Nero Developmental Optometry (Vision Therapy)
Vision therapy is a non-surgical treatment used to teach and train the eyes and brain to “see” and perceive visual information more efficiently and effectively. It is an umbrella term that can include:
Orthoptics- used to describe procedures that actively treat eye teaming and focusing skills, e.g. convergence insufficiency
Eye tracking therapy
Visual information processing/ visual perceptual therapy
Visual-vestibular therapy
Vision rehabilitation, I.e. post-acquired or traumatic brain injury
Sports vision enhancement therapy
We know that, anatomically, the pathways that involve vision encompass roughly half of the brain’s circuits (Ventura et al, 2015). Therefore, with traumatic brain injury, vision is likely going to be affected, irrespective of the severity of the injury. Common symptoms that arise after a traumatic brain injury (TBI), including a mild TBI and concussion, include headaches, eyestrain, double vision, difficulty remembering what you’ve read, tracking difficulties, loss of concentration when reading, reduced visual processing speed, light sensitivity, intermittent blurry vision, difficulties with visual memory or visuospatial skills, and just feeling overwhelmed with visual information. All of these can be helped with vision therapy!
Treatment is typically performed in-office with a vision therapist and or an optometrist. Home reinforcement exercises are typically assigned between office appointments. Treatment is highly individualized and progressive, with no standard protocol because every brain injury (and person) is different. So, it is not uncommon for practices to vary between practitioners.
Treatment may consist of a variety of exercises using lenses, filters, lights, eyepatches, prisms and other equipment. Procedures are noninvasive, and utilize a variety of instruments as well as computer-based techniques.
Overall, vision therapy can be instrumental in improving visual skills. In fact, a records review by Galloway et al published in 2017 found that, if the 80 post-concussion patients who completed vision therapy, 85% of those with convergence insufficiency were successful and 15% improved. And, 33% of those with accommodative insufficiency were successful and 67% improved.
Write Up by Debora M. Lee Chen, OD, MPH, FAAO
References:
Ventura RE1, Balcer LJ1, Galetta SL. The Concussion Toolbox: The Role of Vision in the Assessment of Concussion. Semin Neurol. 2015 Oct;35(5):599-606. doi: 10.1055/s-0035-1563567. Epub 2015 Oct 6.
Gallaway M1, Scheiman M, Mitchell GL.Vision Therapy for Post-Concussion Vision Disorders. Optom Vis Sci. 2017 Jan;94(1):68-73. doi: 10.1097/OPX.0000000000000935.
Doctors:
Debora M. Lee Chen, OD, MPH, FAAO/ UC Berkeley, California
Mark Wu, OD / UC Berkeley, California
Neera Kapoor, OD/ New York
Mitchell Scheiman, OD/ Pennsylvania
Kenneth Ciuffreda, OD, PhD/ New York
Neil Margolis, OD, Developmental Optometrist/ Greater Chicago area
Carl Hillier, OD, FCOVD/ San Diego, CA
Dr. Fitch/ Vision Care Center, Peoria, Illinois
Patient Reviews
With a TBI, it is very common for the connection between the eyes and brain to become damaged. After my TBI my eye sight improved to 20/10, but it would take all my energy to focus on a page to read. My regular optometrist said I was fine. My mom did some research and found UC Berkeley Optomotry TBI clinic. I highly recommend having your eyes checked by a qualified Neuro-optomotrist who specialized in TBIs. I now have prism glasses and can read for over an hour before I get too tired. I'm currently in therapy and can already notice a difference.
Audrey Lambidakis / UC Berkeley
Doctor Pruzenski is very knowledgeable and sympathetic of PCS while being very down to earth. She evaluates your vision through an ocular exam and other specific tests. Getting your vision evaluated when you have light sensitivity is painful I will not lie, but Doctor Pruzenski is aware of this and is sympathetic towards your struggle and lets you take breaks and the time you need. A head injury can disrupt your visual field. This was true in my case so she recommended a kinetic visual field test where you look through a device and they map your visual field by putting different colors into your visual field and you let them know when you can see the color clearly. Another therapy Doctor Pruzenski recommended for me was syntonic filters. Syntonic filters are these 3-D glasses you wear at home with an incandescent light bulb and they communicate with your optic nerve. I was given 2 filters you must wear them for the same amount of time. The first filter was harder for me to wear and would sometimes trigger symptoms if I went too long so I started slow with 30 seconds each and built my way to minutes but the second filter was calming to my brain. This was probably the easiest therapy I have come across. Dr. Pruszenski prescribed me prism glasses to help my eyes converge and this has been huge for me because it lessened eye strain and aided in my process of trying to read, write, and watch videos again. I was also able to tint the glasses to whatever color filter was soothing to my brain and this is huge with light sensitivity. My prism/tinted glasses gave me relief and allowed me to be able to see things clearly again for the first time in months since my injury. After a head injury your functional visual skills can struggle such as eye tracking, moving, and focusing. Your vision can change a lot after a head injury and during your recovery which is why Dr. Pruszenski has you come in every 3 months to check in and see how you are doing. It is pricey to have glasses prescriptions updated this much but they include one free change and have cheaper glasses frames exc. for this program.
Dr. Margolis is my savior in my Post Concussion Syndrome fight. He diagnosed me with PCS: I was basically seeing double and didn't know it, causing an altered gait/head tilt and subsequent neck tightness, nausea, and headaches. He addressed it with prism glasses, a better prescription lens, and 6 months of ocular and vestibular therapy at his office (thank you Karen!). He had me do check ins every 6 months afterwards and was adamant about my long-term health. He's a pioneer in this industry and is the most humble man I've met. Extremely smart and communicates really well. Heard me out and listened, which was exactly what I needed in my time of confusion, doubt, and isolation.
Quentin Williams/Dr. Neil Margolis, Developmental Optometrist in Greater Chicago area
After realizing my eyesight wasn't the best and I was getting headaches more often than I had after my original set of therapy sessions and prism's with another doctor in Chicago, Dr. Hillier helped me understand that once again my vision was causing my brain to work VERY hard. He prescribed prisms and blue light shielding for my glasses and now when I put them on I feel a sincere sense of relief. Dr. Hillier is extremely client-obsessed and looks me in the eye and listens. Incredible doctor referred to me by Dr. Margolis in Chicago.
Quentin Williams/Dr. Carl Hillier, OD, FCOVD in San Diego, CA
If you live in Finland, these therapists are few. To my knowledge, this is also the case in the entire Nordics. These therapists are few but one that works wonders is Mona-Lisa Möller. She is now doing her Ph.D. under the supervision of the guys at Karolinska Institutet (Tony Pansell among others). Vision therapy is not yet an integrated part of TBI rehab in Finland. However, this might change. The Clinic for Brain Damage did a pilot study in how this helps people with TBI. I was one of the pilot patients. It’s pure pain, but it’s worth it. 30-85% of all TBI patients experience reduced vision post-injury.
At panorama optometry with Jeremy Larson, I had about 18 sessions and hugely made my memory better and allowed me to focus on anything for more than 5 seconds when eyes would glitch before.
My only helpful review I have is on my neuro-optometrist. His name is Dr. Fitch and he works in the Vision Care Center in Peoria, Illinois. To told me that I had Mis-aligned eyes due to my brain trauma. He treated me by prescribing some glasses to re align my eyes. They have prisms and a migraine tint. I also have binasals to help with my balance. He has given me so many answers, and been WAY more helpful than any neurologist I’ve had. These glasses have been the only thing that has given me relief in the last 3 years. Incredibly grateful for Dr. Fitch and his help!
Jess Fansler/Dr. Fitch at Vision Care Center in Peoria, Illinois
It's estimated that 50% of PCS patients will develop visual problems (I think it is closer to 100%). A neuro developmental optometrist (also called a behavioral optometrist) is a doctor who specializes in your ability to process visual information, including binocular vision performance and visual perceptual abilities. Since, 80-85% of our brain utilizes visual input, it's a foundational part of PCS recovery. .
From personal experience... visual issues feel horrible and can be difficult to describe. Treatment can range from prism glasses and light therapy to prescribed vision therapy exercises (often times done by an occupational therapist or a vision therapist). While it's best to be treated early, improvements can be made years after a brain injury.
SYMPTOMS you might feel include difficulty reading/writing/driving, feeling out of body, feeling out of real time, decreased reaction time, loss of peripheral vision, light sensitivity, dizziness, fog, freezing episodes, difficulty maneuvering in a crowd, visual tracking difficulties and hallucinations... just to name a few.
Some common CAUSES of these symptoms are:
- CONVERGENCE INSUFFICIENCY: Convergence is the ability of the eyes to come together (ex: reading).
- LOSS OF PERIPHERAL VISION: When the brain is overwhelmed it begins to restrict your peripheral vision so as not to take in as much information. As the brain continues to be overwhelmed, one's peripheral vision will continue to narrow. This can vary from a mild loss in your peripheral field to tunnel vision or even episodes of going black.
- SACCADES & SMOOTH PURSUITS DYSFUNCTION: Inability or difficulty of the eyes to properly track or move back and forth from object to object.
- ACCOMMODATION DYSFUNCTION: Inability to focus or sustain focus on things that are close up.
Highly skilled and educated in vision problems after ABI. Very kind and helpful. Highly recommend
Colette Brown/Dr. Loopeker in Fortius Clinic, Burnaby, BC