The Therapy You Never Knew You Needed with Dr. Jacqueline Theis, Neuro-Optometrist

Making Headway

Are you fatigued after using your eyes? Since your brain injury do you feel anxious in crowds or grocery stores? Are you dizzy or do you get headaches? Does reading bring on symptoms? Do you have trouble tolerating screens even when you take breaks? Is it hard to pay attention? You may need neuro-optometry! 20-30% of brain injury survivors have symptoms caused by oculomotor disturbances that do not self-resolve! Join us with Dr. Jacqueline Theis to learn more about this overlooked profession. We discuss visual processing and how therapy may help you with your lingering symptoms. We were both shocked to learn how much this field can help with many of our ongoing symptoms, you may be too!

Covered in this episode:

• Differences between types of eye doctors
• Ophthalmology: they go to medical school where they learn a little bit about a lot of the body systems. Then they specialize in surgery and diseases of the eyes. They are MDs who specialize in the eye
• Optometry: after undergrad they go to optometry school where they learn a lot about the eye and how other body systems impact the eye. They can then choose to go to school longer for specialities like primary care, contact lenses, pediatrics, or neuro optometry.
• Neuro Optometry: works with atypical visual complaints. Your eyeball looks normal but visual processing is interupted. Typically subtle symptoms
• Neuro ophthalmologist: medical doctors that can fix structural eye issues with surgery
• Neuro optometry: manages vision rehabilitation and vision therapy that can’t be fixed by surgery or medicine. They can also make glasses that help accommodate for visual or eye tracking issues post neurological event
• What Can Neuro Optometrists Help With?
• The signs and symptoms of vision issues post concussion or mild TBI can be very subtle. Providers don’t even know all the signs and symptoms to be looking for
• If you complain of double vision, blurry vision, or light sensitivity you’ll definitely get a referral to an eye doctor. The eye doctor will look at the eyeball for structural issues and most of the time the eyeball is fine.
• In the last 5-10 years they have found that common symptoms that are screened for iin brain injury get sent to other providers but are actually related to vision
• Symptoms of visual disturbances post brain injury
• Fatigue with reading and eye use
• Getting anxiety in crowded areas or grocery stores
• Dizziness
• Headache
• Inattention
• Jaci aims to educate providers about screening for eye movements in patients with ongoing symptoms like those above (symptoms beyond 4 weeks).
• If symptoms don’t self resolve in 4 weeks, there is rehab that can be done to help.
• There is actually something that can be done and you can get better!!
• How do the eyes cause anxiety and cognitive problems? Vision uses your whole brain
• Imagine a soccer ball moving left to right in front of you. The light signal from the ball moves to the retina, it transitions it into a chemical signal and sends it down the optic nerve all the way to the back of the brain to the occipital lobe.
• The occipital lobe sorts the information and then sends it the part of the brain that needs to respond to it.
• It gets sent to the temporal lobe which identifies what the object is.
• At the same time the signal gets sent to the parietal lobe which tells where the ball is relative to where you are.
• The parietal and temporal lobe send the signal to the frontal lobe to make a decision on what you want to do with the ball.
• If it decides you want to kick it it sends a signal goes to the midbrain to coordinate the eyes to follow the ball.
• This whole process moves very fast! In something simple like tracking a ball left to right you have used every part of your brain. If your head moves then your vestibular system and cerebellum get used too.
• Your eyes can make you feel dizzy if they are not communicating with the vestibular system
• In a grocery store: you have fluorescent lighting, tons of sounds, and movement. In a store you have to walk and process information while remembering what you need to grab. Then you need to be able to decide which type of item you want. Then you have to move to get the object.
• If any of these processes are off then you get sympathetic nervous responses of fight or flight. You get visually overwhelmed and become anxious and shut down.
• Pro tip: make short trips to the store rather than one long one to avoid visual overwhelm (short more frequent stents are better than long ones). Try smaller stores with less options.
• How do you diagnose vision issues?
• 70% of the brain is dedicated to vision. It is very likely that any injury to the brain will have a visual component.
• Neuro optometrists work a patient through different eye movements
• Eye movements are mapped to certain areas of the brain If she knows what movements are involved she knows what areas are affected and what symptoms they are having.
• Many injuries don’t have a scan that will show problems
• Deficiencies in eye movements give objective data to what the patient feels (it will show the provider what is wrong when a scan can’t). They are using eye movements on the sidelines of NCAA to help with real time diagnoses
• Eye tracking
• Smooth pursuit
• Cicade
• Moving up, down, right, left are all different areas of the brain
• Convergence
• Holding your eyes in a certain position takes a lot of energy--i.e. Staring at a computer all day
• Take a proactive eye break for 20 seconds every 20 minutes looking 20 feet away. Don’t push your boundaries as it will cause symptoms.
• Brain injured patients will have symptoms with certain movements (dizzy, nauseous, brain fatigue). Developmental eye movement issues don’t usually have symptoms
• Your brain regulates its own self awareness. For instance if you have a leg injury you stop when it hurts. With the brain, you override these signals and try to push through.
• You get too tired to notice your brain is tired then crash
• With the eyes you can get delayed symptoms. You feel fine in the moment and they 2 hours later feel bad.
• Keep a symptom journal of what you did and how you feel. Look for patterns
• Symptoms tell you that you did too much
• Helps you to figure out where you need a break
• You’ll eventually be able to increase
• What is an eye break?
• Close the eyes. Let them rest.
• Recovery is a roller coaster. When you start having good days be careful not to push too hard (which leads to a string of bad days). Recognize your patterns. If you have a day that you feel normal or great that means that your brain has the potential to feel normal and great. Take it easy afterwards so that you can have more good days.
• What can be done to treat these vision issues?
• With subtle oculomotor deficits: need to find a provider who can diagnose and treat it
• The field is working on training more providers what to screen for and when to refer to neuro-optometry
• Nationally, NORA has a list of providers who are qualified to treat to you
• A neuro-optometrist will screen for vision vs. other systems and refer appropriately if it is not eye related
• Therapy can provoke symptoms but having therapy will get you better faster
• Neuro-optometry is a small speciality and not as well known
• Research is helping to show the need for vision therapy
• Providers have learned through research that provoking symptoms is not doing more damage to the brain and actually helps
• Teaching providers what to screen for to indicate a neuro-optometry referral is difficult as brain injured patients show up all over the system: EDs, PCP offices, neurologists, rehab specialists i.e. there are lots of people and specialities that need teaching.
• There is about 10 years between science showing something works and patients getting the “new” therapy
• Neuro-optometry and acquired brain injury (ABI)
• ABIs discussed: stroke and hemorrhage
• Closed head injury patients have many more symptoms with eye movements then ABI (unless a specific area of the brain involved in vision is damaged)
• Most commonly ABI patients will have visual field loss.
• Visual field loss: If the right brain is affected by injury, you can have left vision loss in both eyes and visa versa
• This is hard to accommodate for. The brain will try to mask that the blind spot exists. Your brain actively fills it in. The problem with this after stroke is that patients will feel overwhelmed by things on the affected side or bump into things but they are not aware that it is because of a vision issue because the brain fills it in.
• Your brain will trick you to deny that there is a problem.
• Training for visual field loss starts with awareness
• Visual field rehab will consist of teaching you efficient ways to scan your blind areas and help fight the fear of falling or fear of new places.
• Only 8% of people get their full field of vision back. 50% stay the same as post injury. 40% get partially better. Rehab will teach you how to adapt to things that won’t improve.
• The therapy for visual field loss has nothing to do with getting your vision back. It teaches you how to efficiently accommodate and build new, safe habits.
• Visual processing disorders
• You see ok but you can’t interpret what you see
• Visual crowding- “I can’t pay attention if there is a lot of stuff”
• “I can’t read a map anymore”
• “I can’t find something and it's right in front of me”
• Strategies: wear a ball cap to eliminate excess visual information, hold up your hands and make a triangle or hand shaped binoculars to help filter out all the stimulus around you which will help you find the item you are looking for. It's the idea of wearing blinders to block out all the extra stimulation
• Brain injury and trauma and psych
• Many patients with strokes will blame themselves after a stroke thinking they should have done something earlier or done more to prevent. This guilt does not help you. There are a lot of emotions post stroke
• One area of referral that is huge with stroke and vision loss is psych
• With stroke you wake up and vision is gone. You had no time to prepare for this. Losing your vision has significant emotional and psychological impacts
• You need therapy to help you with this
• Your caretaker needs to go to therapy too so you can function better as a team
• All emotions post injury are valid. Many are angry and that is ok! It's a lot to hold onto by yourself. Get help!
• How do you get help?
• Ask your optometrist if they have an resources for people who do a brain eye exam and specialize in your symptoms
• Telemedicine opens up access to neuro-optometrist
• Some optometrists have overlapping specialties i.e. a pediatric optometrist or low vision doctor may also have the skills needed to treat you
• It’s ok to email the office, tell them your symptoms, and ask if they can help you. They can help figure out which arm of optometry will be best or if optometry isn’t for you
• Prevalence of visual issues post brain injury
• Visual field loss in stroke occurs in 24-67%
• Oculomotor issues in the acute stages of brain injury occurs in 70-80%, in the chronic phase (past 1-3 months) it is 20-30%
• Some will self resolve in 4-6 weeks without intervention
• 20-30% will need intervention
• We need more neuro-optometrists in acute care--therapy will be much more effective if they can get prism glasses to correct double vision
• It is worth looking into neuro optometry post brain injury just to make sure this isn’t an area that needs help!
• Summary of signs that you need help: not being able to interpret what you see, not being able to do what you did before, not being able to read well or comprehend reading, the words move on the page, I lose my place easily, I get dizzy and nauseous with reading, screen time-you should be able to take a break and get back into it. Overwhelm at the store. Your eyes moving when your head is not

Links to any resources mentioned:

• Find vision rehab near you: https://noravisionrehab.org/
• www.virginianeurooptometry.com
• Facebook: virginianeurooptometry

Instagram: @virginianeurooptometry

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