A Debilitating and Commonly Missed Post-Concussion Syndrome

Post-traumatic vision syndrome is often overlooked as a part of concussion rehabilitation, but there’s hope for those who have experienced a head injury.

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Recovery from a traumatic brain injury, even a mild one, can be a long and frustrating journey. Symptoms are complicated and can range from cognitive and behavioral changes to physical imbalances and impairments. One commonly overlooked symptom that can affect all of these aspects of recovery is a dysfunction of the visual system.

Much of what’s currently understood about post-concussion syndrome (PCS) is drawn from recent research. One known complicating factor in treating PCS is the overlap among symptoms with unique origins.

Commonly reported symptoms following brain injury are headaches, nausea, and trouble reading or focusing on moving objects. The eyes make direct projections to the brain, and when the brain is concussed, eye dysfunction can cause a spiral of problems. Post-traumatic vision syndrome, or PTVS, is a subset of specific post-brain injury symptoms pertaining to vision. The good news is, with proper care, it can be reversed.

Post-Concussion Syndrome

According to the National Institutes of Health, traumatic brain injury is a major cause of disability, with an estimated 10 million cases per year. Mild traumatic brain injury, or concussion, is also the most common form of traumatic brain injury, accounting for 75 percent of all brain injuries reported annually. Even mild traumatic brain injuries can have lasting effects. Unfortunately, even a mild traumatic brain injury is significant.

A vast and complex collection of functional symptoms following any minor head injury is now categorized broadly as post-concussive syndrome.

Some people who suffer a brain injury may not become aware of their visual issues immediately because they take time off of work or school for initial recovery. They may not think that some symptoms are relevant enough to report to their treating doctor.

Poor performance at school or work or in social interactions could be a result of visual instability, but the person may not understand why they’re dizzy, fatigued, nauseated, and unable to function as well as they once did.

Sensory problems are often invisible to outsiders and even commonly missed in conventional clinical evaluations.

What Is Post-Trauma Vision Syndrome?

Post-trauma vision syndrome is the official diagnosis for abnormal visual symptoms that appear following a brain injury.

Visual dysfunction is one of the most overlooked complications because symptoms may not become obvious for days to months following a head injury.

“Post-trauma vision syndrome is a neurological issue that affects the visual system after a brain injury,” said optometrist Dr. Charles Shidlofsky, who’s board-certified in vision development and vision rehabilitation and is president of the Neuro-Optometric Rehabilitation Association.

PTVS has been noted by clinicians as visual problems such as seeing stationary objects move, seeing words in print run together, experiencing blurring of scenes, and trouble establishing spatial orientation. Often, however, when people report vision symptoms to their doctors, they’re dismissed because of normal CT or MRI images, or because their eyes appear healthy to a general optometrist.

“If individuals are complaining that they get overwhelmed going to the supermarket or mall, getting frequent headaches, bumping into objects, are nervous walking downstairs, feel like they are falling at times or ‘out of sorts,’ oftentimes these are masquerading symptoms for post-trauma vision syndrome,” Dr. Shidlofsky said.

Your Eyes and Your Brain

Your eyes are connected directly to your brain. When you see objects, what you’re actually seeing is the picture formed in your brain after your eyes send electrical impulses to the visual cortex.

“It is estimated that 70 [percent to] 80 percent of the brain is involved in vision in some fashion,” Dr. Shidlofsky said.

The visual pathway is an arrangement of cells and cell interactions that send outside visual signals to the brain for processing. The optic tract is a bundle of nerve fibers that shuttle visual information through the visual pathway. The pathway begins when light hits the retinal nerve cells and is converted into electrochemical signals that represent the image that we perceive.

Injury to the optic tracts is a key indicator for a diagnosis of a visual deficit and may disrupt other body processes that are dependent on visual input. An increase in intracranial pressure, which can change with a head trauma, will sometimes cause irregularities of the optic nerve function.

What Are the Symptoms of PTVS?

Even after a person has seemingly recovered from a traumatic brain injury, they may not be able to participate in the same work or life activities they did prior to their injury. Post-trauma vision changes can significantly decrease quality of life. Everything from reading, typing, watching television, driving, being a passenger in a vehicle, to even walking straight, can be affected. It’s common for initially unnoticed vision symptoms to come to light several months after a traumatic brain injury event.

Symptoms of post-trauma vision syndrome include migraines and other headaches, double vision, trouble reading, nausea, trouble focusing, loss of coordination and balance, light sensitivity, and depth miscalculation.

“Visual issues such as diplopia, seeing words and print appearing to move, difficulty shifting gaze, difficulty adapting to environments where there is movement in the periphery (such as in a store), and photophobia can arise,” Dr. Shidlofsky said.

A traumatic brain injury can cause vision imbalances. When light enters a visual system that’s malfunctioning, spatial awareness and center of gravity can be miscalculated. The visual process is part of the sensory–motor feedback loop that allows for coordinated body movements. This disconnect between the eyes and the muscles can affect body posture and balance, which over time could lead to chronic pain because of muscle compensation.

Photosensitivity, or increased sensitivity to light, is one common limiting symptom. Most jobs and social activities require excessive amounts of screen time, which could dramatically provoke eye pain and headaches in those affected by post-trauma vision syndrome.

Who Can Diagnose and Treat PTVS?

Those experiencing these types of visual disturbances usually have healthy eyes and otherwise normal visual test results.

Neuro-optometrists aren’t traditional eye doctors who look only at the eyes—they’re trained to treat visual issues related to the nervous system, or the brain. Specialists get to the bottom of these mysterious brain and eye symptoms using knowledge of the connection between the eyes, brain, nerves, and muscles.

What Are the Treatment Options for PTVS?

“PTVS is a treatable condition,” Dr. Shidlofsky said. “The typical treatments are neuro-vision rehabilitation, which may utilize lenses, prisms, tints, or occlusions to create a therapeutic change, and possibly a protocol of neuro-optometric rehabilitation.”

Neuro-optometric rehabilitation is a method designed to properly engage the visual system in order to reduce disruptive visual symptoms post-injury. Neuro-optometric rehabilitation therapy for traumatic brain injury and concussion focuses on specific vision problems and eye movements to improve focus, perceived motion, depth perception, coordination, and light sensitivity.

Each rehabilitation treatment is personalized to the individual and their circumstance, as each brain injury is different. One treatment option for PTVS might be a regimen of special eye movement practices and eye-focusing exercises prescribed specifically by a trained neuro-optometrist called vision rehabilitation. Vision rehabilitation helps to realign the visual system and reintegrate the eye movements with the visual environment, coordinate body movements, and correct spatial orientation. Treatment may also include special prescription lenses called prism lenses, which are uniquely designed eyewear used to address double vision, eye strain, and balance issues.

For more information on treatment options for PTVS, Dr. Shidlofsky recommends visiting the Neuro-Optometric Rehabilitation Association (NORA) website. The organization is made up of neuro-optometrists, occupational therapists, physical therapists, physicians, and other professionals in the neuro-rehabilitation field.

NORA’s “Find a Provider Locator” lists NORA members throughout the world who can help those with PTVS.

“Active neuro-vision rehabilitation can help an individual decrease symptoms and return toward normal function,” Dr. Shidlofsky said.

How to Start Healing From PTVS at Home

One pervasive and, fortunately, addressable symptom of PTVS is visual photosensitivity.

Visual photosensitivity is an increased intolerance to light associated with traumatic brain injury and concussion. Visual photosensitivity causes painful sensations when the eyes are exposed to light, especially artificial light glare.

Intolerance to bright lights and glow from LCD screens can cause constant eye pain and headaches in anyone, but those who have experienced a brain injury and structural or chemical changes to the brain and eyes are particularly vulnerable to discomfort.

One study, published in 2020, found that visual symptoms following a concussion, or mild traumatic brain injury, are significantly worse for individuals who are habitual screen users in comparison to nonscreen users.

The study showed that prolonged exposure to computer blue light can cause damage to retinal cells, which will delay recovery for those with a brain injury indefinitely if not reduced.

One way to potentially speed up the healing process and avoid risking further damage after suffering a concussion is to limit screen use. If this is impossible, taking frequent screen time breaks may help to alleviate headaches and nausea associated with glare and motion sensitivity.

Avoiding fluorescent and artificial light may also help to reduce symptoms, and using tinted sunglasses and the correct prescription lenses can help to ease eye strain.

“For light sensitivity, there are many lens tints that may be helpful on a short-term basis to improve light sensitivity,” Dr. Shidlofsky said. “In addition, undergoing active neuro-vision rehabilitation may also improve light sensitivity.”

He also points to the NORA website, which offers a free, downloadable guide and checklist that has been prepared to assist eye care and rehabilitation professionals in determining the appropriateness of referring patients for neuro-optometric rehabilitation and treatment.