Vision and Rehabilitation After Brain Trauma (Part 3)

Eric Singman, MD, PhD,
Vision and Rehabilitation After Brain Trauma: Part 3

This is part three of a three-part article published to

The Role of the Neuro-Ophthalmologist in Vision Rehabilitation After Brain Injury

Vision rehabilitation after brain injury is usually initiated by the neuro-ophthalmologist. Efforts during the acute period usually involve simple but important measures such as replacing a patient's damaged spectacles, offering the patient an eye patch to alleviate diplopia, or protecting a lagophthalmic eye from exposure and drying out.

Long-term visual rehabilitation evaluations take into consideration the wealth of information often accompanying patients, such as the assessments from other ophthalmologists, physiatrists, neuropsychologists, neurologists, and neurosurgeons. After offering the patient a full eye examination and vision evaluation, the neuro-ophthalmologist can then best decide what ancillary testing and consultations might be needed. Some commonly employed testing devices include:

  1. Automated Perimeter: This device helps to map a patient’s peripheral vision and evaluate for possible damage to the visual cortex and other parts of the visual pathways.
  2. Visual Evoked Potential Analyzer: This device measures the speed and strength of the neuro-electrical signals passing along the optic nerve to determine whether the nerve was damaged in a way often too subtle to detect via other means.
  3. Electroretinogram: This device measures the speed and power of neuro-electric signals created by the retina during the conversion of light energy in order to determine whether there was a loss of function that might be too subtle to detect otherwise.
  4. Synoptophore: This device helps determine whether a patient can still use the two eyes as a team to form a single 3-dimensional image.
  5. Notably there are many variations of these devices and each can provide helpful information to pinpoint and sometimes even confirm the presence of damage.

The Neuro-ophthalmologist will always evaluate a patient for abnormal eye movements and often refer the patient to orthoptists or behavioral optometrists, colleagues with particular training in eye-teaming disorders. He will also investigate whether a patient can be helped with low vision assistance devices such as magnifiers and glare-control measures. At times he will be required to discuss medical and surgical options for patients with uncontrollable diplopia or nystagmus. A referral to a blind-rehabilitation specialist will be required for those patients whose vision loss is too severe to rehabilitate or not amenable to the novel restorative surgeries currently available. The neuro-ophthalmologist must also ensure that he coordinates his rehabilitative plans with those of occupational-, physical- and vestibular-therapists.

For many patients, the neuro-ophthalmologist represents the last step in the rehabilitation plan and the first step in the care patients will need for the remainder of their lives. This includes maintaining vigilance for the appearance of systemic disorders that often result after brain injury and which can directly or indirectly threaten vision, such as depression, weight gain, sleep apnea, migraine, diabetes, hypertension, stroke, and heart attack. Some of the eye conditions that can stem from these medical problems include stroke in the blood vessels of the eye and optic nerve, glaucoma, bleeding in the eye, swelling of the optic nerve, loss of peripheral vision, diplopia, difficulty reading, and loss of visual clarity.

Patients suffering traumatic brain injury might unfortunately experience depression, which can lead to neglect of medical problems and delay in diagnosis of associated medical conditions, including visual problems. Brain trauma can also exacerbate or accelerate underlying cranial disease. It cannot be stressed enough that the team who helped the patient return to maximal medical improvement must also ensure that continuity of care for the patient is available. The patients and their families will rely on that continuity to help them adapt to and accept their new, post-brain injury life in which there are both unfamiliar challenges and new opportunities.

Posted on BrainLine March 2, 2011.

From Stars and Stripes, March 2010,

Comments (5)

Please remember, we are not able to give medical or legal advice. If you have medical concerns, please consult your doctor. All posted comments are the views and opinions of the poster only.

Having suffered a targeted assault to the head, face, chest and spinal cord after being tricked and held hostage from supposed extended family members, which led to many years of depressive episodes, memory triggered anger, repetitive pattern of pain behavior, sudden onset of severe tension headaches and heart racing, I can tell you that TBI is a very serious health challenge that can affect one's life in unpleasant ways that are hard to detect, treat and heal. From my case, for one to understand, administer treatment and move forward, there is the need for quality and down to earth CB therapists, quality health care providers and effort on the part of the sufferer to be completely whole again. I have been on the healing road for 14 years post-trauma assault from a gang of predators am not completely whole to my old personality, but a better version of myself.

My worst headache type was quickly alleviated with my first good Cranial-sacral massage appointment. That headache would have eroded my soul and spirit if it had continued, but with just that first skull re-alignment I experienced massive relief. Now my headaches are mostly related to Visual Therapy and eye strain. I can alleviate them at home with my Upledger Still Point Inducer, a god send devide that undoes all the tension that visual therapy creates.
I wish any of you luck if you are still suffering from TBI months later, and encourage you to keep trying new therapists, and do not stop speaking up for yourself. You can be your own best advocate towards reinstalling as much of the old you as possible, while also learning to do things in new ways and operate daily as the "new you", even though you probably did not ask for this change. It is here, so may as well press for the best coping toolkits you can get!

Hi, My son was in a car accident on April 12, 2017. He suffered a TBI, skull was removed for 3 months and put back on July 11th. He is not seeing anything out of his left eye and some heminopsia (sp?) on right eye where a portion of vision is gone. He is learning to turn and look more with his head. Can you give me more information on the therapies you are using? The neuro opthalmogist has done nothing for him only to wait and see if things change in October. I have started him on some healing herbs from India (I know it sounds crazy) but I will not leave any stone unturned for my son. He is 24 years old and has his whole life ahead of him. His vision bothers him the most. He is a miracle to be here but I am a mother on a mission. So please if you will send me whatever information you may have. We believe in natural therapies more than ever and I believe the body can heal itself if given the extra help it needs. My email is
Many Thanks, Pam

It's been three years since my auto accident . Which I was or am a TBI. I can not remember what happened in accident, but do know I was going 50 miles per hour on my way home from work. I have been in therapies all this time. Twice in Vision Therapy, trying to get my eyes from starring off. Where I could not get them to track. Now I still have one eye which crosses inward, which I then see double. I do not drive, I have had head pain since accident, just not as bad/painful. I used to tell people it was like downing a slurp real fast and woe a brain freeze happens. Except for me it lasted a long time pain. I am now wearing eye glasses called Prism glasses, they have lines going up n down so that my eyes will work together. I have been wearing them for 3 weeks now. They are difficult, like some distortion when walking, plus seems like glasses are dirty. Reading is hard to focus on words, tough to see each letter. Well if any one else has issues like mine would be great to read. Also if headaches ever quit. Thank you

Optometry is a very good resource for help in rehabilitating an individuals vision process after brain injury.  A step by step protocol yields very good results for many people.  Check with your optometrist for evaluation and/or referral.