Neuro-Optometric Rehab

Acquired brain injury (ABI) is an insult to the brain.  It can be from a blow to the head, stroke, or neurological dysfunction.  This can produce a diminished or altered state of consciousness, and may result in impairment of cognitive abilities, sensory processing and/or physical function.  Problems may be mild or severe, but most are amenable to rehabilitation.  Some of the common diagnoses: Traumatic Brain Injury, Mild Acquired Brain Injury, Mild Closed Head Injury, Post-Concussive Syndrome, Cervical Trauma Syndrome, Stroke, Cerebral Palsy, Cerebral Vascular Accident.

Visual Problems

Often, visual problems resulting from Acquired Brain Injury are overlooked during the initial treatment of the injury.  Frequently these problems are hidden and neglected but are critical to address for overall rehabilitation.  Vision is the most important source of sensory information, consisting of a sophisticated complex of subsystems.  The visual process involves the flow and processing of information to the brain.  Because there is a close relationship between vision and the brain, Acquired Brain Injury can disrupt the visual process, interfering with the flow and processing of all information.

Symptoms indicating a vision problem are:

• Blurred vision at distance or near, or fluctuating vision
• Sensitivity to light
• Reading difficulties, words appear to move or double, loss of place
• Headaches with visual tasks
• Comprehension difficulty
• Attention and concentration difficulty
• Double vision
• Aching eyes
• Loss of visual field or bumping into things/ignoring one side of space
• Trouble with mobility and balance
• Dry eyes

Visual Skills Evaluated by a Neuro-Optometric Consultation

Along with a comprehensive eye health evaluation looking for any visual health compromise (dry eye, glaucoma, cataracts, retinal health, optic nerve evaluation) the doctor will test the visual field, looking for compromise due to the area possibly affected by the ABI.  Other areas of testing include:

• Eye Movement Skills:  the ability of the eyes to hold fixation steady and also to have accurate and quick saccadic (eye jumping from word to word) and pursuit (eye following a moving object) skills.  These eye movement skills should be well integrated and not cause dizziness or a sensation of movement.
• Focusing: the ability to be able to look from near to far, and far to near without blur.
• Depth Perception:  judging relative distances of objects by a very fined tuned two eyed vision (binocularity)
• Binocularity: using both eyes together as a team at all distances and positions of gaze.  These skills should be smooth, accurate and quick.  Many patients with ABI have very poor skills with convergence and eye teaming creating eye strain, headaches, intermittent double vision or suppression of some of the information to the brain.
• Visual Acuity:  Distance and near vision should be clear.  ABI often causes shifts in prescription.  Even very small changes in a prescription can cause large changes in visual and overall function.  A very careful refraction is a must for those with ABI, along with the appropriate changes in eye wear.  Often the doctor will incorporate prism at distance or near prescriptions that can immediately help the patient.  The doctor will also determine the best prescribed type of lenses for that particular patient based on the overall visual and vestibular system, and the patient’s needs.  Often a progressive type lens is no longer in the best interest of the patient due to mobility issues.
• Peripheral Vision:  problems with seeing certain parts of the visual field should be addressed.  It is possible to prescribe lenses and prisms to help patients that are facing a loss of right or left side after ABI.  Training eye movements and attention into the affected side of the visual field is an important element of rehabilitation and coping.
• Mobility:  some patients experience difficulty with mobility not directly related to loss of limb function, but because of distortions of visual space.  These patients often have a Midline Shift Syndrome.  These patients can often regain this mismatch of perception with certain types of prism systems incorporated into their prescription lenses.
• Double Vision:  ABI can cause mild or severe double vision due to ocular muscle paresis (decreased or lost function in one or more eye muscles).  This can often be helped with temporary or permanent prism lenses and vision therapy.
• Vision Perception:  the ability to understand what is seen.  Some types of vision perception are visual memory, size and form discrimination, visual closure, sequential visual memory, figure ground, left/right discrimination, and recognition of reversed letters, numbers and words.

Optometry and Rehabilitation

Very few in the health care professions, including head trauma rehabilitation centers, are adequately aware of the visual problems resulting from ABI and the visual-perceptual consequences.  Unfortunately, this creates a gap in rehabilitative services, resulting in incomplete treatment and frustration for the patient, family and treatment team.

The vision care professional can play an important role in the rehabilitation effort early on in the treatment process by the proper use of lenses, prisms and vision therapy.  Developmental optometrists trained to work with Acquired Brain Injury can help improve the flow and processing of information between the eyes and the brain.

Vision therapy can be very practical and effective.  After evaluation, examination and consultation, the optometrist determines how a person processes information after an injury and where a person’s strengths and weaknesses lie.  The optometrist then prescribes a treatment regimen incorporating lenses, prisms, low vision aides and specific activities designed to improve control of a person’s visual system and increase visual efficiency.  This in turn can help support many other activities in daily living.

When to seek services of a Developmental Optometrist after an ABI

It is not necessary to wait months before seeing the optometrist after an ABI, and waiting can, in fact, greatly decrease the rehabilitative process.  Although the visual system can still be changing, the doctor can help create a synergistic prescription that will enhance healing.  Often, if the prescription is likely to change, the doctor can work with the patient to help make changes to the prescription without incurring unreasonable costs to the patient.