The Neuro-Optometric Rehabilitation Association International is an interdisciplinary group of professionals dedicated to providing patients who have physical or cognitive disabilities as a result of an acquired brain injury with a complete ocular health evaluation and optimum visual rehabilitation education and services to improve their quality of life.

BLOG: The OD belongs on the team

Curtis R. Baxstrom

by Curtis R. Baxstrom, OD, FCOVD, FAAO, FNORA

Patients who suffer a traumatic brain injury often have a team of rehabilitation professionals assisting in their recovery. Given that up to 90% of these patients have a visual dysfunction as a result of their injury, it is very important for an optometrist to be part of that rehabilitation team.

Although other professionals, such as occupational and physical therapists, can be invaluable in screening for visual problems, they may not always be able to diagnose or treat appropriately.

For example, a patient who presents with left field loss can often be helped with vision therapy to address unilateral spatial inattention. But if the field loss is actually due to a corneal ulcer, papilledema or Terson’s syndrome, therapy will not help and may delay access to appropriate treatment.

As optometrists, we have the ability to guide therapeutic rehabilitation but also to use specialized tools that can only be prescribed by an eye care professional, such as lenses, prisms, selective occlusion, and tints or filters. I recently saw a patient with visual-vestibular dysfunction who had seen very little improvement over several months of vision therapy with another provider. It turns out that the patient had visual motion sensitivity. The low-plus lenses I prescribed brought immediate improvement by improving the vestibulo-ocular reflex gain and resulted in clear vision during the dynamic visual acuity test.

By addressing the visual issues as part of the rehabilitation team, we can often help a patient succeed in other areas of therapy and speed up their return to normal function. For example, I might treat a patient who has an eye turn from cranial nerve paresis with binasal occlusion instead of unilateral patching. This form of selective occlusion eliminates the patient’s double vision, promotes recovery of range of motion of the paretic eye and preserves the peripheral vision needed for balance and mobility.

There is increasing recognition of the role of vision post-traumatic brain injury (TBI) and great demand for optometrists who can work collaboratively with hospitals, concussion care clinics and rehab facilities. A typical scenario for me is to evaluate a patient while he or she is in the hospital for intensive inpatient rehabilitation. I may see them once or twice at that facility before they are discharged home or to a skilled nursing facility, after which they come to my office for further treatment.

Unfortunately, in most parts of the country, we have a shortage of optometrists providing these services. At a minimum, I would like primary care optometrists to be aware that patients with visual-vestibular dysfunction after TBI may need adjustments to their vision correction. They will typically do better with single-vision lenses for far and near. Progressive lenses or bifocals introduce motion in the periphery, which is very challenging post-TBI. Additionally, patients who have previously been successful with monovision may no longer be able to tolerate it. The injured brain may not be able to suppress the unfocused image, so restoring binocularity can be helpful.

For those who are interested in learning more about how to provide rehabilitation services, I recommend taking the Clinical Skills I and Clinical Skills II weekend courses offered at the NORA annual conference.

As our knowledge base surrounding TBIs grows, optometric rehabilitation will continue to be a growth area for practices. We have a wonderful opportunity to work collaboratively with colleagues in rehabilitative medicine and occupational and physical therapy for the benefit of patients who have suffered from brain injuries.


Ciuffreda KJ, et al. Optometry. 2007;doi:10.1016/j.optm.2006.11.011.

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Curtis R. Baxstrom, OD, FCOVD, FAAO, FNORA, is in private practice in Federal Way, Wash., specializing in vision therapy and rehabilitation. His practice consists of special needs patients, learning disabled children and patients who have suffered TBIs or stroke. He is also adjunct faculty at Pacific University College of Optometry where he lectures for several courses and is director of the Vision Northwest-Vision Therapy, Rehabilitation and Pediatric Eye Care Residency Program. He is the immediate past president of the Neuro-Optometric Rehabilitation Association (NORA).

Baxstrom will offer a lecture on the topic of optometric involvement on the rehab team at the NORA annual conference, Sept. 19-22, 2019, in Scottsdale, Ariz. For schedule and registration, visit

Disclosure: Baxstrom reports no relevant financial disclosures.

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