Concussions: How Your Vision is Impacted
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Lynn Hellerstein


How Your Vision is Impacted

"Visual pathways alone account for more than 50% of the brain’s pathways and, therefore, are commonly affected in concussion.” 
– Steve Devick, O.D.

When a brain injury occurs, the effects on the visual process and the integration of vision with other sensory modalities can be devastating and impact one’s quality of life. Lemkuhl (1993) states that brain injury may lead to impairment in one or more functions including: vision, arousal, attention, language, memory, reasoning, abstract thinking, judgment, problem-solving, sensory abilities, perceptual abilities, motor abilities, psychosocial behavior, information processing and speech.  Zoltan (1996) emphasizes that visual-perceptual dysfunction is one of the most common and devastating residual impairments of brain injury. 
Perceptual deficits may affect the skills necessary for activities of daily living, including dressing, eating, reading, working, etc. Most activities of daily living require effective and optimal visual efficiency, visual processing and visuo-motor performance.   The deficit may be anywhere from a visual efficiency problem of “seeing clearly” to a problem of form perception, eye-hand coordination, or visual attending.  Because of the high prevalence of vision disorders in this population, and the importance of vision in rehabilitation, optometrists should play a role as a member of the rehabilitation team. Optometrists can help co-manage the overall rehabilitation of a neurologically compromised patient by minimizing any deficit of the visual system and providing consultation and guidance to members of the rehabilitative team. 

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

  1. 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.
  2. 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 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  lenses or occlusion (patching) may be necessary immediately. If computer assisted, cognitive rehabilitation is planned on a regular basis, the visual evaluation should be done prior to this portion of the cognitive rehabilitation.
  3. What type of vision examination is necessary? 
    A comprehensive eye health evaluation 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 brain injury. 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.
  4. 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 ophthalmologist, neuro-ophthalmologist, 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 affected by the TBI, how are they affecting 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/developmental optometrist (O.D.). and may take one to three hours to complete. Behavioral Optometrists are usually active in the rehabilitation process, coordinating vision care with other therapies. 
  5. How long will the 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).
  6. What is rehabilitative 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 a brain injury, efforts are aimed at relearning how vision integrates with body movement and perception of the visual world. The end goals of the therapy process are 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.
  7. Can anything be done about 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.
  8. How do you find a behavioral optometrist?

    Request information from:
  • College of Optometrists in Vision Development (COVD), or 1-888-268-3770
  • Neuro-optometric Rehabilitation Association (NORA)


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.
Vision treatment should be concurrent with speech, physical and/or occupational therapy.  Improved visual functioning often will help increase the rate of progress in other rehabilitative areas.
With love and gratitude,

Lynn Fishman Hellerstein, O.D., FCOVD, FAAO

Join Dr. Hellerstein for this upcoming FREE Concussion Workshop

Rehabilitative Vision Therapy Success Story

Tuesday, June 17, 2014

6:30 - 7:30 pm
  • Vision rehabilitation strategies for patients with visual problems from brain injury. 
  • How behavioral optometrists successfully treat these patients with special lenses, prisms, occlusion and vision therapy.
  • Visual related symptoms post-concussion including Blurred vision, Eye strain, Double vision, Headaches, Increased light sensitivity, Balance problems or dizziness, Difficulty reading, Visual processing difficulties
Vision rehabilitation is an integral part of the entire rehabilitation process!

WHO SHOULD COME:  Health care professionals, therapists, coaches, trainers, educators, parents

SPEAKERS: Lynn F. Hellerstein, O.D., FCOVD, FAAO

WHERE:  Hellerstein & Brenner Vision Center, P.C
7400 E. Orchard Road
Suite 175-S
Greenwood Village, CO 80111

FREE and open to the public. Seating is limited. Please call 303-850-9499 to reserve your place.

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