Neuro-Optometric Care following Concussion & Brain Injury
Brain Injury and Vision
The visual process is tremendously complex. So much neurology is involved; therefore, so much is exposed following brain injury. It is not possible to anticipate all of the problems which may result following a brain insult (such as a stroke, trauma, or an infection of the central nervous system). However, the array of possible problems may come to light with an overview of the Visual Pathways.
Where is “Vision” in the Brain?
Visual discrimination/ recognition, the ability to “make sense” of things, is largely impacted after brain injury. This visual information processing takes place in all four lobes of the cerebral cortex. Visual data leaves the eyes, organizes in the midbrain (thalamus) and enters the occipital lobe (at the “striate cortex”). After initial re-organization in the “primary visual cortex,” visual data is transferred to associative cortices to help us make sense of the world:
Data are carried toward the parietal lobe for spatial processing, “WHERE is it?”
- Data are carried toward the temporal lobe for identification, “WHAT is it?”
- The frontal lobe supports visual-motor planning, such as, “HOW do I get there? and WHICH should I manage first?”
Lower Visual Centers in the Brain
While 90% of visual input reaches the cortex, 10% of visual information is gathered and used “subcortically”: It never reaches our conscious awareness. This visual information travels from the eyes to the midbrain. This visual pathway supports our balance, orientation, and our sense of visual stability.
Patients who suffer cortical visual loss after brain injury (e.g., “hemianopia”) can develop “Blindsight,” an ability to see and respond to visual information without it ever reaching consciousness. This can even be trained!
Sight is how little you can see.
Vision is how much you can see!
Oculomotor Impacts of Brain Injury
Most patients’ visual challenges are not limited to “sight,” the ability to identify small images. In a sense, sight is about how little you can see… while vision is about how much you can see! Vision requires the eyes to aim accurately as a team for single vision, to maintain stability, focus clearly, and navigate the visual field.
The brain directly manages motor control over the eyes with six (6) of the twelve (12) Cranial Nerves (CN). That’s half! They support both sight and vision by:
- Carrying visual data, eyes to brain (CN II)
- Controlling eye movement (CN III, IV, VI)
- Controlling eyelids (CN III, VII)
- Carrying eye sensations (CN V)
The control centers for these nerves are in the brainstem. Thus, eye movement control is frequently “unhinged” post-injury (especially following whiplash!).
Tunnel Vision following Brain Injury
After brain injury, “Tunnel Vision” is a common experience. While the retina may be healthy, the brain is not prepared to gather and organize information from a broad area. As part of the “fight or flight” response, blood flow is diverted from the peripheral retina. This protective mechanism may last long after the threat is removed, affecting:
- Orientation: feeling “lost in space” or insecure in one’s surroundings.
- Balance: feeling unsteady, less coordinated, (increasing the risk for subsequent injury).
- Eye teaming: binocular vision suffers, especially when sustained, at near-point (e.g., “convergence insufficiency”).
- Eye tracking: impacting saccades (eye “jumps” used in reading & scanning), smooth pursuit (ability to track moving targets), & fixation (ability to hold eyes steady).
- Simultaneous visual information processing: Tunnel vision creates difficulty seeing the world as a whole. With impaired orientation and concentration, patients struggle to piece things together. This evokes confusion, fatigue, and headaches.
- Spatial memory: reduced sense of orientation impacts incidental recall for location (e.g., Where did I leave my keys? My car? My glasses?)
How Neuro-Optometry Can Help:
- Lenses and/or colored filters may alleviate unnecessary stress, helping patients feel grounded and stable, in support of recovery.
- Lens prescriptions may stabilize focus, eye strain, reduce headaches, fatigue, and help resolve double vision.
- Prism prescriptions may assist patients with balance and walking.
- Syntonic phototherapy (color therapy) helps patients gently expand the peripheral visual field, to overcome the myriad symptoms of tunnel vision.
- Neuro-optometric Visual Rehabilitation (NOVR) supports the patient’s ability to reclaim control over eye aiming, eye teaming, focusing, visual information processing, and multisensory integration between Visual skills and the full array of:
- Input senses: Vestibular (balance), Auditory, Tactile, Ocular Proprioception (eye-feel), and
- Output skills: Gross motor, Fine motor, Oculomotor, Speech, and Visual Perceptual Processing.
- With NOVR, Visual Perceptual therapy provides the scaffolding which helps the patient re-establish an organized, stable foundation.
- NOVR supports: Body organization, Spatial organization, Visual Spatial Memory, Visual Sequential Memory, Tachistoscopic Memory (at a quick glance), Orientation, Visual Motor planning, Eye-hand Coordination, and Visual Perceptual problem solving.
Impacts of Neuro-optometric Visual Rehabilitation
With a comprehensive, holistic approach, Neuro-optometric Visual Rehabilitation helps patients reclaim control over visual input skills and multisensory visual information processing. As symptoms abate, impacts are realized far beyond the visual process! Common results include improvements in: Balance, movement, motor planning, coordination, sustained visual attention, concentration, interest in reading, academic skills, athletic performance, memory, focus, organization and planning.
Are you experiencing the Visual Impacts of Concussion?
Visual problems may result in Avoidance, Reduced Performance, or Physical changes.
Be on the lookout for these tell-tale signs!
□ Eye strain and/or headaches
□ Episodes of dizziness; motion sickness
□ Visual fatigue
□ Intermittent blurry vision
□ Double vision, especially at near-point
□ Light sensitivity; flicker sensitivity (indoors)
□ Short attention span for reading
□ Must re-read to understand
□ Loss of place: skipping or re-reading words or lines
□ Impaired cognitive abilities on visually-dependent tasks
□ Impaired reaction time
□ Reduced coordination on previously automatic tasks
□ Reduced athletic performance, feeling “out-of sync”
□ Disorientation, feeling “lost in space”
□ Balance affected, feeling unsteady on feet
□ Moodiness, irritability, feeling overwhelmed
Your Neuro-Optometric Visual Rehabilitation Needs
If you have been previously diagnosed with a concussion brain injury, or any visually-limiting condition, contact our office for support.* We begin with a thorough consultation, and an evaluation performing a variety of vision and eye health tests. We are happy to co-manage care with primary vision care providers, as well as medical support in allied fields. Once your neuro-optometric visual evaluation is complete, we will have a better picture of your overall eye health and vision status, and can make a treatment recommendation based on your individual needs.
We will create a customized visual rehabilitation plan that is designed to achieve the best possible results through the utilization of various vision technologies, passive and active therapies, and both home- and office-based exercises. Call today to set up an appointment to discuss your visual needs.
* In a recent publication of the American Academy of Pediatrics endorses careful assessment of the visual system following concussion in children, for the probable impacts to the entire visual system, "including an assessment of visual acuity, the visual fields, pupillary reactions, smooth pursuit, saccades, vestibulo-oculomotor reflex, monocular accommodation, and binocular convergence."
Master CL, Bacal D, Grady MF, et al; AAP SECTION ON OPHTHALMOLOGY; AMERICAN ACADEMY OF OPHTHALMOLOGY;AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS; AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS. Evaluation of the Visual System by the Primary Care Provider Following Concussion. Pediatrics. 2022;150(2):e2021056048