Vision Therapy for concussion and brain Injury



The brain injury and concussion patients we see in our Vancouver Vision Therapy Clinic


In recent years, our vision therapy practice has developed to the point that the marjority of our vision therapy patients have had concussions or other brain injuries, often sustained while playing sports or in a car accident. Many of our patients are referred to us by physiotherapists and occupational therapists. Many of the concussions we see were sustained in car accidents and in these cases the Insurance Corporation of British Columbia (ICBC) often pays for vision therapy.


Oculomotor and Visual Symptoms in Concussion and TBI


Concussions and other types of traumatic brain injury (TBI) is recognised as a major cause of morbidity and mortality worldwide. It is estimated that TBI affects 106 to 790 per 100 000 people every year. Because half of the circuits in the brain are involved in vision, many aspects of the visual system are vulnerable to moderate, severe, or mild TBI.


Brain Injuries can be caused by sroke or head trauma like a concussion

Brain injuries can be caused by any blow to the head (a concussion) or by a stroke. Concussions are a major category of brain injury and many people who have suffered a concussion have vision related symptoms. In fact, the most popular medical test for concussions, known as the King-Devick test, diagnoses a concussion by looking for abnormal eye movements.


Vision and eye movement problems are common after a brain injury


A recent study noted that people with traumatic brain injury often have a constellation of eye movement (sometimes called oculomotor) deficits. The study noted that over 90% of patients with mild traumatic brain injury (sometimes abbreviated TBI and sometimes called acquired brain injury) were found to have one or more oculomotor dysfunctions, including nystagmus and/or other abnormalities of version, vergence, accommodation, and eye alignment. Related symptoms include difficulty tracking objects, difficulties in visual scanning and slow reading.


What are the vision symptoms a concussion patient might experience?


The following list of vision symptoms that can be cause by a brain injury comes from the study, "Clinical Oculomotor Training in Traumatic Brain Injury" by Dr. Kenneth Cuiffreda and colleagues:


  • Avoidance of near tasks
  • Oculomotor-based reading difficulties
  • Eye tracking problems
  • Eye focusing problems
  • Eyestrain
  • Diplopia
  • Dizziness
  • Vertigo
  • Vision-derived nausea
  • Increased sensitivity to visual motion
  • Visual inattention and distractibility
  • Short-term visual memory loss
  • Difficulty judging distances (relative and absolute)
  • Difficulty with global scanning
  • Difficulty with personal grooming, especially involving
    the face
  • Inability to interact/cope visually in a complex social situation (e.g., minimal eye contact)
  • Inability to tolerate complex visual environments (e.g., grocery store aisles and highly-patterned floors)


Eye movement problems in people with concussions and other TBI


The following is list of clinical signs that an optometrist can test for in the exam room also comes from the study, "Clinical Oculomotor Training in Traumatic Brain Injury" by Dr. Kenneth Cuiffreda and colleagues:


  • Reduced amplitude of accommodation
  • Increased lag of accommodation
  • Reduced relative accommodation
  • Slowed accommodative facility
  • Uncorrected hyperopia/ astigmatism (due to inability to compensate accommodatively)
  • Receded near point of convergence
  • Restricted relative convergence (BO) at far and near
  • Restricted overall fusional vergence ranges at far and near
  • Abnormal Developmental Eye Movement test (DEM) results
  • Low grade-level equivalent performance on the Visagraph II
  • Impaired versional ocular motility


Optometrists and vision therapy rehabilitation after concussion or other brain injury


Optometrists and vision therapy play an important role in the rehabilitation effort following a traumatic brain injury such as concussion, stroke and aneurism.

Through vision therapy and the proper use of lenses, a behavioral or developmental optometrist specifically trained to work with concussions annd brain injury patients can help improve the flow and processing of information between the eyes and the brain.

Vision therapy can be very effective. After evaluation, examination and consultation, the optometrist determines how a person processes information after an injury and where that 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 vision efficiency. This in turn can help support many other activities in daily living.


Vision therapy treatment of visual symptoms caused by brain injury is effective


Treatments for the concussion related vision problems can include lenses, prism, lenses with special tints or coatings, elective occlusion or vision rehabilitation therapy.


2017 study, published in the journal Optometry and Vision Science, was conducted to determine the frequency of vision disorders associated with concussion, and to determine the success rate of vision therapy for these conditions in two private practice settings. The authors concluded the post consussion vision problems were prevalent and that  vision therapy had a successful or improved outcome in the vast majority of cases that completed treatment.


 In a 2008 study by Ciuffreda et al. published in the journal Optometry, 90% of patients with traumatic brain injury who were treated with vision therapy had significant improvement in their eye movement disorders.


Formal therapeutic protocols for oculomotor training for patients with concussion and TBI have been developed. For more information on these protocols, please refer to the following studies:



Treament for concussion patients can include lenses, prism and therapy


The general approach to visual anomalies following concoussion or brain injury has been described as follows:


Vision disturbances following traumatic brain injury (TBI) include anomalies  of accommodation, version, vergence (non-strabismic, as well as strabismic), photosensitivity, visual field integrity, and ocular health.

Traumatic brain injury patients with complex diplopia patterns, noncomitant strabismic anomalies, and advanced ocular health anomalies are either monitored by or referred to neuro-ophthalmologists and ophthalmologists for evaluation and possible surgical or medical intervention, as needed.

Anomalies of accommodation, vergence, version, photosensitivity, and field of vision are amenable to noninvasive, rehabilitative interventions, such as vision therapy, which is rendered by optometrists and is described in this article. Further, vision therapy may be performed in isolation or in conjunction with the application of the following:

  • Fusional prism spectacles (for diplopia)
  • Tinted spectacles (for photosensitivity)
  • Yoked prism spectacles (for visual-spatial hemispheric inattention, with or without a manifest visual field defect), as appropriate


Dependent on the severity of vision impairment post-TBI, other types of rehabilitation, such as vestibular, physical, cognitive, and occupational rehabilitation, are deferred pending the stabilization of vision function to an appropriate level.

Rehabilitative optometric intervention is appropriate and beneficial for many TBI patients. Therefore, it should be offered as a possible evaluation and treatment option to investigate the patient’s symptoms and determine the prognosis for treatment, as would be done with any other therapeutic modality.

Kapoor and Ciuffreda, Vision Disturbances Following Traumatic Brain Injury,Current Treatment Options in Neurology 2002,4:271–280


Brain injury and reading problems


Reading problems are a common consequence of concussion and other types of brain injury. Reading involves a wide range of functions and abilities, one of which is accurate eye movements. If a brain injury negatively impacts oculomotor control, reading will be affected. Some common reading problems include frequent loss of place, skipping of lines and difficulty shifting to the next line of print.

Studies have shown that reading problems cause by concussion or other types of brain injury can be successfully remediated following completion of a program of vision therapy.


For example, in a 2007 study published in the Journal of Behavioral Optometry, the authors took a large sample of 160 patients mild mild TBI and found that 90% of them had oculomotor deficiencies such as convergence insufficiency or abnormal tracking of saccades that would be expected to impact reading performance. Thirty-three patients from this sample were given vision therapy rehabilitation and ninety percent of those 33 patients exhibited improvement in at least one sign and one symptom. In another sample of nine patients who had oculomotor-based reading problems, all of them improved their overall reading performance and versional eye tracking ability following a basic program of vision therapy rehabilitation. The authors concluded that oculomotor dysfunctions are common in people with mild TBI and the positive results obtained from vision therapy rehabilitation demonstrate the presence of considerable neuroplasticity in adults with mild TBI. They recommend that optometric vision therapy should be instituted in visually symptomatic patients with TBI who manifest oculomotor-based reading dysfunctions.


Studies on Vision Therapy and Brain Injury

Vision Related Literature on Acquired Brain Injury

Updated March 2013
Compiled by Lynn Fishman Hellerstein, OD, FCOVD, FAAO

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