Bump on the Head Part 2

CONCUSSION AND YOUR VISION (PART 2)

Last time I discussed some visual symptoms of a concussion. Now I will talk about other damage a concussion can cause to your vision.

To get from your eyes to your brain the optic nerves have to pass thru bony canals.  It is here that they are susceptible to indirect injury from concussive head trauma. Your optic nerves may be injured by either injury to the front or back of your head as well as cranial-cervical trauma (whiplash).  These injuries may cause profound or subtle visual dysfunction.

Concussion Damage to the Optic Nerves

Patients with concussions may also have injury to their optic nerves. This can cause complete and irrevocable visual loss or mild and subtle visual loss.  The injury causing the concussion does not have to be severe-the first patient I saw with traumatic optic neuropathy was a majorette who was struck in the forehead by a twirled baton.  Usually the head injuries are more severe and are often injuries to the forehead.

Concussions From Blows to the Back of the Head

However the optic nerves can also be injured by trauma to the back of the head. This is known as a contra-coup injury.  The most memorable patient that I have seen with this injury was a truck driver who banged the back of his head while unloading his truck.  He noticed sudden loss of his upper visual field and called his dispatcher saying that he could not drive his rig back to Detroit.  He was mis-diagnosed as a malingerer by several doctors.  When I saw him in consultation (4th opinion) he had an obvious bilateral optic neuropathy and visual field changes to match.  There was no way he could safely drive a truck again so he underwent vocational rehabilitation and found another job.

Concussions, Blindness and Possible Treatments

Patients with more severe head injuries may have one or both optic nerves involved and rendered almost blind or totally blind.  These are desperate cases and over my career many different treatments have been tried.  They include mega dose intravenous steroid therapy, surgical decompression of the optic nerves either by an orbital or transcranial approach.  There are many anecdotal success stories but THERE IS NO TREATMENT PROVEN EFFECTIVE FOR TRAUMATIC OPTIC NERVE INJURIES.  In these desperate situations many clinicians will offer a trial of corticosteroid therapy and it probably does no harm.    Patients with severe head injuries are usually receiving rather high doses of steroids for their brain swelling so a bit more to possibly help their optic nerves recover is reasonable but again unproven treatment.

Monitoring Optic Nerve Damage From Concussions

With the advent of excellent intraocular imaging studies (optical coherence tomography)(OCT) we are finding a subset of traumatic optic nerve injuries in patients with rather good vision.  Their vision just is not the same as it was prior to their concussive head trauma.  OCT allows us to measure the thickness of the million optic nerve fibers that form the coaxial cable that we call the optic nerve.  The computer then compares the patient’s data to database of normal patients allowing us to detect and document minor injuries to the optic nerves.

Why is this important??

As we age we lose optic nerve fibers as part of the aging process.  You can loose 25-30% of your optic nerve fibers and you won’t know it and I could not detect it before the advent of OCT.  Now it can be detected and followed in a reproducible manner.

A young patient has a concussive head injury (CHI) and a mild to moderate injury to his optic nerves.  The nerves and the visual fields appear normal.  The patient still notices that his or her vision is just not the same.  The OCT validates the complaints and may be a harbinger for more potential visual difficulty as the patient ages.  This should be documented for medical and legal reasons.

Progressive loss of optic nerve fibers after traumatic injury can be detected and documented by serial OCT studies.  There is much ongoing research into medications that may render some protection to injured optic nerves.  It would be beneficial to be able to detect injury and ongoing visual deterioration sooner rather then later.  The goldfish is the only animal that can regenerate their optic nerve fibers.  Until we can figure out their secret we will have to do the best we can with what we have.

If you feel that you have had vision loss after a traumatic brain injury (concussion) please contact us at 941-921-5335, and ask to make an appointment with one of neuro-ophthalmologist.

 

Tom Spoor, MD
Oculoplastics and Neuro-ophthalmology
Sarasota, Florida

Tom Spoor,MD
Oculoplastics and Neuro-ophthalmology
Warren, Michigan

 

Comments

  1. matt zahn says:

    my son has visulal snow and trouble focusing and looking at computer screen some types of tv screens. this all followed a
    tv falling off a shelf and hitting the top of his head. we have been to several doctors they looked into his optic nerve after putting
    drops in his eye and say his optic nerve is normal. i live in long island are there any doctors up here you can recomend Thanks

    • Jody Abrams, M.D. says:

      The most likely cause of the “visual snow” is a posterior vitreous detachment and floaters. The gelatenous material filling the back of the eye detaches from the retina, deteriorates and causes symptoms of visual floaters that might be described as snow.
      The difficulty at near is caused by loss of ability to focus the eyes and cross them. This is called accomodative/convergence insufficiency and is extremely common in patients with head injuries (90+%). This diagnosis is commonly overlooked and is simple to rectify with glasses and or exercises.
      The injury to the brainstem the is causing the Acc/convergence issues may also cause difficulty seeing clearly in the distance. If the patient had a pre-existing latent refractive error they may no longer be able to
      focus thru it. Hence the complaint tht i didn’t need glasses before the accident now I do.

      Neuro-op MD in your area (stoney brook) Pat Siboney
      In NY Mark Kupersmith (neurologist)@NYE+E
      Jeff Odel at Columbia

      Tom Spoor, MD
      Neuro-ophthalmologist/Oculoplastics
      Warren, Michigan
      Sarasota, Fl

  2. Marla Resnick says:

    My 19 year old daughter suffered a bad concussion while playing softball. She was covering third base and collided with the base runner (head to helmet) on the left side of her head. This occurred about 3.5 months ago. She also got whip lash from the collision. She is recovering but still has a swollen optic nerve which is limiting the amount of time she can spend on school work. We are looking for a local doctor ( we are in central NJ but anywhere from NYC to Philadelphia would be fine). One doctor was recommended but when I called for an appointment I was told he doesn’t see patients younger than 21 years old.

    Can you recommend a doctor?

    • Jody Abrams, M.D. says:

      I would look at Willis eye hospital. I know they have some neuro-ophthalmologist there but I am unsure what ages they see. The other one I can think of in the NYC area is Dr. Dinkin. I hope that she can get some help.

      Jody Abrams, MD

      • Kyle Terracciano says:

        Jody, hoping you can help me out.

        I am 17 years old and I had coats’ disease when I was 4; leaking retina solved with laser eye surgery.

        On Nov. 30,2013, I received a concussion between the eyes, doctors said in january that vision problems were minor.

        I was improving, but in early february I noticed that every bright light source I look at, I see lines coming straight at me, similar to spokes on a wheel.
        I went to a neuro-opthalmologist and they perscribed me with glasses, (prism and blue tint) and vision therapy.

        What is the cause of this light problem I am having? Can it be solved? Any suggestions? Why did it happen when I was recovering?(I dont believe I got hit again)

        Haven’t received the glasses yet, but with this problem I can’t even consider driving at night.

        • Jody Abrams, M.D. says:

          Kyle
          I am wondering if you do not have some convergence insufficiency. This might cause the eyes to have just enough misalignment that you get that effect. Also you could of have some underlying refractive need for glasses that you were able to compensate for until after the concussion and then your brain could not do it any more. Last thought is that it could be unrelated to the concussion and there is just a change in overall refraction that was going to occur no matter what. Do you know what the new prescription strength is? if there is a small amount of astigmatism that would cause the problem at night.

          Jody Abrams, MD

          • Kyle Terracciano says:

            Thanks Jody!

            The neuro opthalmologist said that I have a slight astigmatism which I received glasses for.

            He also believes that the problem is related to convergence insufficency/eye turn and has given me low power glasses with blue tint and vision therapy; it may take 3 to 5 months, but they believe it will improve.

            I don’t know what caused these new symptoms to occur. I just started vision therapy (1 visit) so I am still seeing bright lights in beams, but hopefully it will improve.

            Thank you for the help.

          • Jody Abrams, M.D. says:

            I think you have a good chance of improving with the vision therapy. I think this is probably an underutilized in most of ophthalmology, so you are lucky to have a doctor who can get you into a program. As for the cause this might never be known. Convergence insufficeny is a common problem even with out any know brain trauma.

            good luck on your therapy

            Jody Abrams, MD

  3. angela bitner says:

    Dr Jody,
    I am also hoping you can help me out by recommending a neuroophthalmologist in the New Orleans area who may be familiar with the effects of concussion injury on vision.

    I suffered a concussion when hit from behind – the other car was going 65 mph and I was going 10 mph. Since the accident I see huge halos in both eyes when i look at lights . The halos are there in both day and night, but are so severe at night that I am not able to drive at night. I am a type 1 diabetic and have had pan retinal photocoagulation and vitrtomies OU; have cataract implants OU and glaucoma OD. Even with all this my vision was good (20/30) with glasses. Prior to the wreck I was able to drive at nite and now I can’t because oncoming headlights are too blinding. The wreck also caused the left lens implant to move which has caused another vision anomaly in that eye. The blinding halos are different and appear in both eyes. No one can explain the halos. .

    I have seen 2 retine specialists and 2 ophthalmologist who can find nothing wrong with my eyes except for the implant.- but my vision has changed in BOTH eyes. Do you know of a doctor here in New Orleans who may be familiar with concussion injury. Please help if you can,

    • Jody Abrams, M.D. says:

      Angela,
      We defiantly see these problems after MVA. I am ashamed to say as a New Orleans boy that I do not know of a neuro-ophthalmologst in the area that is good with closes head injury stuff. If you can get it Shreveport Dr Vekovious would be a great option for you to possible get some answers. Otherwise there is a direct Southwest daily from New Orleans to Tampa and we would be happy to see you in our clinic.

      Jody Abrams, MD

  4. I took a blow to the head in July 2013. I have gone thru a head injury program and I am still have ongoing symptoms which I am seeking help for. One of my symptons is I have been diagnosted with PVD this only started since my concussion. All day every day these floters are there and are noticable which is extremely frustrating. They cause my sight to be off which feels like I am always straining to see, its like there is a constant glare in my eye when any type of light is in it, with these objects I am always looking to see if there is really something coming at me and hard to see things directly in front of me as its almost like my vision is impaired from these objects . My understanding of this and please help me if im wrong but its that my brain isnt fully healed and its still focussing on these objects. Is there anything I can do to make this better or is it a matter of waiting it out to allowing my brain to heal? I just figured after 8 months this condition would have improved. Thanks for your help.

    • Jody Abrams, M.D. says:

      Trudie,
      PVDs can defiantly occur after closed head injuries. I am sure you had a dilated exam to make sure there were no retinal tears.If not please make sure you get one. You are correct with the problem. The brain has to relearn how to ignore some parts of your vision. This can take anywhere from a few months to a year or two. I would keep reading and using your eyes as much as possible to focus on stuff. You have to help retrain your brain on what to focus on and what to ignore.

      Jody Abrams, MD

  5. Julie Bruno says:

    Hi! I had a concussion from rushing into my patio door 6 months ago. Initially I had extreme light sensitivity & blurred vision. I also have snowy vision & tiny flashing lights when I close my eyes at night. I can’t drive at night because the glare from car headlights hurts too much. I have been sent to a hospital optometrist who said my eyes were fine. I then got sent to another optometrist who also said my eyes were fine. When I asked him about the snowy vision & flashing lights he said it was vitreous detachment. When I asked him how come I now need glasses to function when I only needed them for reading before he said it was my age.

    I don’t understand why the optometrists & my doctor will not accept that the radical change in my vision has anything to do with my concussion? I have had my prescription changed twice in 6 months. I find that whilst the distance glasses do help to bring things into focus it also feels like they’re too strong because they give me vertigo.

    I live in the U.K. where unfortunately neuro optometrists do not seem to be so readily available as in the States. I have found a private one who will see me if I get a referral from my doctor. When I mentioned this to my doctor he said “Why pay for a fancy Latin name for something you can’t cure anyway?”

    I’m desperate to find a solution to my vision problems. Given what I’ve told you do you think that I may have convergence insufficiency? If so I will insist on a referral. Many thanks for your time.

    • Jody Abrams, M.D. says:

      Julie I am sorry to hear about your problem. The symptoms you are having do sound like a post concussion vision change. Did you ask the doctors to test your convergence? They might not think about it but you are on the ball. I would make sure you see a neuro-ophthalmologist. There are not many here in the State either but I think it is really important for patients to get a proper workup. Tell the primary doctor you like fancy latin terms. I hope that you can get some help. There are some treatments that can help start down the road to normal vision.

      Jody Abrams, MD

  6. Matthew Cotter says:

    A little over 2 years ago I fell on ice and hit my head resulting in unconsciousness and memory loss. To this day I have spotty memory of what happened for a span of about 4 hours. I went to 3 doctors and have had CT scan, EEG, and neurologist exams. I was told everything seems OK, but things just don’t seem right. I have noticed an increased loss in vision, balance, eye-hand coordination, and concentration. I have even tried those department store cheater glasses at x1.25 now and then. They seem to help clear things up ,but I can only wear them for about 10 minutes before the eye strain starts to bother me. I am at a loss they say I’m fine ,but I know I’m not.

    • Jody Abrams, M.D. says:

      You sound like you might have post concussive syndrome. You need a neuro-ophthalmologic evaluation. Sounds like someone needs to check your convergence ability. This could be causing a lot of your problems. The normal exams would not show this. The cheater glasses you are using might need some prism in them to help you.

      Jody Abrams, MD

  7. Hi,
    I fell at work and hit the back of my head hard on what I think was a tree root in Nov. 2012. I have had a headache every day since with short term memory loss, cognitive problems, vision probems – have a hard time with bright lights and anything with patterns. My doctor said I have Post Cucussion Syndrome but the other night I was watching TV and in my right eye there was like a flash on light – like a camera flash and then everything went black in a half a moon shape with with flashs of dots. I call my doctor and was told go to the ER. At first I was told I had a retina detachment and was admitted but the next day the eye doctor said I have PVD. Now I just saw this doctor in April and I did not have this then but he would not say if this was caused by my headaches from my PCS. What do you think?

    • Jody Abrams, M.D. says:

      These could be related to post concussive syndrome. I think you need to look for a neuro-ophthalmologist to look at your eyes. Many normal eye doctors are not use to seeing patients with brain trauma like PCS. I think that can clear up some of the confusion you are getting from the multiple doctors. Where are you located and maybe I can help recommend someone to see.

      Jody Abrams, MD

  8. Hi,

    4 weeks ago today I took a hockey puck right between the eyes. I didn’t lose concouisness. However, I was sent back to work too early by ER doc and consequently spent 12 straight days laying in total darkness. I still have light sensitivity, blurry vision, ringing in my left ear and I developed the floaters a week ago. I’ve seen an ophthalmologist and neurologist. I am seeing a neurologist and they say recovery takes 2 to 3 months. everything that I’ve read online it’s about how people have taken six months to 1 to 2 years to recover. What are my realistic expectations? I am improving a little every day. My eye doctor said the floaters will settle down and disappear over time.

    • Jody Abrams, M.D. says:

      Matt,
      My first questions to you would be were you wearing a helmet and if so I would really suggest a face mask. You sound like you have had a concussion. The truth is both groups could be correct for the answer. Often concussions can resolve in a few weeks but sometimes they can take a month or more. I believe Sid the Kid was out for almost a year correct? AS for the floater this will become less noticeable in the future but will still probably always be noticeable.

      Jody Abrams, MD

  9. Hi Dr. Abrams,
    Thank you so much for this article. Even though my daughter has been seeing an ophthalmologist, I was still confused about her condition. She just turned 14 and about 7 weeks ago she took a direct hit to her while playing indoor soccer. It was fairly close range and came up at an angle. Colleen had no other damage to her her eye, but she immediately lost about 40 percent vision in her left eye and felt pain, pressure and of course an intense headache. We went to ER and waited a few hours before the Eye Doctor came with his equipment. He saw severe swelling of optic nerve. He said there wasn’t any conventional treatment but did IV steroid to help with swelling. It is almost 2 months and still nothing. Everything else is healthy – no torn retina, no orbital injury. Our Doctor has been good, but it is frustrating. He said there isn’t alot of information about this type of optic nerve injury in someone so young but we should know by 6mos. if she will get any of that vision back. I’m about 2hrs from Phily – should I get another opinion?

    • Jody Abrams, M.D. says:

      Cheryl,
      I am sorry to hear about the injury your daughter had. From your description it sounds like a possible traumatic optic neuropathy. For those kind of cases your local ophthalmologist is correct, there is not a lot of great data on treatment for this. We often use steroids but that has not been proven in large studies to make a difference yet. We base our treatment off the spinal cord injury studies but there are significant differences in the structures. After steroids there is not a lot else to do other then wait for these cases. I often do recommend neuroimaging such as an mri to make sure there is no bone hitting the nerve. There are some good near-ophthalmologist in Phily but I am not sure they can offer more for your daughter.

      Jody Abrams, MD

  10. Yvonne Rieckhoff says:

    Approximately 2 months ago, I was in a car accident after hitting a vehicle making a left-hand turn across three lanes of traffic. The hospital asked a few questions, then sent me home. I started to have different problems, so I saw my regular doctor who promptly told me that I had post-concussive syndrome. He sent me for a CT, and everything came back normal. However, I am still have problems with my vision. I am an avid reader and a college student, so this is quite disruptive. I wear glasses, so I know what it is like for “normal” eye problems and when to get new glasses, but all of my new problems have started since the accident. When I wake up in the morning, my eyes look like little pinholes, and by the end of the day, my eyes are dilated. Also, my eyes react to light, but after a few seconds (notably, later in the day), I can watch my pupils re-dilate. And I used to have excellent night vision, but now I can barely see; same thing if it is too bright. The severity progresses throughout the day, but it is difficult for me to read, my vision is blurred, it often hurts to move my eyes, and sometimes my vision “jumps” (not the normal moving around; it’s more like a twitch that ends up back in the original place). Will all of this go away on its own and, if so, is there a time frame? Do I need new glasses? If not, is there some way to relieve the symptoms?

    • Yvonne Rieckhoff says:

      Oh, also, when I shine a flashlight in my left eye, my right eye barely changes (but when I shine it in my right eye, the left eye changes just fine, though neither eye stays constricted for more than 2 seconds, even when I keep the light on them), and the colors are different between my two eyes.

    • Jody Abrams, M.D. says:

      Yvonne,
      You have symptoms that could be consistent with a closed head injury. You need to see a neuro-ophthalmologist that is comfortable dealing with visual symptoms after head trauma. There are some special exercised and even glasses that could help you recovery faster.

      Jody Abrams, MD

      • Yvonne Rieckhoff says:

        Dr. Abrams,

        That is very welcome news. I went ahead and scheduled an appointment with you for July 15. Thank you so much for posting this article!

Speak Your Mind

*