Concussion and Vision Changes Part 3

Concussion and your vision (part 3): double vision

       Last time I discussed what happens to you ability to see after a concussive head injury.  When your head hits a stationary object or is struck by a concussive blow the brain is jolted around the cranial cavity and is injured by smooth and sharp bones (fig 1).   The three nerves that innervate the muscles that move your eyes exit the brain stem and travel along the base of the skull, coming together behind the eye and enter the orbit thru a narrow canal to innervate their respective muscles that move the eye (fig 2).   These nerves are susceptible to injury anywhere along the route from the brain stem to the eye muscles.   Injury to any or all of these nerves results in a distinct pattern of double vision.   With this knowledge a neuro-ophthalmologist can determine which nerve is involved and how and when to treat the patient.


Thomas Spoor MD

Fig 1 (Click to enlarge)

Closed Head Injuries 01 d002

Fig 2 (Click to enlarge)





Double Vision: 6th Nerve Palsy

The patient in figure 3 has a sixth nerve palsy.  This nerve only moves one muscle, the lateral rectus that moves the eye to the side.   Due to its long passage from the brainstem to the lateral rectus muscle, damage to this nerve is the most common squeal of concussive injuries (fig 3a).  These patients complain of horizontal or side-by-side double vision and cannot move their eye to the side.  The double vision is very bothersome and there is no immediate treatment except to patch either eye.   This will resolve the double vision as long as the eye is covered.  Now begins the waiting game.  You really must wait 6 months to see the extent of spontaneous recovery.  If partial recovery occurs continue to wait until the amount of misalignment is stable.  Appropriate surgery is then very effective resolving the double vision.

Closed Head Injuries 01 d025

Fig 3a (Click to Enlarge)

Fig 3(Click to enlarge) Patient looking to her Right

Fig 3 (Click to enlarge) Patient looking to her Right

If there is no improvement, surgery is still helpful but less successful.  There is always residual double vision when the patient looks to the side but you can usually resolve the double vision straight ahead and in most other gazes.

I will talk about other cranial nerve injuries that can cause double vision from closed head injuries. If you our some one you know is suffering from any of these ocular problems please contact us for evaluation and treatment.

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

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


  1. Madeleine Acimovic says:

    Thank you for this article, it was very interesting considering my husband double vision , I guess we had to wait few more months for him to get better. Madeleine Acimovic

    • Jody Abrams, M.D. says:

      I am glad it helped. Time does help heal a lot of problems from head injuries. Sometimes prism or botox can be used to help on a temporary basis.

      Jody Abrams, MD

  2. I hit back of my head at work and was taken to hospital CT scan showed nothing and neurologist said fine but I now have blurred vision in 1 eye. I am seeing outline on digital numbers and letters that look like fractions and vision isn’t clear. Also I have pain in back of head by neck area that goes to shoulder and headaches still. Dr said he feels I have PCS. Please what do I do my vision isn’t right tomorrow going to ophthalmologist how long does concussion symptoms last.

    • Jody Abrams, M.D. says:

      Post concussion vision changes is not uncommon. It can take weeks to months to get better and even then there can be some residual seen in patients with PCS. If the ophthalmologist does not see an obvious cause my recommendation would be to consult a neuor-ophthalmologist for further evaluation.

      Jody Abrams, MD

  3. Can we get a response to a question online from a doctor about an eye problem after a concussion? Thanks much.

    • Jody Abrams, M.D. says:

      I can not often give specific answerers about your case, but can help give a general answer.

      Jody Abrams, MD

  4. Bob McLaughlin says:

    Hi. Thanks for all the info on concussions and vision. My 14 yr old daughter hit the back of her head on a TV Jan 2. She still has headaches and generally not feeling great. My question is about eye dilation. Even today, if she is reading/doing school work/playing music for 15 minutes, her pupils go from medium to giant – think Bugsy the guinea pig from Bedtime Stories. Is this a normal result of concussion issues as she heals? I took her to the concussion clinic at duPont on Thurs but forgot to ask that question. The dilation thing seems odd and worries me. Her pupils are never small since the accident. Thanks.

    • Jody Abrams, M.D. says:

      After a concussion there can be some pupillary abnormalities. I would recommend when it occurs to take some pictures of them in the light and in dim light and show them to her ophthalmologist. They should be able to help guide you on what is going on. The pictures are a lot better then just telling the doctor since it gives information that you might not notice.

      Jody Abrams, MD

  5. After having a severe concussion and diagnosed with PPCS (Post-Pone Concussion Syndrome) is it normal/possible that, that person sees black streaks mixed with purple?Like, looking at a computer screen then looking away and seeing black and purple streaks. Seeing that color around objects and people? Should the person also expierence their vision being in slow motion and coming up close to them when they’re 7 feet away from that person/object?

  6. Thank you for the blog it helped me out a lot! Me and my brother both were in a recent Atv side by side accident and I was ejected. I was at a summer camp when this occurred. My brother was driving and my camp counselor was sitting in the middle. We weren’t wearing seatbelts or helments because the seatbelts were broke and the camp didn’t have any helments.. The Atv flipped on my side and I was ejected.My brother had a slight concussion and my counselor had a huge bruise on her leg. After the atv flipped and I was ejected my brother and my counselor told me that I stood up and yelled at my brother “why?! Why did you flip the Gator (the Atv)?! Why?!?” And they told me that after I had said that I collapsed. I was rushed to the nearest hospital by ambulance and when I got at the hospital they airlifted me to a university hospital. Nobody knows how long I was out but the doctor believes I was out for a day and a half. I wasn’t awake when they rushed me to the nearest hospital and I wasn’t awake when they airlifted me to the university hospital (I know this because a nurse was with me when I was airlifted and she stayed with me because she felt so bad). I was diagnosed with Post- Concussion Syndrome PCS. I had several MRIs and CAT scans when I was in the hospital. They had a surgical team on stand by for me because I had fluid on the brain and my right side of my face was swallen so my eye socket was VERY puffy. I was in the hospital for 5days because of how severe my concussion was. I had amnesia like symptoms for 3days straight I kept saying “where am i”, “what happened” and other weird questions. I’m writing all of this because I’m still having trouble with my memory and my eyes are acting up so badly I don’t know what to do.. The accident occurred July 31st 2014 and I haven’t been able to go to school at ALL because of the accident. My concussion therapists believes I’m not ready because of the memory problems and the eye sight problems. What’s happening is I would start a sentence and what happens is when I get 3 or 4 words in my sentence my family says that I kind of zone but I don’t remember.. I’m doing OT and PT for my eyes and my memory but I told my OT doctor that its not working.. I loose track of what I’m saying, I see black and purple streaks around people like an energy wave around people and objects, I have angry outburst and after the outburst I lay down because I get super tired and the next day I don’t remember what I did what so ever. Its like I black out. I could set something right next to me and 30mins later I forgot where I put it. I’m having all sorts of problems and I just want to get rid of them. I want to get rid of all of this. I want to go back to school and hang with my friends and joke around with them. I was born with a disease called TAR Syndrome. Thrombocytopenia-absent radius (TAR) syndrome is characterized by the absence of a bone called the radius in each forearm. Affected individuals also have a shortage (deficiency) of blood cells involved in clotting (platelets). This platelet deficiency (thrombocytopenia) usually appears during infancy and becomes less severe over time; in some cases the platelet levels become normal. Thrombocytopenia prevents normal blood clotting, resulting in easy bruising and frequent nosebleeds. Potentially life-threatening episodes of severe bleeding (hemorrhages) may occur in the brain and other organs. I copied and pasted that from if you’re interested in looking more into it. My doctors don’t know if my birth defect TAR syndrome effect the concussion. I need major help and I’m desperate. Please respond back it would mean a lot. Thanks!

    • Jody Abrams, M.D. says:

      I am sorry to hear about your problem. It sounds like you had a severe closed head injury. From what I am reading you are on the correct course with therapy. I know patients can find it a long course to get through but I will tell you there is a light at the end of the tunnel for most patients. I have seen patients take up to 2 years or more to improve. Keep working with your therapist.

      Jody Abrams, MD

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