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Neuro-Optometry Examination

A Neuro-optometry examination is an in-depth look at how the eyes and the brain work together. It is an opportunity to test the important areas of how your vision functions, to see if they are holding you back in your recovery or holding you back in your performance.

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Vision is 70% of the incoming sensory information to your brain and over 90% of your brain is involved in processing vision. In fact, when different senses are giving conflicting information, your brain will almost always use vision to over-ride the other sense.

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Reading & Learning

Sports Vision Testing

Brain Injury & Neuro Optometry

brain injury

Brain Injury & Neuro-Optometric Rehabilitation


When most people think of brain health they think of having an MRI to see the parts of the brain. An MRI of the brain can show larger-scale physical damage to areas, but most MRI’s can’t show the type of damage sustained in a concussion, mild traumatic brain injury (mTBI), or other brain injuries.

A neuro-optometry evaluation involves measuring and examining how the eyes and the brain work together to see if there are areas of dysfunction that are causing symptoms.

There are several key areas that need to be assessed:

Oculomotor function (eye tracking)


Saccadic (eye movement) abilities have been shown to be affected by concussions, and problems with oculomotor function has been shown to be an indicator of brain injury. These should be tested both with targets in real space, and often with computerized eye tracking. Problems with saccades are often diagnosed as oculomotor dysfunction or saccadic dysfunction.

Accommodation (focusing)


Accommodation ability is measured by using lenses to determine the ability of the brain to control how and where the eyes are focusing. Problems with accommodation are often diagnosed as accommodative infacility or accommodative dysfunction.

Depth perception and spatial processing


Depth perception can be measured in a variety of ways. One of the ways this is measured is by using polarized 3D glasses and 3D targets. This does not always rule out problems with depth perception because it only looks at one aspect. Depth and spatial perception can also be tested by using various tests that are in real-space. Problems with depth perception are often diagnosed as reduced depth perception or reduced stereopsis

Visual acuity (how small of a target that can be seen)


Visual acuity is tested on most routine exams. Visual acuity, and the glasses prescription required to see clearly is often the focus of most eye examinations. It can often be quite frustrating for people who feel like their vision is part of their post-concussion syndrome, but after having their prescription and eye health checked, they are told their vision is ‘fine’. Visual acuity and prescription is the testing done where you have to see the small targets and different lenses are used (“better one, or better two”) to determine what prescription allows for the best clarity. A common problem is that the way prescriptions are usually measured and given can result in glasses or contacts that actually contribute to post-concussion symptoms. Specialized testing for glasses prescriptions post-concussion should factor in how the glasses affect balance, dizziness, headaches, migraines, light sensitivity, screen tolerance and more. We often refer to this as Ergoptics prescribing.

Part of the examination process should also be counseling on various treatment options.

Binocular function (eye teaming)


Convergence (eyes moving inwards) and divergence (eyes moving outwards) abilities need to be assessed. The most important tests for these abilities involve using prism to measure the ability of the eye to work together. Problems with convergence or divergence are often diagnosed as convergence insufficiency, convergence excess. Divergence insufficiency, divergence excess, vergence dysfunction, or binocular dysfunction.

Stability of binocular function also needs to be assessed. If the eyes do not maintain stable alignment it can lead to many post-concussion symptoms. This can be measured with a variety of devices. Problems with stability are often diagnosed as unstable fusion, unstable fixation, or binocular dysfunction

Peripheral integration/awareness


Our central visual system is what our brains use for seeing clearly and identifying what we are looking at. Our peripheral visual system is what our brains use for processing movement, motion, guiding eye tracking, balance, coordination and more. This can be seen very quickly if you cover both your eyes entirely except for a very small pinhole of vision, and then try to walk around your house. Peripheral integration is different than just visual field testing, which only tests if you can see it, not whether it’s being processed accurately. This is best tested with a series of functional balance and head movement testing with your optometrist. Problems in this area can often be diagnosed as visual-vestibular mismatch or poor central-peripheral integration

Visual-vestibular integration (how the eyes and inner ear work together)


Our brain is constantly comparing our visual and vestibular inputs. Certain vestibular problems such as BPPV (benign paroxymal positional vertigo) should be addressed before vision is tested. However, vestibular rehabilitation is often dependent on proper visual function, and people will often have trouble with vestibular rehab, or plateau in their recovery if their vision is not working properly. This is often tested by using various lenses to change how vision is being processed, and then testing the visual-vestibular integration through balance tests and head movement (dynamic visual acuity). Problems with visual-vestibular integration are often diagnosed as a visual-vestibular mismatch.

The Most Common Treatments

Glasses Prescriptions

Special glasses prescriptions take into account how your eyes and brain work together. This can improve balance,

Eye tracking, headaches, migraines, nausea, fatigue, fogginess, concentration and more.

The glasses may utilize certain tools such as prisms, tints, bi-nasal occlusion, nasal occlusion, bifocals, progressives, and more. On that note, be very cautious of blue light filter glasses, as your brain needs a certain amount of blue light for your circadian rhythm.

Vision Therapy, Vision Rehabilitation, or Neuro-Visual Training

Vision therapy is about re-training how the eyes and the brain work together. This often has very little to do with the physical eyes. It has more to do with how the brain is processing vision and controlling what the eyes do. The specific exercises and activities are targeted to be able to teach your brain to process your vision more accurately and more efficiently. The home training that is prescribed then re-inforces these new neural pathways. Vision therapy can take anywhere from 10-50 weeks. The average concussion case often takes 20-25 weeks for the best lasting results.

Referrals

Often during the examination it can become obvious that there are other areas that also need care. This may involve the neck, vestibular system, counseling, ocular health, or other various disciplines that will help make the vision treatment more effective.

reading and learning

Reading & Learning


When a child is struggling with reading and learning one of the first suggestions is often to have the eyes checked. Too often the eye exam with the optometrist or pediatric ophthalmologist concentrates only on seeing clearly and the physical health of the eye. This means that problems with eye tracking, how the eyes work together, and how the brain processes the vision are overlooked. It is important to assess these areas as they can cause the same symptoms as dyslexia, attention deficit disorder (ADD/ADHD), developmental coordination disorder, dysgraphia, and other learning disabilities.

Common reading and learning problems caused by vision:

Recognizing letters


The most severe tracking issues can mean that every time a child looks at a letter it looks fundamentally different to them. It can also cause confusion between similarly shaped letters.

Reading fluency


When the eyes jump to unexpected places on the page, it can make it difficult to read smoothly with the right intonation. Being able to read out loud fluently involves scanning ahead of the word you’re reading to put it in context and determine the correct intonation. Try reading a paragraph aloud while you block out all the words ahead of the one you are saying, and you’ll quickly realize you lose fluency.

Sustaining attention


If eye movement is really inefficient, it takes a lot more effort to try to sustain attention. Think of your child riding a bicycle with flat tires. You couldn’t expect them to ride for as long as on a properly tuned bicycle. Studies have shown that vergence (eye teaming problems) can cause 7 of the 9 symptoms of attention deficit disorder.

Recognizing words


Tracking problems can mean that when a child looks at a word, their eyes jump to the end of the word, back to the beginning, and through the word in a random pattern. This means that the next time they see the word, it actually looks different to them. This is commonly noticed when you teach them a word, and three lines later they won’t recognize the same word.

Reading comprehension


If your child’s eyes do not track accurately through the text, they will not be able to take in what they are reading in the proper order. In addition, their brain will be focusing on the act of just trying to track their eyes, leaving less power for comprehending and understanding the material.

Writing


Writing requires the brain to formulate what needs to be written, and then coordinate the motor movements of the wrist, fingers, hand and arm to re-create what has been visualized. Vision problems can result in messy writing, slanted writing, unequal spacing, unequal sizing and more.

See this example here of this grade 4’s writing before the vision problems were treated and after.

sample test

Copying from the board


Efficient copying from the board requires that the learner can accurately move their eyes from board to page, as well as retain the snapshot of the word/words they want to copy from the board. If the eyes don’t work together properly, track accurately or focus properly it cause make for slow and difficult copying.

Spelling


Spelling is visual ‘memmory’ task. What did you just say there? It _____ wrong. You’re right, it doesn’t sound wrong, it looks wrong. Spelling really comes down to visual memory, and if a young learner.

Here is what should be tested:

Eye tracking

If your child’s eyes don’t accurately track through the letters on a page, it can interfere with reading ability in a number of ways. The affected areas will depend on the particular problem and severity. Eye-tracking is tested with standardized tests such as the King Devick, DEM, or computerized eye-tracking.

Before Vision Therapy

before reading vision therapy

After Vision Therapy

after reading vision therapy

Binocular function (eye teaming)


If the eyes do not move together or to the same place, reading will be difficult. It can create a situation where each eye is giving a different picture, which will create confusion about what is being seen.

Visual Information Processing


This can include: visual-motor abilities (writing), spatial processing (hand-eye coordination), visual memory (spelling) and more. Sometimes these problems can be detected simply from asking the right questions.

Part of the examination process should also be counselling on various treatment options.


Accommodation (focusing)


If your child’s eyes struggle to focus accurately, sustain focus, or shift focus, it can create problems with reading, attention, writing and more

The most common treatments are as follows:

Glasses prescriptions

Special glasses prescriptions take into account how your eyes and brain work together. This can improve balance as shown in the video below.

As well as eye tracking:

Also, headaches, migraines, nausea, fatigue, fogginess, writing ability, concentration and more.

The glasses may utilize certain tools such as prisms, tints, bi-nasal occlusion, nasal occlusion, bifocals, progressives, and more. On that note, be very cautious of blue light filter glasses, as your brain needs a certain amount of blue light for your circadian rhythm.

Vision therapy, vision rehabilitation, or neuro-visual training

Vision therapy is about re-training how the eyes and the brain work together. This often has very little to do with the physical eyes. It has more to do with how the brain is processing vision and controlling what the eyes do. The specific exercises and activities are targeted to be able to teach your brain to process your vision more accurately and more efficiently. The home training that is prescribed then re-inforces these new neural pathways. Vision therapy can take anywhere from 25-50 weeks. The average vision problems causing difficulty with learning take around 40 weeks to fully treat.

Referrals

Often during the examination, it can become obvious that there are other areas that also need support and testing. We work closely with other professionals to ensure proper care.

sport vision testing

Sports Vision Testing


When looking for peak performance, it’s not enough to for vision to be working at ‘average’ levels. There are specific areas to measure and enhance that can drastically improve performance in a given sport. Here are a few:

Oculomotor function (eye tracking)


Saccadic (eye movement) abilities have been shown to be a key part of hand-eye coordination. Testing can make sure there are no deficiencies, and can uncover areas of eye tracking that can be improved.

Accommodation (focusing)


Accommodation ability is measured by using lenses to determine the ability of the brain to control how and where the eyes are focusing. This a key element of being able to quickly change focus during sport.

Peripheral integration/awareness


Our central visual system is what our brains use for seeing clearly and identifying what we are looking at. Our peripheral visual system is what our brains use for processing movement, motion, guiding eye tracking, balance, coordination and more. Key play-makers are able to focus on the ball/puck and still pay attention to where their teammates are. In basketball this is often referred to as court-vision. Peripheral integration is different than just visual field testing, which only tests if you can see it, not whether it’s being processed accurately.

Binocular function (eye teaming)


Convergence (eyes moving inwards) and divergence (eyes moving outwards) abilities need to be assessed. The most important tests for these abilities involve using prism to measure the ability of the eye to work together. Problems with convergence or divergence are often diagnosed as convergence insufficiency, convergence excess. Divergence insufficiency, divergence excess, vergence dysfunction, or binocular dysfunction. High performing athletes often do not have a diagnosable problem, but still have areas that can be improved.

Depth perception and spatial processing


Depth perception can be measured in a variety of ways. One of the ways this is measured is by using polarized 3D glasses and 3D targets. This does not always rule out problems with depth perception because it only looks at one aspect. Depth and spatial perception can also be tested by using various tests that are in real-space. Most athletes score well on the depth perception testing booklet, but may be slightly underperforming in other ways. Their hand-eye coordination may seem great, but even top baseball players saw significant changes to their stats when training was taken to the next level.

Visual-vestibular integration (how the eyes and inner ear work together)


Our brain is constantly comparing our visual and vestibular inputs. When your head moves, your eyes need to take it into account and counter the movement. This is what can make sure the eyes are still able to focus quickly when running, turning, or moving. For a racecar driver, it was the key to allowing him to focus faster and more accurately on the road while being jostled around.

Visual acuity (how small of a target that can be seen)


Visual acuity is tested on most routine exams. Visual acuity, and the glasses prescription required to see clearly is often the focus of most eye examinations. It can often be quite frustrating for people who feel like their vision is part of their post-concussion syndrome, but after having their prescription and eye health checked, they are told their vision is ‘fine’. Visual acuity and prescription is the testing done where you have to see the small targets and different lenses are used (“better one, or better two”) to determine what prescription allows for the best clarity. A common problem is that the way prescriptions are usually measured and given can result in glasses or contacts that actually make performance worse. It is important that a prescription for sport takes into account how the eyes and the brain work together.

Serving Neuro-Optometry Patients From:

Victoria | Nanaimo | Duncan | Vancouver Island | and throughout British Columbia