobia, loss of color vision, stereopsis deficit, impaired visual accommodation and visual field impairment have been reported after CCT [ 38 39 40 ]. The main functions of the ocular sensorimotor system are described in Fig.…”

“…TBI, including mTBI, may result in a wide range of ocular sensorimotor dysfunctions reported in Table 1 [ 38 39 42 43 44 45 46 ]. Convergence insufficiency seems to be the most frequent oculomotor deficit following mTBI affecting up to 42% of patients [ 47 48 ].…”