Vision Therapy for Concussion and Traumatic Brain Injury (TBI)

Experiencing a concussion or other traumatic brain injury (TBI) is a life-altering event. While the initial physical symptoms—headache, dizziness, and nausea—often command immediate attention, the lasting impact on the visual system can significantly hinder recovery and quality of life. At Perspective Optometry, our Vancouver Vision Therapy Clinic specializes in addressing these crucial visual consequences, offering a path to restoring visual function and independence for patients navigating recovery.

Our practice has evolved to specifically focus on the rehabilitation of patients who have sustained concussions or other acquired brain injuries, often due to sports injuries or motor vehicle accidents. We frequently collaborate with and receive referrals from local physiotherapists and occupational therapists, recognizing that a multidisciplinary approach is essential for comprehensive brain injury rehabilitation. For many car accident-related injuries, the Insurance Corporation of British Columbia (ICBC) often covers the some of the cost of necessary vision therapy.

The Widespread Impact of TBI on the Visual System

Traumatic brain injury is a major global health concern, with estimates suggesting TBI affects hundreds of people per 100,000 annually. Given that nearly half of the circuits in the human brain are involved in processing vision, the visual system is exceptionally vulnerable to the effects of mild, moderate, or severe TBI.

Brain injuries can result from any sudden blow or jolt to the head (a concussion), or from medical events such as a stroke. Concussions, a major category of TBI, frequently cause a cascade of vision-related symptoms. In fact, eye movement assessment is so crucial to identifying concussions that the widely-used King-Devick test utilizes abnormal eye movements as a diagnostic indicator.

Oculomotor and Visual Deficits are Highly Prevalent

Recent research consistently highlights the prevalence of eye movement (oculomotor) deficits following TBI. A pivotal area of research, dating back over a decade, noted that more than 90% of patients with mild TBI (also referred to as acquired brain injury) were found to have one or more oculomotor dysfunctions (Ciuffreda KJ, Ludlam DP, Kapoor N. Clinical oculomotor training in traumatic brain injury. Optom Vis Dev 2009;40(1):16-23.). These can include:

Nystagmus (involuntary eye movements)
Abnormalities in version (eye movements when both eyes move together, like tracking an object)
Vergence (eye movements when the eyes turn inward or outward to focus on near or far objects)
Accommodation (the eye's ability to change focus)
Eye alignment issues

These physical dysfunctions translate directly into functional difficulties, such as problems tracking objects, difficulties in visual scanning, and slow, inefficient reading.

Symptoms and Clinical Signs of Post-Concussion Vision Problems

For prospective patients or their caregivers, recognizing the symptoms is the first step toward seeking help. The visual symptoms caused by a brain injury are extensive and often mimic other conditions, making a specialized optometric evaluation crucial.

Common Vision Symptoms Post-Concussion

The following symptoms, often cited in research like the study "Clinical Oculomotor Training in Traumatic Brain Injury" by Dr. Kenneth Ciuffreda and colleagues, represent the daily struggles of TBI patients:

Avoidance of near tasks (reading, computer work)
Oculomotor-based reading difficulties (losing place, skipping lines)
Eye tracking and focusing problems
Eyestrain and Diplopia (double vision)
Dizziness or Vertigo (a sensation of spinning)
Vision-derived nausea
Increased sensitivity to visual motion
Visual inattention and distractibility
Inability to tolerate complex visual environments (e.g., crowded grocery store aisles, patterned floors)
Difficulty judging distances (depth perception)

Oculomotor Clinical Signs Diagnosed by Optometrists

During an in-office exam, a developmental optometrist can objectively measure the following clinical signs, which may be a direct consequence of the TBI:

Clinical Sign (Objective Finding)	Description
Reduced/Increased Lag of Accommodation	Impaired ability to focus clearly at various distances.
Receded Near Point of Convergence (NPC)	Difficulty bringing the eyes inward to sustain focus on a near object.
Restricted Fusional Vergence Ranges	Reduced capacity of the eyes to turn in (converge) or out (diverge) to maintain single vision.
Impaired Versional Ocular Motility	Difficulty with smooth, coordinated eye movements.
Abnormal Developmental Eye Movement (DEM) Results	Poor performance on timed tests measuring the efficiency of eye movements used for reading.
Low Grade-Level Performance on Visagraph	Objective measurement showing poor reading eye-movement patterns.

Optometric Vision Therapy: The Rehabilitation Role

Optometrists specializing in neuro-rehabilitation and vision therapy play a critical role in the overall recovery effort following TBI, including concussion, stroke, or aneurysm. They do this by addressing the breakdown in communication and processing between the eyes and the brain.

Following a thorough evaluation, the optometrist determines the patient’s visual processing strengths and weaknesses post-injury. This leads to a tailored treatment regimen incorporating a combination of therapeutic tools and activities:

Specialized Lenses and Prisms: These can be used to shift images, reduce visual stress, or correct alignment issues that cause double vision, making the visual system easier to manage.
Lenses with Special Tints or Coatings: Used extensively for managing photosensitivity (light sensitivity) and improving contrast perception.
Elective Occlusion: Strategic patching to manage complex double vision and reduce visual confusion.
Specific Vision Therapy Activities: Customized, structured exercises designed to improve oculomotor control, visual processing speed, visual attention, and the coordination between the eyes and the brain.¹⁵

Research-Backed Effectiveness of Vision Therapy (Pre-2020)

The effectiveness of optometric vision therapy in treating post-concussion visual problems is well-documented in clinical research:

High Success Rates (2017 Study): A 2017 study published in Optometry and Vision Science investigated the prevalence of vision disorders associated with concussion and the success rate of vision therapy in private practice settings. The authors concluded that post-concussion vision problems were prevalent and that vision therapy led to a successful or improved outcome in the vast majority of cases that completed treatment.
Significant Improvement in Oculomotor Disorders (2008 Study): A 2008 study by Ciuffreda et al. published in the journal Optometry demonstrated that 90% of TBI patients treated with vision therapy had significant improvement in their eye movement disorders.

Oculomotor Training Protocols

Formal therapeutic protocols specifically designed for oculomotor training in TBI patients have been developed and documented by researchers like Han, Ciuffreda, and Kapoor. These protocols guide clinicians in delivering targeted, evidence-based care.

Han Y, Ciuffreda KJ, Kapoor N. Reading-related oculomotor testing and training protocols for acquired brain injury in humans. Brain Research Brain Research Protocols 2004: 14: 1-12.
Kapoor N, Ciuffreda KJ, Han Y. Oculomotor rehabilitation in acquired brain injury: a case series. Arch Phys Med Rehabil 2004: 85(10): 1667-1678.
Ciuffreda KJ, Ludlam DP, Kapoor N. Clinical oculomotor training in traumatic brain injury. Optom Vis Dev 2009;40(1):16-23.

New Evidence: The Need for Early Intervention (Post-2020 Research)

Recent, high-quality research published since 2020 has strongly reinforced the need for specialized neuro-optometric care and provided compelling evidence for early intervention with vision therapy.

The CONCUSS Randomized Clinical Trial (RCT)

One of the most significant pieces of new evidence is the CONCUSS Randomized Clinical Trial (Vergence/Accommodative Therapy for Concussion-Related Symptomatic Convergence Insufficiency), published in a leading sports medicine journal. This RCT, a gold-standard study, addressed the common deficit of Convergence Insufficiency (CI) following a concussion.

Key Finding on Timing: The study compared an immediate vision therapy group against a delayed treatment group (waiting six weeks). The group that started vision therapy immediately achieved an $80\%$ success rate in resolving their concussion-related vision problems. In contrast, only $10\%$ of the delayed group recovered after waiting six weeks to begin therapy.
Clinical Impact: This study provides strong, high-quality evidence that vision therapy for oculomotor and accommodative deficits is effective and suggests that patients with persistent visual symptoms interfering with daily functions should not wait to begin treatment. It supports the recommendation that screening for these disorders should happen early after injury.

Vision Therapy Improves Chronic Post-Concussion Symptoms

Further research has demonstrated that vision therapy remains effective even for patients with chronic symptoms (lasting six months or more):

A 2021 study published in Neurological Research investigated the effect of vision therapy in adult patients with long-term consequences after mild TBI (mean time from injury to therapy start was approximately one year).
Key Finding: After a structured 10-week vision therapy program, significant improvements were measured across multiple parameters, including fixation stability and endurance, Groffman Visual Tracing Test scores, King-Devick Test scores, and reading speed. This provides evidence of considerable neuroplasticity and the effectiveness of intervention even in the chronic phase.

The Role of Therapeutic Lenses (Microprism)

Recent clinical reports have also emphasized the immediate symptomatic relief offered by specific lens modalities:

New protocols utilize therapeutic microprism (small amounts of prism) to reduce symptoms in patients with Post-Concussion Syndrome (PCS), especially those with visually-provoked dizziness, balance problems, and sensitivity to busy environments.
For patients experiencing photophobia (light sensitivity), specialized tints and filters (like FL-41) are increasingly being prescribed as a complementary measure to vision therapy and prism, offering instantaneous comfort and visual filtering.

These recent findings solidify the position of neuro-optometric vision therapy not as an alternative treatment, but as an essential, evidence-based component of a comprehensive TBI rehabilitation plan.

TBI and Reading Problems: A Common Consequence

Reading difficulties are one of the most common and disruptive consequences of concussion and TBI. Reading requires highly accurate and coordinated eye movements (oculomotor control), including precise saccades (jumps between words) and smooth pursuits (tracking along a line).

When a brain injury impairs oculomotor control, reading becomes a painstaking process characterized by:

Frequent loss of place
Skipping of lines
Difficulty shifting to the next line of print

Successful Remediation of Reading Issues

Research confirms that reading problems caused by TBI can be successfully remediated through vision therapy:³¹

A 2007 study published in the Journal of Behavioral Optometry examined 160 patients with mild TBI and found that $90\%$ exhibited oculomotor deficiencies (like convergence insufficiency or abnormal tracking) that would significantly impact reading performance.
Of a subset of 33 patients who underwent vision therapy, ninety percent showed improvement in at least one objective sign and one subjective symptom.
Furthermore, a smaller sample of nine patients with oculomotor-based reading problems all improved their overall reading performance and versional eye tracking ability following a basic program of vision therapy rehabilitation.

The authors concluded that these positive results "demonstrate the presence of considerable neuroplasticity in adults with mild TBI" and recommend that optometric vision therapy be instituted for visually symptomatic patients with TBI who have oculomotor-based reading dysfunctions.

The Holistic Approach to Visual Rehabilitation

As Kapoor and Ciuffreda described in Current Treatment Options in Neurology (2002), the general approach to managing post-TBI vision anomalies involves a tiered strategy:

Monitoring and Referral: Complex issues like noncomitant strabismus (misaligned eyes that change with gaze) or advanced ocular health problems are monitored or referred to neuro-ophthalmologists for medical or surgical intervention.
Noninvasive Rehabilitation: Anomalies of accommodation, vergence, version, photosensitivity, and visual field are highly amenable to noninvasive rehabilitative interventions, primarily vision therapy delivered by developmental optometrists.

Vision therapy may be performed alone or combined with:

Fusional Prism Spectacles: To treat chronic diplopia (double vision).
Tinted Spectacles: To manage photosensitivity.
Yoked Prism Spectacles: To address visual-spatial hemispheric inattention or visual field defects by shifting the patient's perceived space.

It is often recommended that physical, cognitive, and occupational rehabilitation be deferred or modified until the patient’s visual function is stabilized to an appropriate level. Rehabilitative optometric intervention is therefore a foundational and beneficial step that should be offered early in the TBI recovery process.

At Perspective Optometry, we are committed to providing this evidence-based, specialized care, helping our patients regain their visual clarity, restore functional independence, and fully participate in their overall rehabilitation journey.

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