Answer transcribed from <a style="color: rgb(17, 85, 204); background-color: rgb(255, 255, 255);" rel="noopener noreferrer" href="https://www.brightwayhealth.org/podcast-episodes/3%3A-dr.-bryce-appelbaum" target="_blank">Brightway's Interview with Dr. Bryce Appelbaum</a>:&nbsp; Nystagmus is basically the oscillation of the eyes. It's usually horizontal but it can be vertical, pendular, and look different depending on the reason for it. It's essentially the brain sending the signal to the eyes to look at a particular place but just getting these impulses where the eyes are fatigued and constantly searching for a better quality image to fixate on. If there's trouble with holding fixation or discrimination ability, you can't keep your eye on the target and the brain's still telling the eyes to focus there, then a lot of times they're shaking. When that happens, you're not able to use the sweet spot of the vision or the line of sight, which is what allows you to see 20-20 or in clarity. For many people, working on fixation or how to keep the eye steady to inhibit some of these extra movements is very challenging. For some people, nystagmus is better with converging, for some, it's worse than with converging. There's often a null point where a position where the magnitude of the eye movements or direction of the eye movements is different. Taking where somebody is operating better and then expanding that is a lot easier than nystagmus at all positions, but finding the right lens combination with glasses or prism can often help pretty dramatically.

What is nystagmus? 

Answer transcribed from <a style="color: rgb(17, 85, 204); background-color: rgb(255, 255, 255);" rel="noopener noreferrer" href="https://www.brightwayhealth.org/podcast-episodes/3%3A-dr.-bryce-appelbaum" target="_blank">Brightway's Interview with Dr. Bryce Appelbaum</a>:&nbsp; Yes and no. Optic atrophy of something that you're born with is different from optic atrophy of something that's been acquired. I think the real question is what activities of daily living are impacted. If it's just a matter of reversing a diagnosis, it's hard to but knowing that the optic nerve which has been damaged with atrophy is what correlates to our periphery, oftentimes you can with the right prism or lenses raised to somebody's awareness the area of the periphery that has been dampened. In some cases, you can also force the brain to be utilized in ways that it was avoiding so that you can rely on the other eye or a certain input from both eyes in certain fields to fill in missing gaps just from an activity as a daily living and functional standpoint.

I was told I have atrophy of the optic nerve. Is there any way I can get vision in that eye?

Answer transcribed from <a style="color: rgb(17, 85, 204); background-color: rgb(255, 255, 255);" rel="noopener noreferrer" href="https://www.brightwayhealth.org/podcast-episodes/3%3A-dr.-bryce-appelbaum" target="_blank">Brightway's Interview with Dr. Bryce Appelbaum</a>:&nbsp; It would kind of depend on the injury but if it's a matter of blood flow being lost, we in some cases can tap into certain areas using alternate pathways. If there's damage to the actual tissue of the brain, it's a lot harder for something like vision therapy to kind of regenerate it. However, I do think for most people who have some type of central peripheral integration problem, a lot can be done in terms of reading, making the right eye movements, or driving if you meet the requirements for what your particular state says in terms of how many degrees of the periphery is needed. Oftentimes, it's kind of recalibrating the system to learn how to take in that area of space or in some cases, to even learn how to compensate so that you don't need to. I would also say prism would be the first option for one to explore in-depth because I would be shocked if that did not help for that individual.

I'm missing my peripheral vision in my right eye after my TBI five years ago.

Is there anything I can do to improve my peripheral vision?

Answer transcribed from <a style="color: rgb(17, 85, 204); background-color: rgb(255, 255, 255);" rel="noopener noreferrer" href="https://www.brightwayhealth.org/podcast-episodes/3%3A-dr.-bryce-appelbaum" target="_blank">Brightway's Interview with Dr. Bryce Appelbaum</a>:&nbsp; Convergence insufficiency is so common and by the language used, you would think that means can't cross my eyes, which in my opinion is absolutely not what convergence insufficiency is. Convergence insufficiency is kind of a spatial mismatch in that converging happens when we are either looking something up close or something's approaching us. It's a binocular coordination problem where again, our eyes are pointing at a different place in where the target is, which is allowing the images not to fuse. It's addressed on a brain basis to raise to somebody's awareness where their eyes are pointing or how they're taking in that space. You can eliminate that mismatch but rarely does it have something to do with eye muscle strength or length&nbsp;The old school treatment modalities for convergence insufficiency is something called pencil push-ups, which literally is look at a pencil, watch it as it comes in, and do this a thousand times. Then all of a sudden, you're gonna strengthen the system and the problem will be gone. I think for most people, that's going to be not too exciting, very repetitive, and learning won't take place in that setup. Rarely have I ever heard of pencil push-ups working.&nbsp;There are certain spectacle lenses that can be made where you can use a prism, which basically moves the world in this case from midline outward a little so that the eyes don't have to converge as much. Those only really are helpful for certain profiles. You always want to be careful that that type of image displacement doesn't create a new normal where we need a stronger amount of power to create the same effect because we're kind of adapting that prism. That often happens, where it's great to not see things double anymore but then you need something stronger just to maintain that same level of clarity and the same image displacement. Nonetheless, that can be effective for some people. Sometimes just having the right prescription magnifying lens, which helps the brain not have to over-focus the eyes as much, can help engage the periphery. By engaging the periphery, it’s easier for the eyes to line straight ahead. That can be effective in making things more comfortable, at least with reading and computer work&nbsp;From a vision therapy standpoint, if convergence insufficiency is the only diagnosis, though it’s almost never the case, that's a slam dunk for vision therapy. It just comes down to teaching the individual where to look and how to use the internal and external muscles of the eyes to provide the right feedback. Then if the brain is in fact rewired, as long as there's no new head injuries or new visual stress that we don't have the tools in place to meet the demands of what’s been rewired, convergence insufficiency is just a label that essentially goes away because it no longer applies. Also with brain injuries, we know that very busy visual environments can create a lot of symptoms and a sensitivity of motion of being too aware of the periphery, a lot of times convergence insufficiency can just be a matter of as simple as the sounds not knowing where to look. If we can learn where to look, then again that label is just a temporary endpoint that doesn't apply anymore.

I was in a motor vehicle accident 17 years ago and have convergence insufficiency from the injury. I am unable to read or do work on a computer for extended periods. Some days I can read for 30 min, other days not even 5 minutes. Even grocery shopping is affected by looking for products or reading labels.

What can I do to improve or correct convergence insufficiency?

Answer transcribed from <a style="color: rgb(17, 85, 204); background-color: rgb(255, 255, 255);" rel="noopener noreferrer" href="https://www.brightwayhealth.org/podcast-episodes/3%3A-dr.-bryce-appelbaum" target="_blank">Brightway's Interview with Dr. Bryce Appelbaum</a>:&nbsp; Good question. I would definitely say maybe. What that means is it depends on the type of brain injury and the type of case. If a brain injury is causing eye alignment problems, it would be very hard to suspect an eye muscle strength or length issue unless one of the cranial nerves is impacted. If the eyes are not acting like they're working together, it's almost always a coordination problem. If we’re addressing it from a mechanical standpoint, then we'd say somebody's eyes are turned in because the outside muscle out here needs to be shortened so it's easier for the eyes to stay straight. However, knowing that vision occurs in the brain, it needs to be addressed on a brain basis rather than my muscle basis.&nbsp;I would urge everyone who goes into any surgery to do a ton of research ahead of time to make sure they know all the complications and the success rates. Strabismus surgery or eye muscle surgery is rare to improve to create a functional cure as well as a cosmetic cure. I think the best-case scenario would be hoping there is a cosmetic cure, but regarding whether the eyes are pointing and looking like they're working together, to me it's so much more important to know how they're acting. I think being able to learn how to use images together, eliminate double vision, and establish order from a disordered visual world, that's kind of the name of the game for vision therapy. On the other hand, the types of eye problems where you're born with an eye in or out or up or down, are usually much more successful with any type of surgical means. If it's something that's acquired, it kind of depends on what caused that eye turn. But again, how the eyes are acting I think is way more important than how they look.

I had corrective surgery to straighten strabismus in my left eye after my TBI. The surgery was 15 years ago but now I see two separate images, and it worsens when I'm stressed or really concentrating.

Will my brain be able to fuse the two images together?

You can try a couple of different websites to locate vision therapists.  One is the College of Optometrists in Vision Development: <a href="https://locate.covd.org" target="_blank">https://locate.covd.org</a> and the other is the Neuro-Optometric Rehabilitation Association: <a href="https://nora.memberclicks.net/find-a-provider#/" target="_blank">https://nora.memberclicks.net/find-a-provider#/</a>
 
That said, often neuro-physical therapists and occupational therapists do some vision therapy as well, especially if it relates to balance / vestibular issues, headaches, or other issues.  Sometimes these folks are more accessible.

Johns Hopkins Wilmer Eye  Clinic. Baltimore, Md If you come from out of town, they have a coordinator that help you with nearby accomadations. Excellent eye surgery done there.

There were answers about successful therapy but no names of vision therapists given or how they found them.

Where can I find vision therapists?

Yeah I had it. My peripheral vision was all screwed up, I could barely see anything, and visual therapy brought back like 90% of it.

I too have damaged peripheral vision; so superman78, could you please specify what kind of visual therapy you used so that I too may ontain similar 90% recovery? Like what  types of doctors/specialists/organiz did you see to acquire the needed therapy?

Hi, I too would like to know about what specialists were seen and what the therapy looked like as I have been told there is no therapy following hypoxic injury (my son's). I am really trying to drill down and find out what works and what doesn't.  Has anyone had a cortical vision impairment?   Thanks

My husband did. We went to a neuro ophthalmologist and he recommended it. They did it at his office. His evaluation showed improvement but he does still have double vision. In 2 weeks we go back to see if he needs new prism glasses and/or more eye therapy.

In comments I saw vision therapy helped but not at what locations. As the two survivors seem to have had improvements, maybe they could share their doctors/location or how they went abour finding a vision therapist.

I went for two years. I’d probably still be there if workmen’s comp hadn’t cut it off. Dr said I should still be going but I couldn’t afford it. It helped a lot. At first, it drove me crazy but it helped.

Yes, I have been through vision therapy.  You see, one of the consequences of my brain injury is that my left field of vision is missing in both eyes, and I got a pair of glasses that are a big help.  My glasses have a prism on the right lens because there is zone just to the left of center that I cannot see in addition to the far left.  These glasses allow me to see that zone and to look wth both eyes beecause my left eye turns out to make up for my lost left field of vision. I went to my eye doctor's office for vision therapy to learn about my new glasses.

It has been recommended that my son tries it. He's 5, 5 years since his tbi occurred. It’s still all new to me. Any advice or opinions are appreciated.

Has anyone been through vision therapy? 

I went to one vision therapy appointment years ago and along w my prism lens I was given exercises to do at home. Physio can be an option too as I know where I go they do eye therapy on concussion patients.

I was told by my neurooptalmologist that OT and PT can't help until you reach a certain point with vision therapy. I found this to be very true bc my Workmans comp wanted me to start with OT/PT first and it actually made it worseCall your insurance and ask them if there is a neuroptalmologist in your network. Or you can do what I did and fight them. I had to submit my whole medical file and provide evidence why this doctor is so different from any other eye doctor.It took some time but I won. Good luck!

I sustained a severe TBI over 20 years ago. I have just recently started to advocate for myself on different doctors and in helping things that I’ve been struggling with for 20 years. Because as you may know 20 years ago they didn’t have the support available to TBI patients like they do now. I have been to a vision therapist who says he could help me and I was feeling like he could with the exercises and the things he was doing with me on a weekly basis. However he does not take insurance at all, and he is very very expensive. So I have to look into different avenues. Someone had suggested occupational therapy.￼￼￼￼￼

Can occupational therapy help with someone who has vision issues? 

You can look up the NORA website to find a provider that has the training to help and support your healing with your vision. It can get better!

Neuro-optometry can help and mild hyperbaric chamber therapy treatments.

Even better when you carefully park your car and it’s 1 1/2 feet over the line that you carefully navigated.

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