This article is reprinted with permission of Dr. Lynn Fishman Hellstein.

"When vision works well, it guides and leads the body; when not, it interferes." John Streff, O.D.

Many individuals who have suffered a traumatic brain injury (TBI) have residual visual problems. Patients are often unaware that many of their symptoms could be related to their visual system. These vision problems can have a major impact on a person's ability to perform daily living skills, such as reading, working, driving, and/or sports.

Until recently, these problems were left to resolve as best they would with the passage of time. Today, however, behavioral optometrists and low vision specialists are treating these visual problems with special lenses, prisms, vision therapy and field expansion systems. This visual treatment is becoming an integral part of the entire rehabilitation process, which often includes physical, occupational, speech, and cognitive rehabilitation as well as psychological services.

These questions and answers below help the professional, patient and family learn more about vision problems and treatment.

What are the signs or symptoms that may indicate a vision problem?
Double vision, blurred vision, reduced ability to sustain attention on visual tasks, dizziness, headaches, eye strain, difficulty reading (loss of place, poor comprehension), eye "crossing or drifting", closing or covering one eye, bumping into objects, head tilts or turns, balance and coordination problems, poor judgment of depth.

How soon after my brain injury is diagnosed should I seek a vision evaluation?
This will depend upon the nature and severity of other injuries and the progress of rehabilitation. If there is a direct injury to the eye or surrounding structures, a vision examination should be given immediately. In many cases, there is not "direct" eye injury, however, it is useful to have the initial evaluation within the first months after the injury, since it is possible that glasses or occlusion (patching) will help relieve the blurriness, double vision, and/or disorientation. Vision therapy treatment may not yet be appropriate, but rehabilitation is planned on a regular basis, the visual evaluation should be done prior to this portion of the cognitive rehabilitation.

What type of vision examination is necessary?
A comprehensive eye health examination is necessary to diagnose significant pathology or disease. In addition, a thorough refractive, oculomotor, binocular, accommodative, and visual perceptual evaluation should be done to determine glasses prescription, eye movement control, eye teaming, focusing efficiency, and visual processing status. Frequently, glasses prescriptions change after a TBI. The MAJORITY of survivors have binocular difficulties (problems using both eyes together). Special glasses may be prescribed for near work or other specific activities. At times, visual electrodiagnostic testing or a low vision evaluation may also be recommended.

Will all eye doctors give the same examination?
No. Ophthalmologists (M.D's) are skilled in evaluating the eyes for the effects of trauma and disease. The ophthalmologists, neuro-ophthalmologists, or optometrist may be consulted early in the treatment program, especially if direct eye injury occurs. These doctors may recommend medications, surgery, glasses, and/or contact lenses. Once the patient is medically stable, the functional aspects of vision need to be thoroughly addressed, for example; what visual skills have been effected by the TBI, how are they effecting daily life and what treatment is necessary for the most efficient functioning and recovery? This type of functional evaluation is most frequently given by a behavioral optometrist (O.D.) and may take one to three hours to be completed. Behavioral Optometrists are usually active in the rehabilitation process, coordinating vision care with other therapies.

How long will treatment last?
Treatment of visual deficits after head trauma can take from one visit(where glasses are prescribed) to months (when vision therapy is part of the rehabilitation process).

What is vision therapy?
Vision therapy is an individualized program of eye, hand, and body activities directed at treatment of specifically diagnosed vision conditions. In the case of brain injury, efforts are aimed at relearning how vision integrates with body movement and perception of the visual world. The goal of the therapy process is to relieve disorientation, blurriness, dizziness, etc., as well as to improve visual sustenance and efficiency. In most cases, vision therapy is given in thirty or forty-five minute sessions, one to two times weekly. Most doctors prescribe bimonthly progress evaluations which help to monitor progress and continuance of treatment.

Can anything be done for field loss or neglect?
Visual field loss or neglect may result in inappropriate perceptions and cause a safety risk. Appropriate scanning strategies should be taught early in the rehabilitation treatment. In addition, special types of prisms may be helpful to see things more clearly, sooner, and to increase speed and accuracy of perceptual processing.

Vision problems are a frequent and serious consequence of TBI. Early visual evaluation and treatment should be recommended. It is critical that the patient, family and rehabilitation team understand the impact of the visual problems, especially as they relate to cognitive and motor functions