5 exam findings that should spur a neuro referral

January 20, 2020
Melissa Zarn-Urankar, OD, FAAO

Optometry Times Journal, January Digital Edition 2020, Volume 12, Issue 1

Patients can benefit from a referral to a neuro-optometrist when these 5 findings are present

The likelihood that primary care optometrists will evaluate a patient with acquired or traumatic brain injury (A/TBI) history becomes more prevalent daily.

Traumatic brain injury leads to 2.5 million emergency visits annually and affects 4.4 percent of military service members.1 It is widely accepted that not all TBI cases report to the emergency room for initial treatment. A new cerebrovascular accident (CVA) or stroke occurs every 40 seconds and an estimated 7.4 million adults are stroke
survivors;2 this accounts for 3 percent of the United States population. Optometrists are in an ideal position to provide both primary care and neuro rehabilitation for A/TBI patients. As a primary care optometrist, following are five key exam findings which indicate a patient would benefit from referral to a neuro-optometrist who has expertise in
the assessment and treatment of visual disturbances associated with damage to the central nervous system.

Related: ODs must examine more than just eyes

Injury in their histories

Patients with a history of brain injury commonly experience specific visual and visual processing symptoms that persist indefinitely if untreated. Table 1 summarizes the findings from Cuiffreda et al regarding common visual symptoms.3,4 Most common visual effects of CVA are loss of central vision, loss of visual field, visual processing disorders including spatial neglect, and eye movement disorders.5 Traumatic brain injury most commonly leads to symptoms such as blurry vision, light or glare sensitivity, and double vision. A convenient way to establish the level of functional impairment due to visual consequences of brain injury is to use a symptom survey. The Brain Injury Vison Symptom Survey (BVISS) was validated for a brain injury population and pertains to both acquired and traumatic causes of brain injury. The survey can be accessed via the Neuro-Optometric Rehabilitation Association (NORA) website.6,7 A score of 31 or higher on the 28-item survey is predictive for functional impairment from brain injury. A patient with a high score on this symptom survey would benefit from additional evaluation by a neuro-optometrist.

Related: Treating patients with brain injuries

Visual complaints

Blurred vision is common complaint. Near vision blur affects 40 percent of CVA and 43.8 percent of TBI cases. Distance blur affects at least 31 percent of CVA cases. Patients who have experienced A/ TBI are often more sensitive to small changes in the spectacle prescription and can be very sensitive to the distortion induced by progressive addition lenses. In A/TBI patients, sometimes blur is associated with non-refractive sources, such as: 

– Dry eye

– Accommodative dysfunction

– Spatial distortion

– Small misalignment of eyes

– Photosensitivity and glare

If your patient has no change in the refractive findings compared to habitual but still complains of blur, a neuro-optometrist can evaluate the need for adds, prism, tints, and/or occlusion. 

Related: Top 3 lists to take the detective work out of differential diagnoses

Something missing 

Visual field defects are commonly found in the initial assessment of A/TBI patients. Stroke yields a more defined scotoma while trauma, anoxia, and other diffuse injuries yield generalized visual field defects. Visual field assessment is dependent on attention, and A/TBI patients can experience a range of visual attention challenges. Selective visual attention, unilateral spatial inattention, and hemi-spatial neglect have various effects on the visual field presentation. In the first six months of recovery, patients may note significant changes in the visual field which can be attributed to clearing of the damaged components along the pathway as well as improvements in visual attention and spatial awareness. 

Related: 4 ways to use eye tracking in your practice

The visual field presentation typically stabilizes around 12 months post-injury. If you are evaluating a patient within the first year of recovery from A/TBI, a neuro-optometrist may be able to enhance the visual field recovery through therapy. If your patient demonstrates poor visual attention throughout your exam, neuro-optometric intervention can improve the visual attention to allow a true assessment of the visual field. Persistent visual field defects often require adaptations to work around; a neuro-optometrist can provide therapy to speed up the adaptation period. Movement challenges Eye movements involve the coordination of several reflexes and pathways and are dependent on attention. Post-brain injury, patients can experience pain or discomfort with eye movements, gaze restriction, and/or a sense of disorientation, dizziness or unease when moving their eyes. Assessing the quality of your patient’s eye movements can be as simple as direct observation. Use of a standardized grading scale applies quantitative information to your observation of patient performance. Table 2 shows key features of the Northeastern State University Oklahoma College of Optometry (NSUOCO) and Southern California College of Optometry (SCCO) grading scales.8,9 Poor oculomotor stability or efficiency warrants a referral to a neuro-optometrist. Patients with culomotor dysfunction can be treated with therapeutic techniques as well as specialized lens interventions. 

Related: How to care for stroke patients

Strabismus post injury 

Reports of strabismus from A/TBI show variable incidence rates. Strabismus can result from direct damage to cranial nerves during injury, damage to gaze centers in the brainstem, and from medication side effects. The standard rule of thumb for strabismus surgery after a brain injury is to wait 12 months for the angle to stabilize. A neuro-optometrist can elicit the underlying cause of the strabismus and use therapeutic interventions to resolve functional complaints. If your patient is bothered by a misalignment of his eyes or double vision from this misalignment, referral to a neuro-optometrist is often more fruitful than referring to a strabismus surgeon. Finding a neuro-optometrist These findings present great opportunities to support and comanage patients with neuro optometric colleagues. To find a neuro-optometrist in your area, check the NORA website “Find Provider” tool located on the top right corner of the main page (https://noravisionrehab.org).

Related: Treating inflammation tackles filamentary keratitis


1. Centers for Disease Control and Prevention. TBI
Data and Statistics. Available at: https://www.cdc.gov/
traumaticbraininjury/data/index.html. Accessed 1/15/120.
2. Centers for Disease Control and Prevention. Stroke.
Available at: https://www.cdc.gov/stroke/. Accessed 1/15/20.
3. Suchoff IB, Kapoor N, Ciuffreda KJ, Rutner D, Han E, Craig
S. The frequency of occurrence, types, and characteristics
of visual field defects in acquired brain injury: a retrospective
analysis. Optometry. 2008 May;79(5):259-65.
4. Ciuffreda KJ, Kapoor N, Rutner D, Suchoff IB, Han ME,
Craig S. Occurrence of oculomotor dysfunctions in acquired
brain injury: a retrospective analysis. Optometry. 2007
5. Rowe F. Visual effects and rehabilitation after stroke.
Community Eye Health. 2016;29(96):75-76.
6. Neuro-Optometric Rehabilitation Asssocation. Getting
the Most out of Your Appointment. Available at: https://
Accessed 1/15/20.
7. Laukkanen H, Scheiman M, Hayes J. Brain Injury Vision
Symptom Survey (BIVSS) Questionnaire. Optom Vis Sci. 2017
8. American Optometric Association. Optometric Clinical
Practice Guideline: Care of the Patient with Learning
Related Vision Problems. Available at: https://www.aoa.org/
documents/optometrists/CPG-20.pdf. Accessed 1/15/20.
9. Maples WC, Atchley J, FIcklin T. Northeastern State
University College of Optometry’s Oculomotor Norms. J
Behavioral Optom. 1992;3(11)143-150.

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