VISUAL PROBLEMS ASSOCIATED WITH ACQUIRED NEUROLOGICAL EVENTS
Allen H. Cohen, O.D., F.A.A.O., C.O.V.D.
In the United States, incidences of brain injury, including concussion have been on the rise. According to the Centers for Disease Control and Prevention in the United States (CDC), in "In 2010 2.5 million TBIs occurred either as an isolated injury or along with other injuries."
This number would not include the thirty
thousand or more persons per year who are hospitalized for other forms of brain insult
such as cerebrovascular accidents (CVA) and diseases such as cerebral palsy,
multiple sclerosis, etc.
Following an injury or insult to the brain, there is often an interruption to the neurological
system which innervate the extraocular muscles controlling eye movements as well
as the system that regulates focusing (clear versus blurry vision). The common visual symptoms often associated
with acquired brain injury are:
- diplopia (double vision)
- problems with ocular pursuits (eye movements, eye tracking ability)
- saccadics (difficulties with shifting gaze quickly from one point to the
- accommodative inability (focusing).
- binocular vision (eye alignment)
- glare or light sensitivity
- Inability to maintain visual contact (or eye contact)
Neuro-optometrists have long recognized symptoms and visual problems associated
with trauma that affect the functional visual system and have identified a syndrome,
Post Trauma Vision Syndrome (PTVS). The following categorizes the clinical characteristics:
FUNCTIONAL VISION PROBLEMS
PTVS can be treated effectively through neuro-optometric rehabilitation. The treatment
may include different lens prescriptions in conjunction with prism lenses, and
other neuro-optometric rehabilitative approaches, including vision therapy or neuro-rehabilitation therapies.
- Exotropia (eye turned outward)
- Exophoria (tendency for the eyes to turn out)
- Convergence Insufficiency
- Accommodative Insufficiency
- Oculomotor dysfunction
- Increased myopia
- Common Symptoms
- Diplopia (double vision)
- Blurred near vision
- Perceived movement of print
- Photophobia (sensitivity to light)
Additionally, depending on the extent of the injury, there are often deficits
in many areas of visual information processing ability. Problems with visual
processing may contribute to and or exacerbate symptoms of eye strain, fatigue,
headaches, difficulties with balance and posture, depth perception, memory loss,
and excessively slow visuomotor performance affecting handwriting.
VISION: AN INFORMATION PROCESSING SYSTEM
Visual processing is organized through two main and separate systems. The one
that we are most familiar with is called the focal pathway, which is related
to central vision. The eye processes central vision primarily through an area
called the macula located in the retina and seeing clearly is mainly through
this system. However, one can also see receive visual information with their
peripheral vision. For example, when aiming one?s eye at a specific object,
one can use peripheral vision to be aware of other objects about the room. Peripheral
vision is primarily used as a general spatial orientation system and is mostly
a function of the other visual process called the ambient pathway.
The ambient process provides information about where one is in space and contributes
to balance, movement, coordination and posture. Nerve fibers from the peripheral
retina, part of the ambient visual system, are directed primarily to the midbrain
where they become part of the sensory motor pathway. The importance of this
system is that it integrates visual information with information from kinesthetic,
proprioceptive, vestibular and tactile systems which is important for orientation
and movement. Thus, the ambient visual process is important in providing information
about where one is in space and where one is looking, while the focal system
provides information about what one is looking at.
After a neurological event such as a traumatic brain injury (including whiplash),
multiple sclerosis, cerebral vascular accident, etc., the ambient visual process
can be compromised and this would affect one’s ability to match information
with other components of the sensory ?motor feedback loop.
VISUAL FIELD DEFECTS
Visual field loss following a CVA or TBI causes
significant problems for persons when reading or walking, in an unknown environment.
Although the field loss is due to nerve damage, often the prescription of yoked
prism lenses and optometric visual therapy for ocular scanning, will help patients
to identify objects in the affected field and react and process at a more functional
VISUAL MIDLINE SHIFT SYNDROME
An unusual phenomenon that often occurs
following a neurological event is a change in how the ambient process provides
information about orientation relative to the true midline. This syndrome is
usually associated with hemiplegia and hemiparesis and often the patient will
adjust to this visual mismatch by shifting their weight and will actually walk
as if the floor is tilted. The neuro-optometrist can prescribe special prisms
called yoked prisms, which helps to re-establish a visuomotor balance and often
these lenses in conjunction with physical therapy and optometric visual therapy
significantly speed up the overall rehabilitative process.
Neuro-Optometric Rehabilitation is the blending of the art and science of optometry
and vision rehabilitation. Neuro-Optometric Rehabilitation is defined as: An
individualized treatment regiment for individuals with visual deficits as a
result of physical disabilities, traumatic brain injuries, and other neurological
insults. Neuro-optometric therapy is a process for the rehabilitation of functional
visual problems as well as visual-perceptua1 motor disorders. It includes, but
is not limited to, acquired strabismus, diplopia, binocular dysfunction, convergence
and accommodation problems, oculomotor dysfunction, visual-spatial dysfunction,
visual perceptual and cognitive deficits and traumatic visual acuity loss.
Individuals of all ages who have experienced neurological insults can benefit
from neuro-optometric rehabilitation. Visual problems caused by traumatic brain
injury, cerebral vascular accident, cerebral palsy, multiple sclerosis, etc.,
may interfere with their performance and learning ability. Other problems such
as balance and vestibular disorders may be exacerbated by the visual dysfunction.
Often, persons who have a neurological problem will mention these symptoms
to their physician and rehabilitative therapists who may recommend a routine
eye examination rather than a neuro-optometric exam. This often results in the
eye doctor stating that the visual acuity and the health of the eye is normal
and that their problems are not related to the eyes. In addition, if there are
balance disorders, persons will be referred for physical and occupational therapy
and/or vestibular evaluation and treatment. In many cases, if the underlying
visual processing problem is not determined and treated, there will be limited
progress. A neuro-optometric rehabilitation treatment plan improves and or enhances
the specific acquired visual deficits that are identified during the neuro-optometric
evaluation. Treatment regimens encompass lenses and prisms, specifically prescribed
occlusion and optometric visual therapy.
Conclusion: Persons who have suffered a neurological event often have visual
processing problems and functional vision problems that are not adequately managed.
These problems cause extreme difficulty, not only with balance and movement,
but also could affect the person's perception of space and their ability to
process this information. The patient often experiences difficulty functioning
in an environment with a lot of visual stimulation such as a grocery store,
and will experience difficulty finding a specific object on a shelf. Often movement
in a crowded environment becomes quite disturbing and may cause symptoms of
vertigo. This can be extremely debilitating to the patient.
The problems associated with Post Traumatic Vision Syndrome can affect higher
cognitive levels of function as well, by causing a slowing of responses in general
and interference with higher perceptual cognitive function. Therefore, neuro-optometric
rehabilitation will often have a positive affect on cognitive therapy.
Motor function deficits associated with neurological problems often can be
helped with yoked prism therapeutic lenses which help make significant changes
in posture, balance and movement. The use of yoked prisms can be incorporated
into existing physical and/or occupational therapy programs.
The neuro-optometrist is an important member of the multi-disciplinary team
serving this special population.
About the Author:
Dr. Allen Cohen practiced visual therapy and neuro-optometric rehabilitative in private practice from 1965 to 2007.
services. Dr. Cohen is currently Clinical Professor of Optometry, SUNY State College of Optometry and The Raymond J. Greenwald Rehabilitative Center as well as Supervisor Head Trauma Residency SUNY State College of Optometry
He has lectured and
written extensively on the subject of visual therapy and neuro cognitive visual rehabilitation.