CONCUSSION AND YOUR VISION (part 1)

Can a Concussion Affect your Vision?

Mild, moderate and severe concussions cause closed head injuries (aka traumatic brain injuries) (TBI).  A concussion of any severity may cause visual dysfunction.  These visual symptoms may be dramatic and obvious –think blindness and double vision or much more subtle like difficulty focusing at near objects-print or computer screens.

I have been caring for patients with visual problems after concussion and head injuries for over 30 years and have also experienced visual problems myself after a head injury.  Hence I developed a keen interest in how to carefully examine these patients to ensure that no pathology is overlooked.   I subsequently developed a routine for neuro-ophthalmic examination that separates the wheat from the chaff and ensures that no cause of visual dysfunction is overlooked.  In the following series of articles I will examine the causes of visual dysfunction after head injury and concussion.

Vision Symptoms from a Concussion

Accommodative-convergence insufficiency is the most common visual squeal of concussion.  It is also commonly overlooked or ignored.  These patients complain of decreased vision especially at near.  This is the same visual loss that occurs in everyone as they age; but is most dramatic in young people with otherwise healthy eyes.  As we age we lose our ability to focus at near because of changes in the lenses in our eyes.  After a concussion we lose this ability because the portion of the brainstem that controls focusing of the lens is injured by the trauma.  These injuries are almost NEVER evident on MRI scans; but are very real and disturbing to the patient.

Personal Concussion story

When I was in my early forties I was skiing with my family in Montana and my 12 -year -old daughter was getting ahead of me.  I wasn’t going to let this happen so I pointed my skis down the hill to catch up and pass her.  My skis crossed and I went head over heals into a pile of fresh snow and hit my head pretty hard.   After I stopped “seeing stars” and could move all my body parts we skied down the hill for lunch.  I opened the newspaper and could not read it.  Even as a Neuro-ophthalmologist this scared me to death until I remembered my anatomy and physiology and realized that my accommodative convergence center in the mid-brain had been injured causing premature presbyopia.   I bought a pair of drug store reading glasses and my symptoms abated.   Welcome to premature middle age.

I see 2 or 3 new patients a week who have suffered concussions or whiplash type injuries and complain that they never had to wear glasses prior to their accident and now everything is blurry.  A good refraction reveals normal corrected vision but a complicated refractive error that the patients were able to focus thru before their injury (latent refractive error) and can no longer do so after their injury to their accommodative center in their brainstems.  These patients are lucky and their symptoms resolve with a pair of glasses for distance and near.

It took my own injury for me to realize this and to understand why the patient’s need for glasses is related to their accident and head injury.  I still have to fight with some of the insurance companies over this issue but win most of the battles now.

When you shift your focus from distance to near three things have to happen: your eyes have to cross (converge), your lens has to focus (accommodate) and your pupils need to constrict to increase your depth of focus (miosis) (think f stop of a camera lens).  This is known as the near reflex.  It’s a reflex, you cannot control it, and it controls you.

After a concussion and head injury one or all of these mechanisms may become dysfunctional.  We have discussed accommodation and visual loss.  Now lets look at loss of convergence.

Convergence Insufficiency

This may occur with or without loss of accommodation.  These patients complain of difficult reading or working at the computer.

After a short time their vision begins to blur, they get a headache and eventually see double if they continue trying to work at near.    They have injured their convergence area of the brain stem.   The degree of disability depends on the patient’s occupation.  The more your work is a near (reading, writing, computers) the more difficulty you will have with convergence insufficiency.  Once the diagnosis is made treatment with near point exercises and/or prisms may be very beneficial.  This is becoming more of a problem now that most everyone has some computer work in his or her daily schedule.

Total loss of the near reflex is a rarity but may be seen after severe concussion or brain surgery.  These patients cannot converge (cross) their eyes; focus and their pupils are both dilated.

These are straightforward, easy to understand visual problems occurring after concussion and head injury.  They are very treatable if they are diagnosed in a timely fashion.

In the next article I will discuss more serious injuries to the  visual system after a concussion.

If you have noticed visual changes after a concussion (no matter the cause of the concussion) call 941-921-5335 in Sarasota area or 586-582-7860 to schedule an appointment.

Tom Spoor, MD

Oculoplastics and Neuro-ophthalmology 

Sarasota, Florida

Warren, Michigan 

Comments

  1. Patrick Thompson says:

    Hi there, i am a physiotherapist who has done some extra training in vestibular rehab. Because this, I have been seeing a good deal of post concussion folks. In this journey I have picked a lot of visual issues (with much less accuracy than yourself!). My question fro you is if you feel whether some of the losses can be corrected through exercise?

    • Jody Abrams, M.D. says:

      Patrick
      I do feel that there is a role for exercises for these patients. For years we have shown patients how to do pencil pushups. In the last few months we have be fortunate enough to get an occupational therapist at Sarasota Memorial Hospital who is now running a vision rehab clinic. I think the new exercises that she brings to our patients are great. I am now encouraging patients to go there and get help, where previously there was no good treatment options.

      Jody Abrams, MD
      Neuro-ophthalmology/Oculoplastics

  2. Victoria Kroll says:

    I am an 18 year old female that has suffered multiple TBI’s and just finished five months of vestibular therapy and three months of visual therapy because, as discussed in the above article, I lost my ability to cross my eyes as well as all peripheral vision in my left eye after my most recent concussion in 2011. The symptoms took so long to be recognized by doctors because I was cleared two weeks after concussion and sent back to play. The larger issues in my vestibular and ocular systems weren’t realized until I was a part of the UNC Chapel Hill concussion centers post-traumatic brain injury clinic for athletes. Through extensive testing, the clinic found the issues that didn’t show up on MRI’s or CT scans. Two years after the accident, my only remaining symptoms were migraines and short term memory impairment but two weeks ago I began having double vision. At first I thought there must be some mistake and that I was simply being lazy and allowing my eyes to cross; however, I now believe there may be a larger issue. I’m in college away from the team of specialists I was seeing for the eight months and was wondering if you had any thoughts on what could be causing the double vision. I don’t think it’s a new concussion because I can’t recall any new head trauma other than occasional and minimal bumps on the head. I thank you for any light you can shed on the subject.

    • Jody Abrams, M.D. says:

      Victoria,
      While you might not of had a direct blow to the head, and sudden stops or jolts might be enough to cause some regression in your therapy. What sport are you playing now? I would restart some of your exercises for your eyes. If might be that you just need to constantly preform these to keep the brain/eye connection in top shape. If that does not help I would look for neuro-ophthalmologist in your area. If you tell me where you are at we could possible suggest one.
      Unfortunately it is not uncommon for the traumatic brain injury symptoms to be missed since there is not a change on MRI/CT testing. This is why it is important to see a doctor use to dealing with these injurers and complaints.

      Jody Abrams, MD
      Neuro-ophthalmologist
      Sarasota Retina Institute
      Sarasota, Florida

  3. Would a concussion cause you to see stars 6 weeks after the injury?

  4. I had a car hit me from behind while I had come to a complete stop and totaled my car. Since then my vision
    Has changed. I now have a macular hole. Could this be possible.

    • Jody Abrams, M.D. says:

      It could be related. If there was no history of this prior to the accident and now you have the hole, it is possible that the force caused traction on the retina from the vitreous.

      Jody Abrams, MD

  5. My daughter had an exercise bench fall on her head 2 years ago. Since that day she has had “white noise” vision. If your TV loses reception and gets the white fuzzy noise on it, that’s the explanation of “white noise” She is able to see through the spots and streaks but always has this in her view. Then just 3 weeks ago, the spots got “smudgy” which makes the vision worse. Then last week she hit her head again and the spots got larger. They are not considered stomata. Is there any way to make this better? Any corrective treatment known?She has other serious TBI symptoms, all of which have not improved in 2 years yet to me this is the most frightening.

    • Jody Abrams, M.D. says:

      Debbie,
      I am sorry to hear about the problems your daughter is having. This is not an uncommon complaint after head injuries. We do not completely understand why this occurs but there are some thoughts that the injuries take out some of the filters in our vision that take these visual images out of our perception. If she has not seen a neuro-ophthalmologist I would suggest she get a complete workup to make sure there is no structural problems. Often times a mild optic nerve damage will be found from traumatic brain injuries. While we can not fix the damaged nerves there is some training to help retrain the brain. With some visual therapy training patients can often learn to block the visual snow. We are lucky to have a vision rehab program here in Sarasota at Sarasota Memorial Hospital. If you are in the area we can help see your daughter and then make arrangements for treatment. If not look around for a rehab program in your area that does vision therapy.

      Jody Abrams, MD
      Oculoplastics/Neuro-ophthalmology

  6. My daughter had an accident.. she was hit from behind, she was at complete stop. The truck that hit her was traveling according the investigation around 45 mph.
    Her head and neck flew forward then back hit the seat her seat broke, then the back of her head hit the back seat. After complaining of feeling nauseas and actually getting sick- mood swings- forgetting things- and having trouble focusing on her school work- reading appeared to be more difficult. We had cat scans- mri etc.. thank god no bleeding or cracks in her skull or brain etc. But the her vision seemed not right she said. She has worn glasses since 12 years and contacts at 15 yrs of age. She has had an eye exam every year and only had minor adjustments each year. Then we took her to the eye doctor after the accident because she said she just can not see right. The eye doctor found that her eye has moved in a downward postion, he had a prisim of 3 doppler put in her glasses.. now she can read without the words moving and the feeling ill has gone away. Can a concussion cause this injury.. and how do we prove this to the insurance company.. if MRI and the Cat scans did not show this. One more thing.. can her retina have future tearing in later years she is only 19 yrs of age. Now she is not able to wear contacts because the prism can not be put in a contact. The glasses allow her to have a relax feeling of being able to see, without causing a headache. The contacts are not as comfortable and after wearing them she gets a headache. thank you for your help- concerned mother

    • Jody Abrams, M.D. says:

      Cindy,
      I am sorry to hear about your daughters accident. After a closed head injury there can be deviation of the eye that could require prism. This has been shown in studies. A history of normal eye exam prior the accident and then a change after can help lead to the diagnosis of this being related to the accident in many cases. Often the imaging studies are not detailed enough to show this cause, but there is some microscopic change in the brain or nucleus controls of the eye motility that has occurred and is causing the problem. As for contacts unfortunately you are right with no prisms she will not tolerate this long. I am not sure if you meant she had a retinal tear or not, but these can occur from accidents due to the sudden jarring of the vitreous jelly in the back of the eye.
      I hope this helps
      Dr. Jody Abrams

  7. Don frazier says:

    Weird that the opthalmologists I’ve been seeing don’t seem to know about this. Do you know of anyone who treats this in the Denver/boulder area?

    Many thanks!

    D

    • Jody Abrams, M.D. says:

      A lot of ophthalmologist have minimal training in neuro-ophthalmology and do not get much exposure to closed head injuries during this time. Part of the problem I believe is that often there is nothing on MRI or other pure objective test, and the symptoms are subjective often. Doctors often have a hard time with this.
      In your area I would look for a neuro-ophthalmologist and start there. I do not know any specific there but the university has two on staff that I saw.

      Good Luck
      Dr. Jody Abrams

  8. Andrew Macfarlane says:

    I came across your article searching for vision loss due to concussions. I was in a terrible car accident march of 2012. A truck pulled out in front of us traveling 65 mph and hitting us then we t-boned a mini van in the median of the highway. The air bags didn’t deploy and the seat belt didn’t keep me in place so i broke through the dash with my knee (which i just had surgery on), slammed my head against the windshield getting a terrible concussion, and many other problems with my back and spine. I am only 20 years old and I am in terrible condition, feeling very old, migraines constantly all day every single day. I went to the doctor a week after the accident due to being stranded in Florida with a totaled van and no way home and the police leaving us on the side of the high way. The exam came back significant eye loss in my left eye. 2 months ago i went to the eye doctor because its going on almost 2 years here in March. Took a visional field test and lost the bottom right peripheral vision in my right eye, and loss of vision in my left eye by -1.00. Is there any additional information you can give me beyond whats going to happen in the future as far as further loss especially since I am only a twenty year old student. If you could please provide me some feed back, that would be greatly appreciated. Thank you!

    • Jody Abrams, M.D. says:

      Andrew
      I am glad you survived such a horrible sounding event. Your symptoms are very common for patients after an accident causing a closed head injury. The field of vision changes could be from optic nerve damage and can be verified with testing such as Optical Coherence Tomogrophy (OCT). This should be stable a few months after the accident. If there is continued change you need to have more workup to see if there is something else going on. I would want to know how much the fields have changed form the initial eval. Also for the headaches I would look at possible botox injections. These have been used for many years now and have been game changers in many cases of closed head injury related headaches.
      If you are still in Florida please come see us to try and get some help. If not please find a neuro-ophthalmologist in your area for further eval.

      Dr. Jody Abrams

      • Andrew Macfarlane says:

        Thank you for your reply! I am no longer in Florida, I have relocated to Idaho. From my notes from my eye doctor Lisa Porter in Idaho my old prescription for my right eye is( -1.75/ – .25*180) previous left eye ( -1.75/ -1.50*165) . My current prescription since the accident March 4th 2012, (AR OD: -2.25/-1.50*014 ;AR OS: -2.75/-3.25*154), (MR OD: -1.50-2.00X016 ;MR OS: -2.00-3.00*158 ; VA: 20-2) (FINAL OD RX: -1.50-2.00X016 ; FINAL OS RX: -2.00-3.00*158) The field test showed loss of peripheral vision on the right eye the whole bottom right from 3- o’ clock to 6- o’clock. The crazy thing is that my right eye felt fine, I completely thought I passed with my right eye since I have so much pain in my left eye, my guess is the left eye is overly strained. My only concern with doing a botox is ending up looking like mama Elsa Patton, that would be horrible. Since it’ll be 2 years here on March fourth and my headaches are never ending, I really have no idea what to do since i already did an MRI head scan and done an OTC. Its almost as if I need sunglasses everyday and walk around like Stevie Wonder because my head hurts so bad. At least my left eye has decreased drifting off to my ear. I have not filed a claim yet but since its only been not even two years and the problems just never end and the prescription is already worse, I have no doubt that my vision will get worse over time. My eyes and migraines literally ruin my days every day, What do you suggest would be a good compensation for each eye and the migraines I receive. I was advised twenty thousand an eye but with the problems I am going through I feel that doesn’t even add up to my pain and suffering every day.

        • Jody Abrams, M.D. says:

          Mr. Macfarlane,
          With an experienced injector you have a minuscule amount of risk for problems with the Botox such as you fear. With your symptoms I really would encourage you to find a local clinician who preforms this procedure and discuss it with them. I have seen great results. This can even help the light sensitivity you are dealing with. The more I hear the more I would recommend further neuro-ophthalmologic eval with some one fellowship trained in this. As for your legal questions I can not answer that. I would suggest those questions be discussed with a legal expert.

          Jody Abrams, MD

  9. October 11, 2013 I suffered a concussion. I was hit in the back of the neck/base of the skull area by a Softball. I was knocked out for a couple seconds, I could still hear everything around me but it was black for a couple seconds. Scary! I got over the major symptoms within the 2 week window. Since then I have been suffering from a multitude of lingering symptoms. Some come and go; clogged ears, dizziness, jaw pain (TMJ), focus issues, ringing of ears, trouble falling asleep and anxiety. I luckily did not have any headaches, just tension ones once in a while nothing crazy. I went to a concussion clinic but have not gone back for my follow up. They seem to think there may be an issue with my neck causing some of my problems. Being that my neck was injured I am afraid to have it cracked as I dont want to be set back further than I have come. I could not take time off work after the initial injury, I only took off one week so it is taking along time to heal. Both my CT and MRI were normal. Neck X-Ray also normal. I took a while for me to be able to focus and be able to work all day without issue. I however still have problems focusing sometimes. My eyes will just go out of focus and get really blurry for a few seconds. Its like putting on a pair of coke bottle glasses for a minute and they get really dry while trying to get my focus back. I also have white floaters here and there. I thought I needed new glasses went in and got them from like Direct Optical or something and they did not help, I cannot wear them while on the computer they hurt my eyes. My eyes feel like they have a constant gloss or are like foggy. I play alot of sports, i can still play but dont feel quite like my formal self. I have not lost depth perception at all. I went in to get a quick eye exam at that place as you know how they do it, and when he was looking at the back of my left eye with the tool that shines in the bright light (which hurts super bad), he kept looking and looking in there. Not sure if he saw anything but it really hurt. He said he was checking for retina detachment. Obviously I dont think I have that going on as I can still see pretty good. I do have very sensitive eyes. I dont know what happend but i just want to feel like my old self again!! I dont like to share with people about my issues becuase they think i am crazy. No one knows about this unless they have gone through it and the thought of not being able to feel as good as I did before the accident, is just not acceptable to me. I saw above after reading this article that you have an office in Michigan? Please advise, thank you for your time and listening to my story.

    • Jody Abrams, M.D. says:

      you are not the lone ranger we see many patients with symptoms like yours after a variety of head and neck injuries and very often there is a reasonable and effective treatment or at the least reassurance that you have had a complete neuro-ophthalmic exam and your symptoms will likely resolve with time and no intervention is necessary.
      of course we can’t say anything without examining you. Our main office is in Warren Michigan and Dr Lin is also available in Toledo and Saginaw.
      Warren office number is 5826-582-7860.

      T.C. Spoor MD. FACS

  10. Dr. Abrams,

    I just stumbled on this post, and I really wanted to thank you for it and for taking the time to share with everyone. After reading your description and the comments below, while it pains me to see other patients who suffer from these issues like I do, it’s a relief to me because now have a good understanding of all the eye trouble I have been having since I was struck by a car and thrown to the ground and struck my head quite hard. Ever since then, I have been having sever headaches, trouble focusing (convergence insufficiency) whenever I do reading ,computer work, or use my phone for any period of time. This have significantly impacted my daily life. It took about 1.5 years for me to find my way to a neuro-ophthalmologist because several doctors attributed the headaches to all kinds of things and I underwent MRI’s, CT’s, eye exams, etc, only to find “nothing.” Quite simply, most medical professionals just don’t about this. And neither do people who suffer from it. Going forward and treating it will be a challenge to say the least, but at least now you’ve left me with a better understanding, which begins to place us on the path towards treatment.

    Thanks,
    Julius

    • Jody Abrams, M.D. says:

      Julius,
      I am glad we can help give more understanding to your problems. I wish you luck in your recovery. The good news is there is help and people can get better.

      Jody Abrams, MD

  11. Brittani says:

    Dr. Abrams,

    My name is Brittani and I live in WA state. I turn 21 in July and I am a student. About two weeks ago, I was flloing around and jerked myself back and fell really hard backwards that my head left a dent in the wall. I then, according to my significant other, slid down and fell onto the floor. There I remember blacking in and out for about five to ten minutes. That night I had symptoms such as dizziness, sensitivity to light, headache, vision loss, confusion, memory loss and tiredness/weakness. I decided after a few hours debating to go into the ER. They gave me an xray and catscan then gave me a painshot and Tylenol prescription. They said if the pain doesnt go away within three days to go to Urgentcare since I do not have a primary doctor. Well 4 days later I went into Urgentcare in the next town over because my head and back was killing me. The doctor was very, very rude and acted like he didnt believe me. He was a bit sarcastic with me as well and told me he couldnt help me and to go back to the ER, so in a rush I left that office and that rude doctor and went back to my town and into the ER. Well after waiting three hours, I finally saw the doctor. He asked me what was going on and I told him I was in so much pain that I couldnt function. I am a student and started work the day before and had to leave work because I couldnt concentrate. I also told him I was afraid i might get stomach ulcers from taking too many Tylenol and that my pain tolerance was high, so high that when I was younger no over the counter meds has ever helped me ans the pain shot the doctor’s gave last time didnt help at all. The doctor told me he willl give me some hydrocodon for the pain. I asked if that had acidametaphine in it and he told me it did. Well, of course I didnt want to take anymore of that because it makes me sick and doesnt help. In fact it makes me feel terrible and I think I am allergic to it. Then in reply he gave a laugh and said “sorry I am not going to do anything else for you.” very rudely, so I took it anyways because I was willing to try it from being in so much pain, even though like I predicted, it didnt even work. I took 3 5mgs at a time and it didnt take the pain away whatsoever. I took all 15 in 3 days with no help in pain and sickness. Well that was a few days ago and sincs I am still having bad headaches and memory loss as well as my vision is TERRIBLE as I write this it is blurry to me, sort of like a fog over my eyes and temple headaches. I have tried everything, have been to the doctor 3 times and do not want to go back to be treated terribly. What do you reccomend? Why are the doctors rude to me? Is there a clinic in WA state close to Port Angeles you would reccomend? I am tired of being in pain, what does this mean!? Thank you for your time!

  12. Can you recommend someone in the Boston area who works with vision related issues due to concussion? Thank you.

    Concussion 1 month ago. Sx: dizziness, trouble reading or watching tv or too much visual stimulus (being outside) leading to dizziness and headache.

    • Jody Abrams, M.D. says:

      I know Dr Joe Rizzio and Dr Mitch Strominger are both neuro-ophthalmologist in the Boston area. I am not sure how much they do closed head injury but they can be a great start and help direct you to possible some one in the area who can help more if they can not.

      Jody Abrams, MD

  13. Your article is very helpful. My daughter is having vision induced headaches following a concussion. Can you recommend neuro-opthalmologist in the Orlando, FL area.

    • Jody Abrams, M.D. says:

      Dr Lyn Sedwick is in the Orlando area. She is an excellent neuro-ophthalmologist. If you can not get in to see her we actually have a few patients that come from the Orlando area to see us after concussions.

      Jody Abrams, MD

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