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Signs and Symptoms

Behavior Observed

Suspected Deficit

Focusing problems

Accommodative problem

Possible Third nerve injury

Covering or closing an eye


Third, Fourth Sixth nerve injury

Blurred, or fluctuating vision

Accommodative spasm

Binocular disorder

Refractive error

Headaches with use of eyes

Accommodative insufficiency

Convergence insufficiency

Binocular disorder

Diplopia (Double vision)


Third, Fourth, Sixth nerve injury

Loss of place when reading

Oculo-motor dysfunction in saccades

Visual attention deficit

Spatial relations deficit

Visual field loss and/or neglect

Occipital cortex injury

Parietal cortex injury

Tendency to reread and/or reversals

Oculo-motor dysfunction in saccades

Visual attention deficit

Spatial relations deficit

Head tilt

Hyper or hypo-tropia

Fourth nerve injury

Asthenopia (Eye strain)

Binocular disorder, Accommodative or convergence problem

Poor attention for visual tasks

Visual perception deficit

An eye turns in, out, up, or down


Third, Fourth, Sixth nerve injury

Visual confusion

Visual perception deficit

Poor eye-hand coordination

Ataxia of smooth ocular pursuits

Visual-motor integration deficit

Poor localization

Spatial relations deficit

Depth perception deficit


Ataxia of ocular fixations,


Orientation and Mobility

Balance and Posture





Visual Problems Resulting From Brain Injury and Stroke

Although there are many visual problems that arise from brain injury and stroke, three are more devastating and impairing than the rest. These are visual field loss, intractable double vision, and visual / balance disorders.


With a visual field loss the patient loses half of their field of vision. This places the person at increased risk of further injury and harm from bumping into objects, being struck by approaching objects, and falls.


A two-fold approach is used to treat visual field loss. Visual rehabilitation activities are prescribed by the doctor and administered by the therapist to teach scanning of the hemianopic field loss. This is a difficult task. It is the act of seeing something that brings our visual attention and scanning to bear. However, these patients do not see the field they are being trained to scan and attend. Therapy is aimed at teaching that and several approaches have been developed to assist in this, but remediation still requires a lot of effort and patience.


Special visual field awareness prism lenses are used in treating visual field loss. As the patient scans into the prism the optics are shifted so as to perceptually gain about 15 to 20 degrees of visual field recognition. Since diplopia is perceived when scanning into the prism, fixation in the prism must be brief. These are used as spotting devices only to determine if there is an object in the periphery that deserves further visual attention. When such an object is spotted, the patient turns their head to view it in detail with their intact central vision.


Double vision (diplopia) is a serious and intolerable condition that can be caused by strabismus, ophthalmoplegia, gaze palsy and decompensated binocular skills in patients with brain injury, stroke and other neurologically compromising conditions. Prisms, lenses and / or vision therapy can often times help the patient achieve fusion (alignment of the eyes) and alleviate the diplopia. If and when these means are not employed, the patient may adapt by suppressing the vision of one eye to eliminate the diplopia. If lenses, prisms, and / or therapy are not successful and the patient does not suppress, intractable diplopia ensues.


In this population of patients, patching has frequently been used to eliminate the diplopia. Although patching is effective in eliminating diplopia it causes the patient to become monocular. Monocular as opposed to binocular vision will affect the individual primarily in two ways; absence of stereopsis and reduction of the peripheral field of vision. These limitations will directly cause problems in eye hand coordination, depth judgments, orientation, balance, mobility, and activities of daily living such as playing sports, driving, climbing stairs, crossing the street, threading a needle etc.


A new method of treating diplopia that does not have these limitations has been successfully evaluated. It is called the “spot patch” (invented and named by this author) and is a method to eliminate intractable diplopia without compromising peripheral vision. It is a small round or oval patch made of Transpore tape, 3-M blurring film (or another such translucent tape). It is placed on the inside of the lenses of glasses and directly in the line of sight contributing to the diplopia. The diameter is generally about one centimeter, but will vary on the individual angular subtense required for the particular strabismus, or gaze palsy.


Visual balance disorders can be caused by oculo-motor dysfunction in fixations, nystagmus, and disruptions of central and peripheral visual processing. A full description of these disorders is beyond the scope of this paper. The treatment will depend on the visual diagnosis and etiology. Lenses, prisms and visual rehabilitation activities are used in the remediation of these disorders.

Vision Problems Following Traumatic Brain Injury, Stroke, Multiple Sclerosis, Aneurysm, and Other Neurologic Diseases/Injuries

  • Visual Field Loss

  • Hemianopsia (Loss of half of the field of view right or left)

  • Quadranopsias (Loss of about 1/4 sector of the visual field)

  • Central Loss

  • Peripheral Loss

  • Total Loss of Visual Field

  • Attitudinal Losses (Loss of upper or lower portion of the visual field)

  • Photophobia (Sensitivity to light)

  • Reading Disorders

  • Diplopia

  • Exotropia (An eye turns out)

  • Esotropia (An eye turns in)

  • Hypertropia (An eye turns up, or down)

  • Ophthalmoplegia (Paresis of nerves controlling eye muscles & function)

  • Changes in prescription can become significant

  • Nystagmus (Uncontrolled shaking of the eyes)

  • Lagophthalmos (Incomplete blink)

  • Dry Eye

  • Decreased Blink Rate

  • Visual Hallucinations

  • Anisocoria (Unequal pupil sizes)

  • Pupil Abnormalities

  • Accommodative Problems (Focusing disorders)

  • Convergence Problems (Eye teaming disorders)

  • Eye Movement Problems: Fixation, Pursuit (Tracking), Saccade (Scanning)

  • Headaches (Related to use of eyes)

  • Visual Perceptual Disturbances

  • Disturbances of spatial relationships

  • Agnosia – difficulty in object recognition

  • Apraxia – difficulty in manipulation of objects

Modified from a list by Allen Cohen, O.D. and Lynn Rein, O.D.

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