As I have discussed in previous blogs, there is often no definitive test to detect a traumatic brain injury (TBI). CT scans and MRI scans are extremely insensitive to detecting brain injuries unless those injuries are severe.
Glasgow coma scales which are used to assess a patient’s awareness in the emergency room immediately after accident are useful in initial emergency intervention but cannot predict long-term outcome in traumatic brain injury. The obsession over initial Glasgow scores is just that – an obsession over a number that has little predictive value.
Cognitive deficits are best measured by neuropsychologists who are doctors of psychology specially trained to make detailed evaluations of a person’s functional status after a head injury. They often spend 4-5 hours with a patient trying to determine pre-injury status (not all people start out the same) and then conduct a battery of written and visual tests to create a cohesive picture. These reports are considered valid in the real world, and even posses mechanisms for detecting malingering (clients trying to fake injuries) deficits.
How does this relate to me, an ophthalmologist? Well, many tests of a patient’s functioning not only relate to memory but a current assessment of visual-spatial relationships. Once again, visual skills play a central role in brain function. Even if the eyeballs are working, the visual information must be interpreted by the brain. If a neuropsychologist determines a given patient is having visual problems. one cannot ignore the possibility that there is an intrinsic eye disease (like glaucoma) which may be contributing to the problem. Only eye doctors can detect a silent disease like glaucoma.
Ophthalmologists, by the very nature of their medical practices, do not have the hours necessary to administer a huge battery of tests. Head trauma can make up a significant percentage of of a neuropsychologist’s practice. I have incorporated TBI into my practice but have continued to practice standard comprehensive ophthalmology. I continue to treat glaucoma and do cataract surgery. This allows me to maintain my skill level as an expert in all fields of eye care.
There is so much overlap in what ophthalmologists measure and what can be detected by neuropsychologists, I am often fascinated when I read their medical records when I review documents associated with a particular case, yet I rarely interact with neuropsychologists. The approach to a head trauma patient remains fragmented. Every specialty carves out their own niche, but the approach to the brain injury patient should be across specialties. Patients are confused by what different specialists are saying and doing.
One purpose of my blog is to recognize the importance of other specialists who are central in making a long-term assessment of the TBI patient and neuropsychologists play a central role.
But as long as vision defines a person’s level of function in the modern world, and looking at a computer screen is the fastest growing task in the workplace and at home, then I will also play my role in evaluating TBI victims.
Steven H. Rauchman, M.D. is an eye physician and surgeon who has been in private practice for 30 years. He has served as a Traumatic Brain Injury (TBI) medical/legal expert for the last 6 years specializing in the area of personal injury and related traumatic brain injuries.