Vision Therapy
After a concussion, patients often experience impairments related to vision, some of which may not be recognized as vision problems, such as problems with concentration, light sensitivity, and headache. Concussion evaluations (for example, by a primary care provider) usually involve basic tests of vision, which can help identify some of these issues. However, these tests can miss subtle deficits in vision, and you may need to seek a specialist for diagnosis. A study found that 82% of patients post-concussion were diagnosed with an oculomotor issue (relating to how the eyes move together). If these visual impairments are left untreated, they may prolong concussion recovery.
Vision therapy and visual-vestibular rehabilitation are used to treat vision issues stemming from concussion. Specialized optometrists, referred to as neuro-optometrists, and physical therapists with additional training in vision issues can diagnose and provide therapy for your vision. Many people experience vision problems within 1-2 weeks after a concussion. For most, these symptoms resolve on their own within 4 weeks. Those whose symptoms persist past 4 weeks should seek the specialized care discussed on this page.
Melissa Sodko, RHIT, MPH(c), facilitated the review of this page for accuracy
This page is designed to help you identify if you are experiencing symptoms of post-concussion visual system dysfunction, suggest options for care, and help you find qualified providers.
Contents
Diagnosis and treatment options
What is a comprehensive eye exam?
Signs and symptoms
Common symptoms of vision issues include
Blurred vision
Eye Pain
Headaches
Light Sensitivity
Inability to shift focus between objects
Inability to track an object
Visual motion sensitivity (characterized by nausea, dizziness, and imbalance in response to motion in the visual environment)
Double vision
Visual Field loss
Inability to concentrate or symptom provocation during visual tasks like reading, computer, or phone use
Real-life examples of these symptoms include
Close work—such as reading, looking at a screen, or sewing—takes longer because of fatigue, headache, double vision, losing your place, or inability to focus
Being able to do close work better when closing one eye
Difficulty switching the eyes’ focus between close work and work farther away, such as switching from reading a book to checking a clock on the wall
Feeling overwhelmed, headachy, or fatigued in complex visual environments such as malls, grocery stores, or parties
Getting a headache or eye ache when in the presence of bright lights
Trouble with coordination, including walking and hand-eye coordination, such as grabbing a pencil off a desk or catching and throwing
Dizziness and nausea with scrolling on a computer or a phone
Diagnosis and treatment options
See the section below for how to access vision diagnosis and therapy
Neuro-optometrists
Optometrists specializing in vision rehabilitation due to brain injury or neurologic disorders, referred to as neuro-optometrists, will perform a comprehensive exam to assess your eyes for problems and determine whether you could benefit from neuro-optometric vision therapy. Primary care optometrists do not regularly perform these tests of visual function, but rather evaluate the health and structure of the eye. A visit to your general eye doctor may not be sufficient to determine if you have functional problems with your visual system. If there are structural issues with your eyes, or if you need a surgical consultation, the neuro-optometrist might refer you to an ophthalmologist.
The neuro-optometrist will develop an individualized treatment plan involving vision therapy exercises, adding new exercises as you improve. Your neuro-optometrist may collaborate with a physical or occupational therapist to work with you on vision exercises.
To learn more about neuro-optometrists and find a provider in your area, see our section below, How to Access Vision Diagnosis and Therapy.
Physical therapists
A more affordable option for vision therapy may be working with a physical therapist, as insurance companies more often cover these providers. Physical therapy can help improve some vision issues but is often not as comprehensive as vision therapy prescribed by a neuro-optometrist. Please also note that in some states, it is illegal for physical therapists to perform vision therapy without the oversight of an optometrist.
It’s a good idea to ask potential physical therapists if they have experience working with vision problems after a concussion. A knowledgeable PT may be effective at treating concussion-related vision issues. However, not all PTs are knowledgeable or trained in this area. If the vision therapy exercises assigned by your PT are not the correct exercises for your specific eye issue, it can make your symptoms worse. If, after a month, your symptoms are getting worse from doing vision exercises prescribed by your PT or not improving as expected, consider consulting with a neuro-optometrist.
If you get an examination at a multidisciplinary clinic, such as a concussion clinic or outpatient rehabilitation clinic, they may refer you to an in-staff physical therapist. If you are seeking a physical therapist on your own, look for a physical or vestibular therapist with experience working with vision issues in concussion patients. Please note that many patients have symptoms due to cervical-oculomotor (neck-related vision issues) and not vestibular-oculomotor dysfunction. An orthopedic physical therapist specializing in treating whiplash injury or neck-related issues may also be a resource for any unresolved issues.
Working with an experienced physical therapist with a visio-vestibular specialization will more likely be covered by insurance. However, sometimes patients will need glasses and prism lenses, which a physical therapist is unable to provide. Additionally, as mentioned, some patients may need the expertise of a vision therapy-trained optometrist to fully remediate symptoms.
To find a provider in your area, see the next section.
How to access vision diagnosis and therapy
Affordability
Vision therapy is usually effective, but its cost may be an issue for some people. Neuro-optometrists are sometimes covered by health insurance, but it can get expensive if you pay out of pocket, depending on the practice from which you seek care.
There are ways to reduce the cost of vision therapy. You can ask about discounts or customized payment plans–they may be willing to compromise on cost.
Hybrid Office/Telehealth Treatment
Another option is to look for a neuro-optometrist who offers home-based vision therapy. In this modality, after your in-person diagnosis, the neuro-optometrist will teach you personalized vision therapy exercises that you would do at home. Next, in a telehealth or in-office follow-up visit, your neuro-optometrist can observe you to make sure you are doing the exercises correctly at home. Your neuro-optometrist would then follow up with you on a regular basis and adjust your therapy plan as you progress–but with fewer overall follow-up visits than a traditional weekly in-office vision therapy plan.
Neuro-optometrists
You can self-refer to a neuro-optometrist; neuro-optometrists do not require a referral. Look for neuro-optometrists who are fellows or members of the Neuro-Optometric Rehabilitation Association (NORA) or the College of Vision Development (COVD). You can also look for a neuro-optometrist who is residency trained in vision rehabilitation, neuro-optometry, vision therapy, or binocular vision.
To look for this specialized residency training, check the bio of the neuro-optometrist on the clinic’s website. A residency is a year-long post-doctoral program where the optometrist studies specific neuro-optometric rehabilitation under the guidance of an attending physician, which is regulated by the Association of Colleges and Schools of Optometry (ASCO). A residency is different from fellowship training in the organizations mentioned above, where an optometrist is a member of the organization and did a home-based self-study program. An optometrist can be both residency and fellowship trained, or one or the other.
Since every brain injury is different, not every patient requires or benefits from the same treatment. Finding the right treatment can be frustrating for a patient since they may get different treatment depending on the training and clinical experience (number of patients seen) of the neuro-optometrist they see. Below are links to the search tools for fellows or members of NORA and COVD.
Use the search tool above to find a provider who is a fellow or member of the Neuro-Optometric Rehabilitation Association (NORA). All NORA optometrists are dedicated to working with concussions and acquired brain injury.
Use the search tool above to find a provider who is a fellow or member of the College of Optometrists in Vision Development (COVD). Ask if they have experience with concussions or brain injury-many do. However, the majority specialize in other areas, such as developmental children's vision issues, cortical visual impairment, or autism, and may not have experience with concussions or adults.
Physical therapists
Ask your doctor (primary care provider or general practitioner) for a referral for physical therapy. There are a variety of terms for the kind of therapies physical therapists use for vision issues: visual-vestibular rehabilitation, concussion therapy, vestibular-oculomotor rehabilitation, and vestibular physical therapy.
These therapies can be provided by a physical therapist or a vestibular therapist. You can also look for a physical therapist with a neurologic specialty. To learn more about this and for links to search tools to find providers, click on the button below to go to our Find Providers page.
What is a comprehensive eye exam?
Researchers and medical associations recommend that people with a concussion whose symptoms last more than four weeks should receive a comprehensive eye exam. A comprehensive eye health exam by a primary eye care provider, like an optometrist or ophthalmologist, will evaluate for refractive (glasses) and ocular health-related issues causing your complaints. This exam may also include a dilated eye exam or additional structural testing for the optic nerve, retina, and visual fields.
Neuro-optometric exam
A comprehensive neuro-optometric eye exam includes the eye health exam described above, plus tests for convergence, eye movement, accommodative function, and visual processing disorders. A new report recommends testing for fifteen visual issues that are common after a concussion. These tests may not be done by your family optometrist or a neurologist but are performed by neuro-optometrists specializing in vision development or trained in neuro-optometric rehabilitation. The vision exam will involve an in-depth assessment of several factors, including:
Eye-teaming: how the two eyes work together at different distances, how they respond to stress, and what happens in different positions of gaze.
Eye scanning and tracking ability
Eye stamina, focus, and adaptability
Visual perception and processing ability
Peripheral Awareness Assessment
Visual-Spatial Functioning/Visual Midline Shift Testing (spatial awareness - the ability to understand your position in space)
Patient History (changes in your vision before and after concussion)
Neuro-optometric exam
After an in-depth assessment of your eyes, the neuro-optometrist determines if you need vision therapy and will develop an individualized treatment plan as needed.
Exams performed by physical therapists
One of the primary exams a physical therapist will use is the visio-vestibular exam (VVE), which takes about four minutes and is demonstrated in the video below. Another type of exam is the Vestibular Ocular Motor Screening (VOMS) test. The VOMS is a screening test that can be done by any provider but is not a complete diagnostic test for vestibular-oculomotor dysfunction. A vestibular physical therapist can perform a complete diagnostic test.
”The visio-vestibular exam (VVE) identifies visual and vestibular system deficits which aid in the diagnosis of concussion and can predict prolonged recovery in those who are identified as having such deficits. These systems are responsible for integrating balance, vision, and movement. Understanding these deficits early can have a substantial impact on a child’s visual function ability to return-to-learn and sports after a concussion.
The VVE screening assesses how eyes track a moving object, jump quickly between visual targets, and their ability to view an object at near distance without double vision. Taken in the context of a preceding injury, abnormalities on this testing can assist in the diagnosis of concussion, as well as potentially aid in predicting children who will suffer from prolonged symptoms.” ~ Children’s Hospital of Philadelphia, Center for Injury Prevention and Research
How does vision therapy work?
Dr. John Abbondanza, FCOVD, explains how vision therapy works and shows the variety of exercises that are used to help patients learn visual skills.
Vision therapy improves the communication between the eyes and the brain through various exercises led by the provider. Through vision therapy, you will work on and improve visual skills like eye tracking, focus, eye-teaming, depth perception, and hand-eye coordination.
A study found that convergence insufficiency (CI) and accommodative insufficiency (AI) were the most common vision issues following a concussion. (See How does concussion impact vision?). The researchers compared concussion patients with these vision issues who underwent vision therapy to those who didn’t and found a marked improvement in the former. Vision therapy completely remediated CI in 85% of patients and improved it in 15%. Vision therapy remediated AI in 33% of patients and improved it in 67%. The researchers concluded that vision therapy was very effective at treating these common post-concussive vision issues in the vast majority of cases.
Self-care
Vision professionals advise against doing exercises you find online, as doing the wrong exercises for your vision issues may make your symptoms worse.
Self-care can be a great option to relieve milder vision issues and help manage symptoms; taking care of yourself and accommodating for symptoms is important. Here are some things you can try:
Take frequent breaks. Reading, looking at a screen, or doing other tasks for too long can be taxing and flare up your symptoms. Taking breaks (for example, 1-2 minutes of eye rest for 20 minutes of a visual task) gives your eyes a rest and can help you work for longer with fewer and less-intense symptoms overall.
Increase image and text size. If you need to look at a screen, doing this can relieve the strain on your eyes.
Use text-to-speech. Similar to increasing text size, this can allow you to read more without straining your eyes.
Stay organized. Keep items you commonly use in a consistent place. This will reduce eye strain as you won’t have to search for them.
Keep your eyes moisturized. Dry eye is more common in people with a history of brain injury. You can use over-the-counter eye drops to prevent dry eye.
Hats. Wearing hats indoors helps block harsh overhead light and is helpful outside.
Sunglasses. Avoid wearing sunglasses indoors, as this behavior may exacerbate patients’ sensitivity to light.
Concussion Alliance also provides more ideas for self-care on our Sensory Sensitivity page.
How does concussion impact vision?
In this 3-minute video, Dr. Shirley Blac, FNORA, discusses how the visual system works, how it is affected by concussion, and vision symptoms after a concussion.
Eye coordination and focusing
A study exploring the proportion of people who experience visual dysfunction after an mTBI concluded that 56.3% of mTBI patients have some type of vergence dysfunction. Vergence is the movement of both eyes to create one single image. Accommodation, on the other hand, is the ability of each eye to engage focus to see a clear image. You need both accommodation and vergence systems to work appropriately to see clearly and singly at all distances.
Convergence Insufficiency (CI)
The Cleveland Clinic defines convergence insufficiency as “the way our eyes move together and point inward when we look at near objects. With CI, the eyes do not point together inward as one looks at objects close-up.”
Another study concluded that CI was common (~42%) in athletes evaluated within one month after a sports-related concussion.
This image demonstrates the first-hand experience of deficits in the area of eye-teaming, such as Convergence Insufficiency. GIF from the Neuro-Vision Development Center.
Accommodative Insufficiency (AI)
A patient with accommodative insufficiency may experience blurred vision and be unable to focus on objects from varying distances.
For example, an object may start to look blurry as it gets closer to the patient, or an object may be intermittently blurry over time.
A patient who has experienced a concussion or MTBI often experiences issues with eye accommodation as seen in the visual animation. GIF from the Neuro-Vision Development Center.
Eye tracking movement: saccades and smooth pursuits
Saccades and smooth pursuits both involve communication between multiple areas of the brain. They are both susceptible to changes during a concussion because of how complicated they are.
This visual demonstrates how an individual may experience difficulty with eye movements post-concussion. GIF from the Neuro-Vision Development Center.
Saccades are rapid eye movements between fixation points–side to side and up and down. Saccades are used for tracking objects quickly as well as scanning while reading. Up to 30% of patients with a concussion have saccadic dysfunction. In these patients, the eye movements may be inaccurate, take longer to initiate, or be too fast or too slow.
Smooth pursuit is the movement of the eye following a singular slow-moving object. Smooth pursuit eye movements are used for visual motion sensitivity, and tasks like scrolling and problems with smooth pursuits can elicit visual motion sensitivity. Compared to those without concussions, patients with concussions had slower smooth pursuit eye movement. Issues with eye movement can manifest as difficulty concentrating, headaches, dizziness, nausea, or brain fog following a relatively short period of near work. Eye movement problems can also result in the appearance of jumbled words when reading.
Photophobia
Photophobia has multiple definitions relevant to concussion. These definitions all stem from discomfort from light and fall under the broad category of general aversion to light. Photophobia can present as experiencing eye pain or a headache under specific lighting conditions.
People with photophobia after a concussion have brainstems that appear different from patients who do not experience photophobia. A study examining photophobia in patients with concussion found that 76% experienced symptoms of photophobia. Photophobia is an issue that patients with a concussion may face and can be short-term or long-term.
When to wear a hat or sunglasses
One way to lessen the light that may trigger headaches or pain is by wearing sunglasses and hats outdoors–and hats indoors to help block harsh overhead light. Vision specialists advise against wearing sunglasses indoors, as this behavior may exacerbate patients’ sensitivity to light. Some patients, particularly those with migraine, may benefit from tinted lenses. It is recommended that those seeking tints find a provider with expertise in prescribing tinted lenses–like a neuro-optometrist or low-vision specialist. Indoor tints in some patients may exacerbate photophobia, so seeing an appropriate specialist is particularly necessary.
Online resources
Model Systems Knowledge Translation Center provides a broad factsheet covering all vision issues, treatment, and strategies.
Visionhelp.com has links to helpful articles about this topic as well as a doctor search tool.
Neuro-Optometric Rehabilitation Association has some helpful articles, plus a doctor search tool.
COVD.org is the College of Optometrists in Vision Development, which has explanations about vision diagnosis and therapy and a doctor search tool.
MinnesotaVisionTherapy has a good page explaining the vision therapy process. Their program makes use of optometric phototherapy (Syntonics), which is colored light frequencies to enhance visual processes.
This Lifemark article Vision issues following a concussion - there is hope and help does a good job of describing the different kinds of vision issues and symptoms typical after a concussion.
Podcasts
Dr. Jessica Schwartz, the host of Concussion Corner podcast, interviews Dr. Neera Kapoor on the role of neuro-optometry in concussion management. Midway into the interview, Dr. Kapoor gives the best description we've heard of the kinds of vision problems people with concussions experience.
Amy Zellmer, the host of Faces of TBI podcast, interviews Kara Christy, occupational therapist and certified brain injury specialist, about cognitive-perceptual motor retraining and vision therapy.
Dynamic Center for Vision Therapy provides many podcasts relating to vision therapy.