Turn Text Only Off
Page Utilities
Vision Issues After Brain Injury: BrainLine Talks with Dr. Gregory Goodrich
Victoria Tilney McDonough, BrainLine
Page 1 of 3
BrainLine sat down with Dr. Gregory Goodrich to talk about the problems with vision that can arise after a traumatic brain injury. Dr. Goodrich is the supervisory research psychologist assigned to the VA Western Blind Rehabilitation Center in Palo Alto, California. He also serves as the program coordinator for the Optometric Research Fellowship Program at the VA hospital in Palo Alto.
BrainLine: How common is it to have vision problems after traumatic brain injury (TBI)?
Dr. Goodrich: For TBI in general, the literature says 20-40 percent of people with brain injury experience related vision disorders; however, the exact prevalence is not known. 1, 2
In the military population — although we don’t have a definitive statistic — we have found in mild TBIs that troops exposed to one or more blasts can have trouble with their eyes coordinating with one another, what we call “oculomotor or binocular dysfunction.”
In moderate to severe TBI, about one third of the troops tested have some sort of visual impairment, which can include visual acuity and field loss, binocular dysfunction, and spatial perceptual deficits.
Complete visual examinations are now a required part of testing for brain injury in all four VA polytrauma centers, which will help with data collection since, until this mandate was passed, comprehensive visual examinations were not an integral part of interdisciplinary protocols for brain injury. The hope is that in the future this comprehensive test will be part of any evaluation of someone with a TBI whether civilian or military.
BrainLine: What are the tests for visual problems like currently?
Dr. Goodrich: To date, if a person has a traumatic brain injury, he is not given a full visual examination. What is administered most often is a basic test called the Confrontation Visual Field Test, or CVFT. Basically, it consists of a doctor standing at arm’s length away from the patient, wiggling his fingers in different areas of the person’s visual field, and saying, “Can you see this?” This is a good, quick-and-dirty test, but unfortunately, it often misses significant visual problems.
Comprehensive visual examinations include the types of examinations you would receive normally for annual ophthalmological and optometric examinations. They look at eye health, refractive errors, visual fields, contrast sensitivity, and so on. What is unique about these comprehensive examinations is that they include examinations for occult injury, binocular function, and other specialized testing which goes beyond what is normally provided. In short, they are designed to detect vision disorders which are not commonly seen by clinicians and which require specialized testing to uncover.
Again, we hope that soon a complete visual examination will be a requirement of an interdisciplinary evaluation of someone with a TBI — civilian or military.
BrainLine: What are the most common kinds of visual problems?
Dr. Goodrich: The two big categories are visual acuity loss and visual field loss.
Let’s start with visual acuity loss. If a person wears prescription glasses and takes them off, he will have a loss of acuity — or clarity. With brain injury, people can have a relatively small visual acuity loss or significant loss.
Visual acuity loss results from damage to the eye, the nerve fibers that carry signals from the retina in the eye to the brain, or to the visual cortex. This loss can sometimes be effectively treated with glasses, magnifiers, or electronic reading aids such as closed-circuit televisions. How much the loss impacts an individual’s life depends on the degree of the loss. Needing a small amount of magnification is in some ways similar to those of us who need bifocals. A need for more optical magnification than that can require different devices and training.
Visual field loss is a bit more complicated. Think of your visual field as a pie. Visual field loss is categorized by which part of the pie is affected.
- If you have hemianopsia, half of your pie — or visual field, either vertically or horizontally — is gone; you cannot see it.
- If you have quadranopsia, a quarter of your visual field is lost.
- If you have homonymous hemianopsia, the same quarter or half is lost in both eyes.
- If you have bitemporal hemianopsia, you are missing the outer half (or inner half) of both the right and left visual field.
Hemianopsia and quadranopsia are the most common types of visual field losses; but going back to the pie analogy, other types of field losses include loss around the edges of the pie or loss from the middle going outward. And, of course, there can be differing combinations depending upon the individual injury.
Visual field loss is caused by damage to the nerve fibers that carry the visual signal from the eyes to the visual cortex and/or connect operations between different parts of the brain.
BrainLine: Are these vision problems temporary or permanent?
Dr. Goodrich: Just like people, all brain injuries are unique, and that includes the process of recovery; so it is difficult to generalize. After a brain injury, once the person is medically stable, we will start visual rehabilitation. If the visual problems resolve, great; if not, we have a head start by starting that early. Vision is integrated into other problems that can occur post-TBI like muscular imbalance and vestibular problems (dizziness, imbalance, vertigo, etc.)
BrainLine: Can people with brain injury suffer from both kinds of vision loss?
Dr. Goodrich: Yes, people with TBI can suffer from both visual field loss and visual acuity loss. After all, 40-50 percent of the brain is involved in vision; so if a person’s brain is damaged in a specific location or several locations, there is a high probability that his vision will be affected in some way.
BrainLine: If someone has hemianopsia, for example, and she can’t see the left side of her world, can she learn how to compensate for that, or “see” it?
Dr. Goodrich: Broadly speaking, there are two kinds of visual field losses — those with neglect and those without neglect, and this is a huge oversimplification but perhaps useful to begin understanding field loss.
BrainLine
Gregory L. Goodrich, PhD,
Dr. Goodrich received his PhD in Experimental Psychology in 1974 from Washington State University. His career with the US Department of Veterans Affairs began in 1974 and he is currently supervisory research psychologist (Psychology Service) assigned to the Western Blind Rehabilitation Center.
The contents of Brainline (the “Web Site”), such as text, graphics, images, information obtained from the Web Site’s licensors and/or consultants, and other material contained on the Web Site (collectively, the “Content”) are for informational purposes only. The Content is not intended to be a substitute for medical, legal, or other professional advice, diagnosis, or treatment.
Specifically, with regards to medical issues, always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on the Web Site. If you think you may have a medical emergency, call your doctor or 911 immediately. The Web Site does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Web Site. Reliance on any information provided by the Web Site or by employees, volunteers or contractors or others associated with the Web Site and/or other visitors to the Web Site is solely at your own risk.
Comments [8]
Dr. Goodrich, when i read all the articales ABOUT TBI it refer directly to me. I was injured in an jeep accident in the USArmy in September 1959. i was unconstius when found and rushed to rhe nearest hospital. the next day I started losing my vision and having terrible headaches. I was rushed to Landsthul Hospital Germany. i stayed there for the next 113 days, where i suffered from several periods of blindness, double vision, changing vision and gait problems. None of these symptoms ever went away, there was only periods of less severed. all the Army doctors said that i should be back to normal soon, the brain will heal itself. well my brain never heald itself. Whenever my symptoms was really bad i seeked help and none of the Ophthalmologist knew what to do for me, they finally said go back to the VA hospital.i really didn't want to go back to the VA; because in 1962 the VA hospital only wanted me to be seen by a psychiratist, i told them i was not crazy my problems are real. these last few yeare i seen many well known Neuro-ophthlamologist and neurologist. they have all said that my conditions, symptoms are very real and very rare; however they are secondary to my brain injury. They said i need to be treated that first. I was told to go to an Brain Concussion specialist group.ARE THEY RIGHT? HOW DO I GO ABOUT MAKING ARRANGEMENTS TO THESE SPECIAL GROUP? SOMETIMES MY CONDITION IS ALMOST AS BAD WHEN I FIRST HAD MY ACCIDENT. I NEED HELP WOULD YOU RECOMEND ANY SPECIAL GRoup or any solution to solve my problem. respectfully CHARLES
I didn't read this word by word as reading on the computer is hard for me. But I did not pick up on a mention of midline shift. I have multiple visual affects from my brain injury, field loss, double vision and midline shife the predominant ones. Many, many, many survivors of brain injury have some degree of midline shift and that creates many of the problems that uninformed practitioners apply to vestibular problems even if there is little to no dizziness. If you walk a crooked line, always heading to one side or the other without realizing it, get checked for midline shift. Behavioral optometrists are trained in this. The doctors at Mass. Eye and Ear did not find it; my optometrist did.
Is there a reason monocular diplopia is not mentioned anywhere (double vision in a single eye--irrespective of binocular focus or visual neglect issues)? That is my problem since TBI, as well as issues (perhaps related) with high contrast "vibration" especially with type (black on white page) or stripes.
It should be noted that in many TBI patients with symptomatic epilepsy, the treatment is anterior temporal lobectomy. As the optic nerve travels through the temporal lobe (Myer's loop) it is often damaged by the surgery, resulting in permanent quadrantopsia.
Thank you for highlighting this issue. Thanks to hearing an expert in the field at a Brain Injury Assoc. caregivers conference, I was able to obtain vision therapy from a qualified optometrist for my husband who has global eschemia from hypoxia. The results so far are subtle but encouraging.
Thank you for sharing this article. I was wondering why there was not more discussion on the cognitive/perceptual deficits that are related to TBI?
Bravo for this article on vision issues after TBI. I have struggled with this since sustaining mTBI in 1994 (and 1998). But I have found that my best compensatory strategy has been my sense that part of the difficulty I encounter in the community is TBI related and the other part is the lack of knowledge on the part of the general public of the role played by environmental issues. I thought I could no longer read, until I learned that I could read pages that were "ragged right" (not fully justified). I advocated with BI organizations to make their print material more TBI-friendly. And I ask the state office of legislative services to print proposed legislation for me in a ragged right fashion. Although I can find science on what TBI does to vision, and what vision impairments contribute to reading difficulties, I cannot find the authoritative statement that puts them together (if I could, I could effect more change). Accommodating print colors, styles, line widths (and other practices of good design for print material) goes a long way to reduce the "I can'ts" that come with vision problems (aagh - filling out forms). Please do not ignore advocacy and civil rights issues when it comes to helping people learn to accommodate the impairments that come with vision disturbances following TBI! I wish that some group would come up with guidelines for print (and web) material to make the most readable materials for people with TBI vision impairments (and just for folks who are plain getting older). The CDC has been the BEST in this area; but unfortunately some organizations serving TBI populations need to develop awareness and make changes! I am glad vision issues have been brought out of the darkness. In vision, as well as other TBI-affected impairments to resuming life as best we can, self-advocacy and a good healthy sense of the American with Disabilities Act goes a VERY LONG WAY. And for those folks who participate in surveys about disabilities: speak up when a survey asks about vision impairments that are solely eye-ball related. Explain vision issues you experience so that future survey questions can be broadened (Surveys usually imply problems are with dimness; my problem is with glare!) Education and advocacy may not provide a "cure," but getting accommodations sure goes a long way in helping us see the light!
See All TBI Topics
BrainLine Footer
Getting Started |
Site Features |
Follow Us |
About |
Facebook
Twitter
LinkedIn
YouTube
RSS Feeds
BrainLine.org is a WETA website funded by the Defense and Veterans Brain Injury Center through a contract with the Henry M. Jackson Foundation. Government funding support is not an endorsement of WETA or any of its products, including this website.
© 2013 WETA All Rights Reserved
Thank you to Dr. Goodrich for addressing these issues. We also find that many people who have suffered mild to moderate brain injury also have what is commonly known as the 'supermarket syndome'. They cannot tolerate crowds, find that pushing a grocery cart up and down crowded store aisles unbearable, cannot have their children's friends playing busy and loud games at home. have light sensitivity, and many other problems with function that make life difficult and result in family issues, arguments, etc. Because there are often no scars or broken bones - these individuals look perfectly normal, yet cannot function in their environments and families as they did before the TBI. Ocular motor and accommodative work is helpful but has to be taken very slowly, should be done in sitting in an arm chair for protection from dizziness to begin, AND remember to always have a watepaper basket at hand for nausea and perhaps vomiting. It is slow progress but well worth the effort on the part of the Optometrist and Vision therapist and the patient.
Feb 16th, 2013 5:11pm