Advanced Vision Therapy
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Traumatic Brain Injury
Vision is our dominant sense
More than just sight is measured in terms of 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 a multitude of skills. Research estimates that eighty to eighty five percent of our perception, learning, cognition and activities are mediated through vision.
The ultimate purpose of the visual process is to arrive at an appropriate motor, and/or cognitive response.
There is 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.) Rosalind Gianutsos, Ph.D.
The process of vision can be broken down into three categories:
1. Visual Acuity and Visual Field
2. Visual Motor Abilities
3. Visual Perception.
Visual Acuity & Visual Field
This refers to clarity of sight. It is commonly measured using the Snellen chart.
This is the complete central and peripheral range, or paNORAma of vision. Various neurologic conditions, such as stroke, cause characteristic losses of the visual field, for example hemianopsia.
Other areas affected by traumatic brain injury include:
- Visual Closure
- Spatial Relationships
- Figure-Ground Discrimination
Attention patients with head injuries: Please print and fill out this form to determine if we can help you!
Read more about vision and brain injury at the Neuro Optometric Rehabilitation Association (NORA) website.
Read more about the occurrence of oculomotor dysfunctions in acquired brain injury here.
Read about recovery from traumatic brain injury on this inspiring blog Cavin Bounce: Adventures in Brain InjuryThe author, Cavin Balaster, will speak at the 2014 NORA conference.
Vision Therapy and Traumatic Brain Injury
by Eric Singman MD PhD
Vision difficulties after traumatic brain injury (TBI) are common and often difficult to
recognize. I have had an opportunity to formally review efforts concerning both the assessment of visual dysfunction as well as therapies available for these concerns. Although there are relatively few studies defining the best approach to rehabilitating patients suffering TBI, current evidence supports a multidisciplinary program. As with any large team endeavor, coordination of responsibilities is necessary for success. Among the critical members of this team, there should be vision specialists dedicated to working with patients who demonstrate deficiencies in eye teaming, loss of visual acuity and/or visual field as well as uncoupling of “visuospatial awareness”. For the most part, the optometric and neuropsychological communities have embraced visual rehabilitation efforts; notably, these providers have documented successes in helping brain injury patients improve their quality of life.
To read more, click on the complete article.
- Dr. Singman's Statement on Vision Therapy64.11 K | 1/29/2015
Syntonic - or Optometric - Phototherapy may be a vital feature of your treatment plan. In his article, "The Theory and Practice of Syntonic Phototherapy: A Review", Dr. Larry Wallace illustrates the benefits of Syntonic Phototherapy when prescribed as a supplement to traditional treatments for Traumatic Brain Injury. "The application of colored light for healing dates back to the earliest times of recorded history, including Egyptian and Mayan civilizations," writes Dr. Wallace. "The vascular system serves as a major carrier of light sensitive chemicals. The classic example is the use of blue light to treat neonatal jaundice. Bilirubin is a yellow chemical that accumulates in the tissues, and that readily absorbs light at 450 nanometers. It is broken down and eliminated after exposure to blue light. The blood contains photo acceptor molecules that absorb visible light radiation and then regulate various biochemical activities." When applied correctly, energy treatments like Syntonic Phototherapy - which can enhance everything from binocularity and accommodative facility, to visual discrimination and information processing - may mark a new epoch in the long-term treatment of TBIs.
To read more, click on the complete article.
- Syntonic Phototherapy119.44 K | 4/1/2015
Both TBIs and strokes affect the brain, the Vision Information Processing System (VIPS) is also affected. This is the "wiring" of the visual system as it relates to visual input. in most cases, the Visual System can be reprogramed with Vision Therapy.
Concussions and Vision Therapy
Vision therapy has shown to help remediate many symptoms of concussions. Learn more by reading the attached study.
- Effect of Vision Therapy for Concussion Patients217.87 K | 10/10/2016
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Symptoms Requiring Neuro-Optometric Rehabilitation
Traumatic Brain Injuries (TBI) come with many potential symptoms. These include: blurry vision close or at a distance, eye fatigue or burn while reading, eye strain or headaches, double vision, a need to squint or adjust posture to see clearly, struggling to read line-by-line, lack of coordination, dizziness or motion sickness, confusion reading familiar words, struggling to see out of one eye or only seeing "half" of a picture, inability to multitask, and loss of peripheral vision. Many of these symptoms may suggest a need for vision therapy.
View the complete questionnaire below for more details.
- Neuro-Behavioral Questionnaire140.68 K | 9/8/2016
Reading Problems & Traumatic Brain Injury
Reading problems may occur from various problems after a stroke or head injury. It is crucial that the type of reading problem be diagnosed. The list below contains some of the more common causes of reading problems after brain injury with introduction to how they may be treated. The problems may occur individually or be part of a constellation of problems related to Post Trauma Vision Syndrome. Treatment of PTVS through various neuro-optometric rehabilitative interventions may resolve many of the problems below.
Post Trauma Vision Syndrome
Essentially, individuals with PTVS begin to look at paragraphs of print almost as isolated letters on a page and have great difficulty organizing their reading ability. It has been found that the use of prisms and bi-nasal occlusion can effectively demonstrate functional improvement, while also being documented on brain wave studies by increasing the amplitude (this is like turning up the volume on your radio).
Reading Problems Due to Visual Field Loss Field loss patients often lose their place in reading. Simple techniques, like boundary marking, sticking a Post-it note along the side of a column of print, can mark the beginning or end of the column and reduce confusion. A right hemianopsia patient may lose his or her place at the end of a line. The right hemianopsia patient may leave off words at the end of a line. A left hemianopsia patient may have difficulty at the start of each line and may not return to the very beginning of the line. Convergence Disorders Affecting Reading Patients may experience reduced convergence after stroke or head injury. Our eyes must turn in together accurately as a team to prevent double vision and eye fatigue in reading. Prisms may aid some patients. Orthoptic therapy may aid some, but not all patients with convergence insufficiency will respond fully to therapy due to the variation in the extent of trauma which may be present.
Post Trauma Vision Syndrome, Visual Midline Shift Syndrome
Following a neurological event such as a traumatic brain injury, cerebrovascular accident, multiple sclerosis, cerebral palsy, etc., it has been noted by clinicians that persons frequently will report visual problems such as seeing objects appearing to move that are known to be stationary; seeing words in print run together; and experiencing intermittent blurring. More interesting symptoms are sometimes reported, such as attempting to walk on a floor that appears tilted and having significant difficulties with balance and spatial orientation when in crowded moving environments. These type of symptoms are not uncommon. Frequently, persons reporting these symptoms to eye care professionals (optometrists and ophthalmologists) have been told that their problems are not in their eyes and that their eyes appear to be healthy. What is often overlooked is dysfunction of the visual process causing one of two syndromes: Post Trauma Vision Syndrome (PTVS) and/or Visual Midline Shift Syndrome (VMSS).
Recent research has documented PTVS utilizing Visual Evoked Potentials (VEP). This documentation concludes that the ambient visual process frequently becomes dysfunctional after a neurological event such as a TBI or CVA. Persons can often have visual symptoms that are related to dysfunction between one of two visual processes: ambient process and focal process. These two systems are responsible for the ability to organize ourselves in space for balance and movement, as well as to focalize on detail such as looking at a traffic light. Post Trauma Vision Syndrome results when there is dysfunction between the ambient and focal process causing the person to over emphasize the details. Essentially individuals with PTVS begin to look at paragraphs of print almost as isolated letters on a page and have great difficulty organizing their reading ability. It has been found that the use of prisms and binasal occlusion can effectively demonstrate functional improvement, while also being documented on brain wave studies by increasing the amplitude (this is like turning up the volume on your radio).
Visual Midline Shift Syndrome also results from dysfunction of the ambient visual process. It is caused by distortions of the spatial system causing the individual to misperceive their position in their spatial environment. This causes a shift in their concept of their perceived visual midline. This will frequently cause the person to lean to one side, forward and/or backward. It frequently can occur in conjunction with individuals that have had a hemiparesis (paralysis to one side following a TBI or CVA). The shifting concept of visual midline actually reinforces the paralysis, by using specially designed yoked prisms that can be prescribed, the midline is shifted to a more centered position thereby enabling individuals to frequently begin weight bearing on their affected side. This works very effectively in conjunction with physical and occupational therapy attempting to rehabilitate weight bearing for ambulation.
The Neuro-Optometric Rehabilitation Association (NORA)offers referrals to our member doctors to treat individuals who may suffer from the symptoms of PTVS or VMSS. For further questions concerning these syndromes and/or referral sources, please contact NORA.
Loss of Accommodation (Focusing) Affecting Reading
Young head injury patients may experience decreased focusing ability. It is often missed because at an early age doctors don't expect loss of accommodation. It happens naturally at about age 42. Individual with reduced accommodation may benefit from bifocals. Alexias /Word Blindness Affecting the Ability to Read If the patient is unable to read due to damage to areas which process reading, but can understand verbal reading, electronic machines are available such as the Kurzweil Omni 1000 and 3000 and the Zerox Expert Reader. These machines scan all typed print, interpret it and read it aloud to the patient. Talking books and reading radio are also very helpful. Loss of Cognitive Skills May Affect Reading and Comprehension Patients may need to relearn their reading skills developed in childhood or the damage may online pokies be so severe as to preclude reading. Therapists may be able to re-establish reading over time. Low Vision Causing Reading Problems When visual acuity is significantly impaired, high add bifocals or low vision devices may be indicated. Magnifiers, Electronic Magnification CCTVs, special and microscopic eye wear may help the patient read again. Diplopia Causing Disruptions to Reading If the binocular vision problem can be treated, therapy, surgery or prisms may be used to re-establish binocular vision. If the double vision is not curable, then occlusion may be required. Partialsemi-opaque occlusion may reduce diplopia while minimizing the disruption to to ambient vision caused by total opaque. Eye Gaze Disorders Patients with inferior gaze paresis may not be able to look down into the bifocal, but may read with single vision reading eyewear. Clip on reading lenses or single vision reading lenses may also employed. Eye Movement /Tracking Disorders Affecting Reading Eye movement disorders may also interfere with reading. As we read down a line of words, we must make a series of accurate saccades or jumps from one group of words to another. As our head or the paper moves, we must make rapid adjustments of our eye position called pursuit movements. These rapid eye movements are mediated by the vestibular system. Failure of these movements to work smoothly may impair smooth comfortable and may cause vertigo effects.
Unstable Ambient Vision Brain injury patients may present with vertigo, sensitivity to light and extreme sensitivity to motion around them. Trying to sustain reading becomes very difficult. The patient may experience nausea, loss of attention, difficulty fixating on the words and fatigue. Unstable ambient vision is a hallmark of Post Trauma Vision Syndrome.