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Optometrists and Traumatic Brain Injury

2021 AOA Optometry’s Meeting: TBI Visual Evaluation and Management

AOA TBI Evaluation and Management 2021 Simonson




KDT Baseline Pocket Card

Course Learning Objectives:

  1. Understand the impact of TBI on patients’ neurological and visual performance.
  2. Diagnose visual deficits related to TBI utilizing optometric testing including: oculomotor, eye alignment, accommodation, pupil function, contrast sensitivity, depth perception, and peripheral vision assessments.
  3. Develop management strategies for TBI-related vision disorders including the use of lenses, filters, prism, partial occlusion, and vision therapy rehabilitation.
  4. Know when to refer a TBI patient to other physicians and rehabilitation therapists.
  5. Educate patients on optometrist’s role in the prevention of further injury.
  6. Provide recommendations for appropriate accommodations to improve work and academic performance.

TBI Visual Evaluation and Management Outline:

  1. TBI is an acute brain injury resulting from mechanical energy to the head from external physical forces.
    1. TBI incidence in the US: 1.7 – 4 million (CDC, Journal of Neurology)
      1. falls (35%)
      2. motor vehicle-related injuries (17%)
      3. strikes or blows to the head from or against an object (17%), such as in sports injuries
    2. Neurology of the visual pathway
      1. diffuse axonal injury (DAI) has emerged as one of the most common and important pathological features of traumatic brain injury (TBI)
      2. diffuse axonal injury does not show up on scans.
    3. Effects of TBI on the visual system
      1. Areas of potential injury (pathways and lobes)
      2. Types of TBI
      3. Visual field defects and spatial inattention
      4. Post-traumatic vision syndrome
        1. Common symptoms
          • Headache (30 – 90%)
          • Dizziness
          • Light sensitivity
          • Blurred vision
          • Visual motion sensitivity
          • Sound (especially background noise) sensitivity
          • Insomnia
          • Mood alteration
          • Memory issues
        2. These intracellular responses are NOT directly correlated to severity of TBI
        3. Some people with mTBI can have more microtubule damage and post inflammatory damage than people who recovered from more severe TBI
        4. Diagnosis of TBI-related visual deficits (~90% of people with TBI have vision problem)

concussion infographic brain injury signs symptoms 450w






Expected Recovery Timeline

  1. Balance Recovery <7 days
  2. Symptom Scores 5-14 days
  3. Cognitive Recovery 7-21 days
  4. Oculomotor Recovery 21-28 days


    1. History BIVSS
      • photophobia
      • reduced concentration
      • Inattention
      • objects appear to move
      • balance and coordination issues
      • motion sickness
      • difficulty working under fluorescent lights
      • visual-perceptual motor dysfunction

Key questions to ask post-injury (Goodrich et al, 2013)

  1. What changes have you experienced in your vision?
  2. Are you light sensitive, in- or outdoors?
  3. Do you experience double vision?
  4. Have you noticed a change in your peripheral vision?
  5. Do you have blurred vision at distance or near?
  6. Has there been a change in reading?
  7. Do you lose place while reading?
  8. How long can you read before you need to take and break or stop?
  9. Do you experience Headaches?
  10. Do you have trouble remembering what you’ve read?

Emergent Visual Conditions

  • Flashes of light
  • Floaters in field of view
  • Restricted field of vision
  • “Curtains” billowing into field of view

Urgent Visual Conditions

  • Inability to completely close eyes
  • Difficulty moving or turning eyes
  • Pain with movement of the eyes
  • Pain in or around eyes
  • Wandering eye
  • Double vision

Vision Rehabilitation Conditions

  • Blurred vision for distance viewing / Blurred vision for near viewing
  • Slow shift of focus from near to far to near
  • Difficulty copying or taking notes
  • Pulling or tugging sensation around eyes / Discomfort while reading/ Eyes get tired while reading / Headaches while reading
  • Unable to sustain near work or reading for periods of time / General fatigue while work/reading
  • Covering, closing one eye
  • Loss of place while reading / Easily distracted when reading / Difficulty remembering what has been read
  • Decreased attention span / Reduced concentration ability

concussion infographic poster kids 450w

Post-concussion Vision Evaluation:

Pediatric post-concussion Check-list (CDC) Concussion Checklist Kids

Visual acuity, refractive status, oculomotility, accommodation, binocularity

Northeastern State University College of Optometry’s Oculomotor Test

VOMS: Vestibular/Ocular-Motor Screening VOMSExam

Ocular health

Visual field, visual neglect, egocentric localization (midline shift) BESSmanual

Visual Perceptual testing: Visual Figure-ground, Visual Closure, Visual Reaction Time, Visual Memory

Acute Concussion Evaluation Form

TBI Prevention, Education, and Outreach

Patient population: Athletes, Parents of children, Recreational activity participants


  1. Awareness, Risk assessment
  2. King-Devick Test
  3. Pre-season training protocols
  4. Vision screenings
  5. Sports training

Spectacle Prescription

    1. Small refractive errors often make a large difference
    2. Tinted lenses (Blue, grey; light and dark tints)
    3. Treating diplopia with lenses: low plus, prism, occlusion
    4. Field loss: Prism to increase field awareness
    5. Yoked prism

Environmental Accommodations

ACE_care_plan_school_version_a (1)


    1. Lighting
    2. Screens
      1. Reduction in screen time and near work often necessary
      2. Changing color spectrum and brightness
    3. Classroom and work accommodations: Classroom Accommodations Letter detailed
    4. Rehabilitation
      1. Vision therapy designed for patient’s diagnosis and goals
  • Are there any activities that you wish you could do?
  • What are your visual needs to return to school, your sport or work?
  • What are your recovery goals?

Visual-vestibular therapy often required

Specialized therapy for visual inattention and other visual processing deficits

concussion infographic children safe from brain injury 450w

General Reading References:

  2. Review of Optometry, “Save a Life, Neuro-Optometry Primer: The Brain” by Mario Gutierrez, OD, FAAO.
  6. Vision Therapy for Post-Concussion Vision Disorders. Gallaway, M, et al. Optometry & Vision Science: Jan 2017 – Vol 94 – Issue 1 – p. 68-73 .
  7. A Review of the Current Practice in Diagnosis and Management of Visual Complaints Associated with Concussion and Post concussion Syndrome. Heinmiller, L and Gunton, K. Curr Opin Ophthalmol 2016; 27(5): 407-412.
  8. Current and Emerging Rehabilitation for Concussion: A Review of the Evidence. Broglio, S, et al. Clin Sports Med 2015 April; 34 (2): 213-231.
  9. Concurrent Vision Dysfunctions in Convergence Insufficiency with Traumatic Brain Injury. Alvarez, T, et al. Optom Vis Sci. 2012 December: 89 (12)


    1. Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A brief vestibular and ocular motor screening (VOMS) assessment to evaluate preliminary concussion: Preliminary findings. Am J Sports Med; in press.Form Sources: Instruction Set
    2. Anzalone AJ, Blueitt D, Case T, McGuffin T, Pollard K, Garrison JC, Jones MT, Pavur R, Turner S, Oliver JM. A positive Vestibular/Ocular Motor Screening (VOMS) is associated with increased recovery time after sports-related concussion in youth and adolescent athletes. AJSM 2017;45(2)474-479
    3. Yorke AM, Smith L, Babcock M, Alsalaheen B. Validity and reliability of the Vestibular/Ocular Motor Screening and associations with common concussion screening tools. Sports Health. 2017;9(2): 174-180.
    4. The King-Devick Test:
    5. NSUCO-Oculomotor-Test Instruction SetNorms for Oculomotor Skills: Pursuits and Saccades:
    1. Tests for Neglect/Unilateral Spatial Inattention:
    2. amsler-grid
    1. Visual Vertigo
    2. Balance Error Scoring System manual
    3. BIVSS Symptom Assessment: BIVSS_clinicalBrain_Injury_Vision_Symptom_Survey__BIVSS_.98478_08.2016
  4. BINOCULAR (Sensory Fusion/Motor Alignment)
    1. Worth 4 Dot W4D results
    2. Bagolini Lens Bagolini Test Responses


  1. Neuro-optometric Rehabilitation Association:
  2. Vision Training can decrease concussions:
  3. Collins M, Kontos A, Okonkwo D. et al. Statements of Agreement from the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion .Neurosurgery. Dec 2016;79(6):912-929.
  4. Katz BJ, Digre KB. Diagnosis, pathophysiology, and treatment of photophobia. Surv Ophth. 2016;61:466-477



College of Optometrists in Vision Development & Neuro Optometric Rehabilitation Association Issue Joint Recommendation for Optometric Evaluation Following Brain Injury

Brain injury can affect a person in many ways, extending from physical limitations to changes in perception and cognition. In the United States, an estimated 1.7 million people sustain a TBI each year1, with about 75 percent of them a result of concussions or other forms of mild traumatic brain injury2. “Studies show that at least 50 percent of TBI patients suffer from visual dysfunctions, with one such study3 finding a 90 percent incidence of post-trauma visual complications, such as blurred vision, sensitivity to light, reading difficulty, headaches with visual tasks, and difficulties with eye movements,” says NORA president Susan Daniel, O.D. “About two-thirds of stroke survivors have visual impairment that typically relates to diminished central or peripheral vision, eye movement abnormalities, or visual perceptual defects4,” she adds.

“Clinicians regularly assess a concussion or other acquired brain injury to the symptoms that an individual manifests at the time of injury but, unfortunately, vision-related problems are often overlooked during initial evaluation,” says COVD President, Dr. Christine Allison. “Some symptoms, like visual discomfort and vision-mediated functional difficulties such as slowed reading and compromised attention, may not be present until days, weeks, or even longer following the incident. The consequences of these occurrences may also include cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings and frustration, along with motor and sensory issues leading to impaired academic, work, and sport performance.”

Given the high rate of visual symptoms and known impact, both COVD and NORA urge healthcare professionals to consider the possibility that a patient’s ocular or visual signs or symptoms may have been a result of a brain injury and refer him/her to an optometrist who has special expertise in the assessment and treatment of visual disturbances associated with damage to the central nervous system. “Doctors of Optometry who have been educated and trained to diagnose and manage ocular dysfunctions and visual processing deficits related to brain injuries will examine not only the visual issues, but also other subtle factors involved in the complex visual process, such as posture, spatial awareness, visual memory, and motor output — all areas that can have wide-ranging effects on daily activities and on quality of life,” explains Dr. Allison. “Left untreated, they can have serious consequences,” she warns.

Both COVD and NORA stress the importance of an interdisciplinary, integrated team approach in the diagnosis and rehabilitation of patients with concussions, stroke or other neurological deficits. “When a person has a brain injury, often a single-approach to rehabilitation is not enough to address all of his/her needs,” says Daniel. “An integrated team approach that incorporates the training and expertise of a variety of professionals can play a vital role in rehabilitation.” In addition to optometrists, rehabilitation team members may include such specialists as neurologists, physical medicine and rehab physicians, nurses, physical and occupational therapists, speech-language pathologists, chiropractors, neuropsychologists, audiologists, and ophthalmologists.

Both COVD and NORA offer resources to help patients and caregivers find the help they need following a concussion as well as tools and resources for optometrists and other healthcare professionals. Both associations also feature doctor locaters on their websites for access to providers who specialize in brain-injury related visual problems. For more information, visit them at and


1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.

2. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2003.

3. Ciuffreda KJ, Kapoor N, Rutner D, Suchoff IB, Han ME, Craig S. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry 2007;78(4):155-61.

4. Rowe F.J. Stroke survivors’ views and experiences on impact of visual impairment. Brain and Behavior, 2017; e00778 DOI:

The Optometrist’s Role in Traumatic Brain Injury (TBI) Care

Additional Resources for Vision Assessment and Care after Traumatic Brain Injury:

  1. Lecture Handout: TBI presentation DMOS 2017
  2. Dr. Slotnick’s Blog:
  3. VOMS: Vestibular Oculomotor Screen
  4. The King Devick Test:
  5. Tests for Neglect/Unilateral Spatial Inattention:
  6. Norms for Oculomotor Skills: Pursuits and Saccades:
  8. Neuro-optometric Rehabilitation Association:
  9. Vision Training can decrease concussions:


Optometrists and Traumatic Brain Injury

Join us on May 8th for a talk about Traumatic Brain Injury (TBI) and the role Optometrists play in prevention and treatment. This 1-hour continuing education event will be headed by our very own Optometrists: Dr. Simonson, OD, FCOVD and Dr. Talaber, OD, who will provide knowledge and confidence to diagnose and treat vision conditions related to TBI.

RSVP via phone: 303-443-2257 or email: