Can Vision Therapy Help After a Brain Injury?

A traumatic brain injury (TBI) — a concussion on the soccer field, a fall, a car accident — can change how a person sees long after the scans come back normal. Blurred or double vision, trouble reading, sensitivity to light and dizziness in busy places are among the most common complaints we hear after a head injury.

Here is what a brain injury does to the visual system, what neuro-optometric rehabilitation involves, and, honestly, what the research does and does not show. For the wider literature, start with our pillar article, Vision problems after concussion: what the research shows.

Key takeaways

• Vision problems are common among people referred for care after a brain injury: 90% of TBI outpatients in one vision-rehabilitation clinic had an eye-movement or focusing problem (Ciuffreda et al., 2007), and about seven in ten adolescents in concussion programs had a vision diagnosis (Master et al., 2016; Scheiman et al., 2021).
• Most children’s visual symptoms settle on their own within about four weeks. The American Academy of Pediatrics and its co-authoring eye-care bodies recommend a vision-specific examination for those that do not (Master et al., 2022).
• Vision therapy after brain injury is supported by uncontrolled case series and two small controlled studies, not by large trials. No controlled trial has shown that it speeds overall concussion recovery.
• The best care comes from a team: neurology or sports medicine, physical and occupational therapy, and a neuro-optometrist working together.

How a brain injury affects vision

The eyes have to focus, aim and move as a team, and the brain has to make sense of what comes in. A jolt to the head can disturb any of those links even when the eyes themselves are perfectly healthy. A review by Kapoor and Ciuffreda groups the visual consequences of TBI into focusing, eye movements, eye teaming, light sensitivity, visual field loss and ocular health (Kapoor & Ciuffreda, 2002).

Focusing (accommodative) problems. The eye’s focusing system can become slow, weak or hard to sustain. Print blurs, the eyes tire quickly and headaches follow near work. See accommodative disorders.

Eye teaming (vergence) problems. To read, both eyes must turn inward together and hold that alignment. When they cannot, words double or slide out of place. This pattern — convergence insufficiency — is one of the most common diagnoses in concussion samples and a leading cause of double vision after a head injury.

Eye-movement (saccadic and pursuit) problems. Reading requires quick, accurate jumps along a line; following a ball requires smooth tracking. Either can become inaccurate or effortful. See ocular motor dysfunction.

Visual field loss. In a retrospective analysis of 220 acquired-brain-injury outpatients, 46.36% had a field defect; after TBI the most common type was scattered patches of reduced sensitivity (58.06%), while after stroke half-field loss predominated (47.5%) (Suchoff et al., 2008). Field loss quietly affects reading, walking in crowds and driving.

Light sensitivity (photophobia). Bright light and screens can be genuinely painful, and recovery is slow. Among 62 adults aged 18 to 40 who already had light sensitivity after a mild TBI, half showed a reduction over time, most of it after the first year; continued tinted-lens use was associated with persistence, while avoiding tints was associated with recovery (Truong et al., 2014). That is why we prescribe tints thoughtfully and plan to taper them.

How common are these problems?

The numbers depend heavily on who is examined. In a specialty vision-rehabilitation clinic, 90% of 160 TBI outpatients and 86.7% of 60 stroke outpatients had an oculomotor dysfunction (Ciuffreda et al., 2007). Among 100 adolescents in a concussion program, 69% had a vision diagnosis: accommodative disorders 51%, convergence insufficiency 49%, saccadic dysfunction 29% (Master et al., 2016). Among 113 adolescents examined 4 to 12 weeks after concussion, 70% had an oculomotor diagnosis — and brief office screening caught only 63% of the abnormal convergence findings and 43% of the reduced focusing findings (Scheiman et al., 2021). Adults are affected too: among 103 adults still reporting neurological symptoms 2 to 6 months after a concussion, 20.4% had symptomatic convergence insufficiency, and they carried a heavier overall symptom load (Nisted et al., 2024).

These are referral samples without uninjured comparison groups, so they overstate how common vision problems are after concussion in general. What they show is that when symptoms persist, a measurable vision problem is more likely than not.

Many people recover on their own, and that matters

The 2022 clinical report from the American Academy of Pediatrics, the American Academy of Ophthalmology, AAPOS and the American Association of Certified Orthoptists states that visual symptoms are common after concussion, that most children recover on their own by four weeks, and that those who do not deserve a vision-specific examination of acuity, alignment, pursuits, saccades, the vestibulo-ocular reflex, near point of convergence and accommodation (Master et al., 2022). The natural history agrees: of 67 children with an abnormal near point of convergence after concussion, 46% recovered with standard care alone, 41% after vestibular therapy that included convergence exercises, and only 13% were referred for office-based vision therapy (Storey et al., 2017). That shapes how we practice. Early on we take our lead from the physician managing the injury and the return to activity, and we reserve vision therapy for the subset whose visual problems persist.

What neuro-optometric rehabilitation involves

Neuro-optometric rehabilitation is provided by optometrists with additional training in binocular vision and acquired brain injury, working alongside vision therapists. Dr. Christina Murray is a Fellow of Optometric Vision Development and Rehabilitation (FOVDR). Our vision rehabilitation program has four parts.

1. An evaluation that goes well beyond 20/20: focusing, convergence, fusional reserves, saccades and pursuits, the vestibulo-ocular reflex, visual fields and light sensitivity.
2. Lenses, prisms and tints. Modest plus lenses can relieve focusing fatigue, prism can realign the two images in double vision, and tints can make light tolerable while the system recovers. See prisms.
3. Office-based therapy with home reinforcement. The procedures are the vergence and accommodative activities tested in the Convergence Insufficiency Treatment Trial in uninjured children, where office-based therapy produced a successful or improved outcome in 73% versus 35% with placebo (CITT Study Group, 2008). The larger 2019 replication is an important corrective: office-based therapy again improved the eye-teaming measures far more than placebo, but symptom scores improved about as much in the placebo group (CITT-ART, 2019, treatment), and reading-comprehension gains were identical in the two groups (CITT-ART, 2019, reading). So we borrow the procedures, not a promised outcome. After a brain injury we grade and pace them carefully to avoid flaring headaches or dizziness. One of the simplest tools is the Brock string — see Who is Brock, and why does he string?
4. Coordination with the rest of the care team, described below.

What the evidence shows, honestly

Case series suggest benefit in people who finish therapy. In a university clinic, 40 patients (33 mild TBI, 7 stroke) completed therapy out of 220 records reviewed; 90% of the TBI group showed marked or total improvement in at least one primary symptom and one primary sign (Ciuffreda et al., 2008). Across 218 post-concussion records from two private practices, therapy was recommended for 80% of patients; 54% of those advised (95 of 175) completed it, and among the completers with convergence insufficiency 85% were classed as successful and 15% as improved (Gallaway et al., 2017). Encouraging — but neither study had a comparison group, both count only the people who finished, and, as the Storey data show, some of that improvement would have happened anyway. The 2017 authors themselves call for prospective trials.

Two small controlled studies show the eye measures improve. A crossover study of 12 adults with mild TBI found that oculomotor training significantly improved vergence speed, convergence amplitude, depth perception, symptoms and visual attention, while placebo training changed nothing (Thiagarajan & Ciuffreda, 2013). A randomized trial of 50 people aged 11 to 30, seen within 10 days of concussion, found that home Brock string exercises improved the near point of convergence by 8.9 cm versus 3.8 cm with usual care over one to two weeks (Trbovich et al., 2025). Both are small, and both measured a clinical sign rather than return to school, work or sport.

What is still missing. A 2018 Cochrane review of interventions for eye-movement disorders after acquired brain injury found only five randomized trials with 116 participants in total and concluded that they provide insufficient evidence to inform treatment decisions (Rowe et al., 2018). No controlled trial has shown that vision therapy shortens overall concussion recovery. The AAP report goes only as far as saying that early identification and management of convergence or accommodative insufficiency may mitigate the effects of concussion. Anyone promising more than that is ahead of the data.

Working with neurology, physical therapy and occupational therapy

Vision is rarely the only system affected. Among 101 children referred to a concussion program, vestibulo-ocular dysfunction — trouble holding the eyes steady while the head moves — was present in 28.6% of those with acute sport-related concussion and 62.5% of those with post-concussion syndrome, and it raised the adjusted odds of developing post-concussion syndrome about fourfold (Ellis et al., 2015).

So we co-manage. The neurologist or sports-medicine physician directs medical recovery and return to play; vestibular physical therapy addresses balance and gaze stability; occupational therapy addresses daily function and the return to work or school. We treat the visual deficits we can measure and send findings and progress reports back to the team. If dizziness is a leading complaint, see vision therapy for motion sickness and dizziness.

Our clinical perspective at Vision & Learning Center

We see children and adults after concussions, car accidents, falls and strokes at our Coconut Creek, Boynton Beach and West Palm Beach offices. Offered as clinical experience rather than settled science: the visual system deserves a careful look whenever post-injury symptoms last beyond about a month, and sooner if there is double vision or a suspected field loss. Therapy should target deficits we have actually measured, with goals we can re-measure, and it should end when those goals are met. We use prism for stable double vision; reports that prism relieves broader post-concussion symptoms come from one linked physiatry-and-optometry practice’s uncontrolled series (Doble et al., 2010), so we call that use promising rather than proven — see our evidence review of prism lenses for binocular vision dysfunction.

When to schedule a vision evaluation after a brain injury

Consider a neuro-optometric evaluation if any of these persist more than a few weeks after a head injury:

• Blurred vision that comes and goes, especially with reading or screens
• Double vision, or closing one eye to see clearly
• Losing your place, skipping lines or rereading
• Headaches or eye strain with near work
• Sensitivity to light or to screens
• Dizziness in busy visual environments, or bumping into things on one side

Our concussions page describes how we evaluate these problems, and our symptom checklist helps you organize what you have noticed before your visit.

If vision is still getting in the way of recovery after a head injury, we invite you to book a comprehensive evaluation at any of our four offices — Schedule an evaluation online today.