Dr. Fuerst spoke with future ODs on the latest eye-tracking technology from RightEye at the annual UC Berkeley student day on February 17, 2020. His interpretations of eye-tracking technology's application for mTBI (head trauma) and sports vision are outlined below. For more information on how eye tracking can give you information about sports performance and head trauma progression, visit the neuro optometry section of our website: https://www.eyecenteroptometric.com/eye-care-services/neuro-optometric-rehabilitation/
Presented here in full text, is Dr. Fuerst's full presentation.
There are so many opportunities within this profession and it’s only increasing with the aging population and with technology.
A long time ago, the big new technology coming out of the military was GPS. And when it first came out, initially they were very fearful that this could be taken over by bad actors on the international stage. And so they needed to learn it couldn’t be more accurate than about a quarter-mile. And then they brought that down to about a hundred yards, and now that’s down to literally a few meters.
In the movie Top Gun, Tom Cruise is a Navy fighter pilot and he’s out there working like crazy and he locks on the target, hits the button, and shoots the missile and blows up the Soviet mig and averts a more widespread war.
Now in the military, they use high-speed eye-tracking. You don’t do any of this with a center stick, you lock on visually and blink. RightEye is one of the first civilian applications of this technology, and it really fits well within our practice.
I’m going to talk about the need for this, the opportunity, and the implementation within our optometric scope to encourage you as future ODs to be able to think about, for whatever practice modality you’re in, how something like this could be implemented. It’s all about patient flow and the way patients come in through the office. There are all kinds of tests we can run, but if it takes two hours to get the patient through, that won’t work. RightEye fits in well in that sense, also.
We’re going to talk about functional vision. What it is, why it works and why the assessment and treatment of it is a growing area of concern. I’m going to talk about RightEye’s solution to help ODs meet the growing demand for functional vision testing, how we use it at our practice, and show you a couple of patient case studies. I think we’ve had a couple of volunteers today so we’ll run through their reports as well. This generates a pretty sophisticated report so we will show you those results as well.
Melissa Hunfalvay was an Australian professional tennis player. After retiring, she began teaching and coaching at Georgetown University and then decided she wanted to go back for her Ph.D. She was always fascinated by sports and how you process visually when you play, along the lines of the Wayne Gretzky quote: “I don’t follow the puck, I look at where the puck’s going to be.” So she began studying and got her Ph.D. in eye tracking, developed RightEye, and got it approved as a functional vision assessment by the FDA.
When you have MRIs and CT scans for concussion and head injuries and minimal traumatic brain injury--they don’t show the effects those injuries have on vision or give a way to track improvement through functional vision. With tracking tech like RightEye, there are now tests are available that are able to measure that.
My father started our practice in 1960. I was really fortunate. When I came up as an OD, I had a ready-made place and opportunity in the industry. When I was a kid, because my dad was an optometrist--back in the day, you didn’t learn to read until first grade. I seemed like a fairly verbal kid and my parents marched to my parent-teacher conference expecting to hear good things. But what they heard was, he’s struggling. They were told I was in the lowest reading group, and when it was my turn to read I would look at the pictures and make something up. They told my parents, ‘it’s like he can’t see the words on the page.’ And my dad is an optometrist. Those are fighting words to an OD. He says, ‘Randy has 20/20 vision. I’ve been checking it since he could talk.’ And that was our introduction to vision therapy. My dad learned about it and I went through all kinds of exercises with him to improve my functional vision so I could read. By 4th grade, I was in the advanced group. I ended up doing very well and to this day am a voracious reader. This therapy was one of those pieces of the puzzle that ended up being very personally meaningful to me. And because of that, my dad is still in practice at the time, and he’d see kids going through what I went through, struggling with reading. And he’d ask their parents about these struggles and started sharing the tactics he had used with me, treating my functional vision. From that came the vision therapy practice that we have today.
So to fast forward, I graduated from optometry school in 1983 and in 1984, the San Francisco 49ers began doing their summer camp training at Sierra College in Rocklin. And I was fresh out of school so I had more time than patients, and so approached them, and they were interested in vision training. And then in 1985 the Kings moved to Sacramento from Kansas City, and so again I approached them, and they were also interested. So being in the right place at the right time gave me this great opportunity to work with functional vision in a performance aspect through working with those athletes. Then there was a personal injury attorney in Sacramento who went to church with us, and we got to talking about vision and performance and he mentioned he had clients with head trauma who complained of blurriness, double vision, problems with reading and other visual issues that are affecting their livelihood. So I took a look at those clients and again, got the opportunity to study functional vision in that context.
So with functional vision and RightEye, now having an objective way to do things as opposed to subjectively measuring has been a game-changer. I still do pursuits and saccades, but I can show the patient what I am seeing, what their eyes are doing and where the tweaks need to come. I can break the data down and show a patient how their data sets begin to differentiate by age or skill level. That's something I think is incredibly powerful. Being able to compare afflicted readings with a naturalized data set, and be able to tell that patients within a high confidence level that they have a statistically significant issue. Being able to look at saccadic movement, pursuits, and fixations in an objective way is incredibly valuable. So I believe there is a need.
Areas that I look at using RightEye technology are:
Number one: Vision therapy. Only one in three students read proficiently by the end of third grade.
Number two: Sports. 80% of perceptual input is visual. There is an enormous fit here in studying performance ability.
Number three: Head trauma. 90% of patients with traumatic brain injury will suffer from visual dysfunction.
The Journal of the American Medical Association published a study on February 13, 2020. What they found is that with subconcussive head injury (head impacts)-- from heading soccer balls to being tackled or whatnot--they are finding they can show a statistically significant impact on visual performance in terms of eye movements.
In January 2020, another published study found that vertical eye tracking helps differentiate between moderate and severe mTBI (minimal traumatic brain injury). Again, this isn’t showing up in the MRI or the CT scan. But eye tracking can show it. Commonly, a neuropsych evaluation called the impact study is used to measure the effects of concussion. An evaluation that one study gave a 50-50 probability of being accurate. However, that’s what many of your universities and bigger high school programs are using now. Again, it’s a neuropsychological evaluation, and it’s not objective.
Now there’s a portable, handheld ERG that we’re starting to see used that has some specific programming to it to be able to get the baseline, we can see objective measures of where a specific athlete is--the severity or incidences of trauma. We can look at their vision to determine when they get better, and/or can return to play. In traditional approaches, you get a concussion, you’re out for two weeks, no questions. The problem is, your brain immediately starts trying to fix itself and can develop pathways that are suboptimal to put it mildly. And so you see some head trauma cases that have all kinds of vision problems and nausea and dizziness and eye strain that can linger for years. We are in the right place at the right time with this technology that is purely within the realms of the purview of optometry.
Let me talk to you about the University of Cincinnati. Their football program is currently 22nd in the nation in Division 1 NCAA. Joe Clark is a Ph.D. Neurologist at their med school. During his college career, he became a certified athletic trainer. When he got hired at the University of Cincinnati, he went to the football team and said, I’m a certified trainer and a lot of things we do to help rehab stroke and head trauma and concussion patients we can do on a lesser scale with the players. We may be able to get them back to playing sooner because I can work with them immediately. And the team said we’d love to do that. So Joe began working with kids that had concussion on peripheral awareness, stereopsis, depth perception and reaction time. They found the kids liked doing it, they liked the competition aspect and it also made them more aware. Today, there’s so much computer gaming and burying your face in devices, you’re just centralizing and focusing up close, and ignoring peripheral awareness. A lot of the players get fixated on catching the ball and missing the other guy who’s barreling down on them from the side. So Joe began working with the team, and they began to realize this was helping their performance, their catch rates, their timing. But the big thing that was really interesting was, that the average Division 1 school averages 11.5 concussions per season. Across the NCAA, the average is around 12, and in the NFL it's around 15.5. In the 2006 season, University of Cincinnati football had nine concussions. In 2007 there were eight, in 2008 there were seven, and in 2009 there were 11. In 2010, Joe Clark first started working with them doing, in essence, sports vision, with the entire team. There was one concussion on the team that season. The numbers continued to be low until 2017 when vision training was suspended. The team resumed it the following season.
The team had three this past year, in 2019. Dr. Clark was pretty tweaked about that because one of the kids got a concussion on the first day of spring practice so they hadn’t even begun working with him yet. All that to say is, this is intriguing because as we are aware, the whole issue in terms of concussion and the concern surrounding the risk of it. There are over a million fewer kids playing youth football annually because of the fear of concussion. If my kid goes out there and gets a concussion, how do we know if down the line this is going to cause a life-altering or worsening of his quality of life? So we have got to be able to look at these things and be able to measure them. You’ve got to admit, the data is pretty compelling.
The opportunity is, again, instead of manually looking at entrance testing and doing pursuit and saccades and you analyzing that--and you need to do that, as your entrance testing for your patients. Instead of that, being able to objectively quantify this entrance testing data to uncover and treat eye movement dysfunction quickly and effectively.
When you read, you use your peripheral vision or your pericentral vision to locate the next word or target spot, you plot the coordinates, and your eyes snap to the right to that point. Then you go to your central vision to decode the word, once you recognize it you then snap back to your peripheral vision to locate the next one. As you get into chapter books, you start to read in sentence fragments instead of word by word and that precision for saccadic movements is crucial. But beyond that is also fixation. You say okay I want to move my eyes from here to here, and as you’re moving to utilize your central vision, your eyes start to drift. That fixation ability is important, but what do we do to measure fixation? There’s nothing in a routine eye exam. However, the Right Eye data starts to give that to you.
So let’s talk about RightEye. You all have one at Berkeley, and 12 major league baseball teams also use it. Now they can tell with statistical significance how your eyes compare to single-A player, AA, AAA, a major league player, and the top 1% of major league baseball players, in terms of your overall functional vision and tracking.
RightEye looks at pursuits: circular, horizontal and vertical. And movements: vertical and horizontal. There’s measurements of fixation stability and sensory-motor, how well the eyes work together. And reaction time, in milliseconds for what it should be for your age group and what it actually was, then it breaks it down into visual speed and cognitive. Then you get an overall score. You get a quick gage of performance from five-minute tests you don’t even administer. You just look at the results and go over them with the patient.
Sources
Vertical Smooth Pursuit As a Diagnostic Marker Of Traumatic Brain Injury
Melissa Hunfalvay-Claire-Marie RightEye LLC - https://www.futuremedicine.com/doi/10.2217/cnc-2019-0013
Neuro-ophthalmologic Response To Repetitive Subconcussive Head Impacts
Madeleine Nowak - https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2761538?resultClick=1
