Head Injury and Stroke Vision Rehabilitation

(Neuro-Optometric Rehabilitation)
Post Trauma Vision Rehabilitation & Hidden Vision Problems

By Stanley A. Appelbaum, OD, FCOVD

Studies show an extremely high incidence (greater than 50%) of visual and visual-cognitive disorders in neurologically impaired patients (traumatic brain injury, cerebral vascular accidents, multiple sclerosis etc.). Much more than just eyesight (visual acuity), vision is the process of deriving meaning from what is seen. It is a complex, learned and developed set of functions that involve many skills & abilities. Research estimates that eighty to eighty five percent of our perception, learning, cognition and activities are mediated through vision.

Visual problems resulting from Acquired Brain Injury are many times overlooked during initial treatment of the injury. Frequently these problems are hidden and neglected, lengthening and impairing rehabilitation. Vision is the most important source of sensory information. Consisting of a sophisticated complex of subsystems, the visual process involves the flow and processing of information to the brain.

Dr. Appelbaum has medical staff privleges at the Maryland Kessler Adventist Rehabilitation Hospital where he sees patients with visual problems from strokes, head injuries and other major disorders. Treatment and results include knowing where straight ahead is, knowing where things really are located, reduction & frequently correction of double vision and the ability to have a person's eyes land on the right spot when reading or looking around the environment. This contributes to balancing problems. If you or a loved one has had a stroke or head injury, you need this type of evaluation and treatment to improve recovery and perhaps even drive again.

Do you or a person you know suffer from any of the following symptoms?

1. Double vision
2. Headaches
3. Blurry vision
4. Dizziness or nausea
5. Attention or concentration difficulties
6. Staring behavior (low blink rate)
7. Spatial disorientation
8. Lose place when reading
9. Can't find beginning of next line when reading
10. Comprehension problems when reading
11. Visual memory problems
12. Pulling away from objects when they are brought close
13. Disturbance of behavioral or emotional functioning
14. Partial or total functional disability
15. Physiological maladjustment
16. Visual dysfunction

These are all symptoms of Post Trauma Vision Syndrome.

Do you or a person you know suffer from any of the following symptoms?

1. Blurred vision
2. Sensitivity to light
3. Reading difficulties; words appear to move
4. Comprehension difficulty
5. Attention and concentration difficulty
6. Memory difficulty
7. Double vision
8. Aching eyes
9. Headaches with visual tasks
10. Loss of visual field
11. Dizziness or nausea
12. Spatial disorientation
13. Consistently stay to one side of hallway or room
14. Bump into objects when walking
15. Poor balance or posture
    For example: leaning back on heels, forward, or to one side whenwalking, standing or seated in a wheelchair)

These are all symptoms of Visual Midline Shift Syndrome.

Post Trauma Vision Syndrome & Vision Therapy

Children & Adults who have sustained head injuries, strokes or other neurological impairments often find that their vision has been effected as a result. Dr. Appelbaum has received special training in neuro-optometric rehabilitation and treatment. The following information may be a first step in determining if visual difficulties are interfering with the rehabilitation progress.

Insults or injuries to the cortex produced by a traumatic brain injury cause stress in the central and autonomic nervous systems. The effect on vision seems to be an interference with the visual processes. As a result, a head injured person may experience double vision, binocular dysfunction or concentration difficulties.

In the past, these symptoms were diagnosed as individual eye problems or muscle imbalances. However, the visual system is really a relationship of sensory-motor functions which are controlled and organized in the brain. The eye alignment imbalances and other reported difficulties that result from a head injury often occur because of dysfunction of the ambient visual process affecting sensory-motor spatial disorganization. This causes an eye to turn outward or a strong tendency for both eyes to diverge. The resulting binocular problems are characteristic of what is known as the Post Trauma Vision Syndrome.

Vision therapy can be a very practical and effective. After evaluation, examination and consultation, the optometrist determines how a person processes information after an injury and where that person's strengths and weaknesses lie. The optometrist then prescribes a treatment regimen incorporating lenses, prisms, low vision aides and specific activities designed to improve control of a person's visual system and increase vision efficiency. This in turn can help support many other activities in daily living.

Visual Midline Shift Syndrome

After a hemiparesis (paralysis to one side following a TBI or CVA), there is frequently a shifting of visual midline that actually reinforces the paralysis. However, when specially designed therapeutic lenses (yoked prisms) are prescribed, the midline is shifted to a more centered position thereby enabling individuals to frequently begin weight bearing on their affected side. After a neurological impairment such as a stroke or TBI, disorders of vision can also occur which cause shifts in concept of a person's midline. This can cause the person to shift their body laterally or in other ways which affect balance, posture and gait. This shift in visual midline has been termed the Visual Midline Shift Syndrome.

Rehabilitation: Due to the major impact of the visual system on cognitive and motor function, the visual rehabilitative needs of a person with a head injury, stroke, or a neurological impairment must be addressed as early as possible. Neuro-optometric rehabilitation is an individualized treatment regimen for patients with visual deficits as a result of such injuries. The treatment plan improves specific acquired vision dysfunctions determined by standardized diagnostic criteria. Treatment regimens encompass medically necessary non-compensatory lenses and prisms with and without occlusion and other appropriate rehabilitation strategies.

Behavioral observations during therapy sessions or medical examinations, in-depth interviews and screenings provide information about potential visual and neuro-motor dysfunctions.

Yoked Prism Glasses

Yoked prisms can affect the muscle tone as well as the myofacial imbalance. Dr. Appelbaum works closely with the physical and occupational therapists when evaluating and treating. Subtle changes in the myofacial tissue with yoked prism positioned in particular directions may be analyzed by the OT or PT. Yoked prism glasses are utilized therapeutically to alter the visual midline concept of a person who has suffered a neuro-motor imbalance as a result of a cerebral vascular accident, traumatic brain injury, or who has had a physical disability from multiple sclerosis or cerebral palsy to name several causes. Persons who have a hemiparesis or hemiplegia will have a shift in their concept of their visual midline usually away from their effected side. These shifts in midline can also occur anteriorally or posteriorally.

This visual midline shift, causes the person to unconsciously think that their body center is shifted in the direction of their midline. In turn, the person will lean toward the midline shift and essentially reinforce their own hemiparesis or hemiplegia. The visual midline shift has been documented in literature and neuro-motor problems affecting posture and balance have also been written extensively about in journals of rehabilitation regarding physical and occupational therapy.

Using yoked prism glasses, the visual midline can be shifted to increase the person's ability to transfer weight over to the affected side. Yoked prism lenses have been used effectively through neuro-optometric rehabilitation in hospitals and rehabilitation programs throughout the United States. When a person has a visual midline shift, physical therapy will frequently plateau and reach a limit if the visual midline is not effected through the use of medically necessary yoked prism lenses. These yoked prism lenses are therapeutic and are not compensatory in nature. The purpose of these special prisms are to shift the visual midline thereby enhancing the effect of the physical and occupation therapy. It has been determined that the potential for physical and occupation therapy can be increased and reached more quickly when incorporated with the use of yoked prisms. Prescription of yoked prisms may include low amounts of prism incorporated in the person's glasses and a second higher amount of yoked prism for short term use in conjunction with OT and/or PT.