Neuro-optometric rehabilitation is known by many names, including neuro-optometry, vision rehabilitation, and brain injury rehabilitation. These services provide assessment and management of visual problems stemming from neurological etiologies such as traumatic brain injury, stroke, cranial neuropathies, or multiple sclerosis. It is important to note that neuro-optometric rehabilitation differs from neurology and neuro-ophthalmology: neuro-optometric rehabilitation services address the vision issues caused by problems in the neurological system, while the neurologist and neuro-ophthalmologist address the brain issues that are the source of the vision problems. In other words, the neuro-optometric specialist focuses on managing visual, perceptual, and oculomotor disorders that affect the visual performance and vision quality.
A neuro-optometric examination includes a comprehensive eye examination with ocular health exam, and special attention to sensorimotor, binocular, and accommodative function. Evaluation includes assessment of pupil function, tracking abilities (pursuits and saccades), oculomotor function, and visual fields. The practice of neuro-optometric rehabilitation may include components of low vision, vision rehabilitation, and/or developmental optometry. Some neuro-optometrists practice with a focus on visual development and visual perception, including learning disorders. Others incorporate vision rehabilitation into their low vision or primary care practices. Regardless of the practice mode, the goal of neuro-optometric rehab is the same: to diagnose and minimize visual disability and functional sequelae of a neurological deficit, and to support activities of daily living (ALDs), such as reading and mobility.
What conditions are diagnosed and managed within neuro-optometric rehabilitation?
There are many visual sequelae of neurological conditions that are commonly and appropriately managed with neuro-optometric rehabilitation:
- Oculomotor dysfunction: These sequelae may include tropias and large phorias that impair or inhibit fusion, and can be associated with poor tracking and difficulty reading.
- Binocular vision and accommodative dysfunction: These common complications of traumatic brain injury and post concussion syndrome can be associated with eye strain and headaches.
- Cranial nerve palsy: This cause of diplopia can be of traumatic, vasculopathic, or neurologic etiology.
- Spatial disorientation: This deficiency in proprioception causes an inability to accurately determine the body's position and movement in space. This can be associated with visual field defects or poor depth perception, and can occur alongside visual neglect.
- Visual field deficits: Such loss is common after acquired brain injuries and coping mechanisms can be addressed through rehabilitation.
Indications for Neuro-optometric Rehabilitation:
- traumatic brain injury
- cardiovascular accident
- post-concussion syndrome
- cranial neuropathy
- oculomotor dysfunction
- accommodative dysfunction
- binocular vision dysfunction
- visual-spatial dysfunction
- developmental delays
What kind of treatments does neuro-optometric rehabilitation provide?
The core of therapy is to provide methods and tools to improve each patient’s daily activities of living. Therefore, management includes individualized treatment plans that may incorporate prescription of optical, non-optical, and electronic assistive devices. Components of other specialties such as vision therapy and low vision may be incorporated as well. Counseling on lifestyle changes may also be appropriate, and may include sleep hygiene, the importance of exercise, and proper electronic device use. Ongoing evaluation to assess vision and address new patient needs is also crucial.
Neuro-Optometric Treatment Methods
- Optical tools: Prescription lenses, prism and filters can be employed to improve visual comfort and clarity.
- Non-optical tools: Magnifiers, occlusion, or patching may be employed. Video magnifiers or text-to-speech apps may be helpful.
- Coping strategies: Eccentric fixation and scanning, may also be necessary for some of neuro-rehab patients.
Many, if not all, of these patients require an interdisciplinary and integrated care team. This team starts with the neurologist, neuro-ophthalmologist, or primary care provider who is managing the underlying neurological entity and may have referred the patient for rehabilitation. The patient may also be seeing other eye care specialists, a retinal specialist for example, if the etiology or sequelae of the neurological deficit calls for it. The team may include social workers to coordinate care and resources; occupational, vocational, and physical therapists who train new skills and modify tasks so that they can be accomplished despite any visual impairment; orientation and mobility specialists who help the patient learn to move efficiently and safely through their environment; and of course, neuro-optometric rehab specialists who evaluate the visual impairment and prescribe management plans for overcoming and coping with vision loss.
Furthermore, the visual dysfunction associated with neurological disorders can provoke psychological complications, such as depression and anxiety. It is important the neuro-optometrist be educated and prepared to detect signs of depression or anxiety, and refer to mental health specialists as indicated. Coordination of care is imperative for these patients and the neuro-optometric rehab specialist must advocate for the patient to receive any and all services that may assist in the patient’s journey to recovery, as the basis of neuro-optometric rehabilitation is collaboration with the patient’s interdisciplinary team.
Who can offer neuro-optometric rehabilitation care?
With the right expertise, any licensed optometrist can provide neuro-optometric rehabilitation services. Because there are various approaches to this specialty, each neuro-optometry practice may look a little different. For example, vision rehabilitation and low vision are often offered at VA Medical Centers, where an integrated team of neurologists, optometrists, and physical therapists are readily available; neuro-optometry and vision rehabilitation can be practiced within a neuro-rehabilitation hospital or an academic setting; low vision and neuro-optometric care may be incorporated into a primary care practice.
Any level of neuro-rehab expertise can be incorporated into any given mode of practice. A primary care optometrist who is familiar with detecting and diagnosing neuro-optometric conditions can identify neurological issues during a comprehensive eye examination, then refer to a colleague who specializes in neuro-optometric rehabilitation for further management. If knowledgeable and interested, the same doctor may offer therapy for some aspects and refer for others. As the doctor increases their neuro-optometry expertise, their practice can grow and incorporate more treatment options. It does not have to be all or none; neuro-optometry can be practiced at many levels.
Optometrists of all specialties can learn to be receptive to patient complaints of difficulty with visual tasks and poor comprehension, poor vision despite appropriate refractive error correction, or frequent headaches. These symptoms may improve with neuro-optometric rehabilitation if the patient has a recent or past history of a neurological condition. Moreover, if a patient presents with no prior diagnosis, but the optometrist’s findings include visual sequelae of a neurological etiology, it is imperative to refer the patient for further evaluation and diagnosis of the underlying condition. Therefore, a robust referral network is critical, and it is very beneficial for neuro-optometric rehabilitation specialists to have an established working relationship with a neuro-ophthalmologist or neurologist.
What certifications or specialty training is required?
No certification or specialty license is required, though thorough knowledge of the affected visual systems and management options is necessary. To increase knowledge and expertise in this type of practice, seek out literature and seminars on the topics that are most interesting. Make use of both in-person and online resources. Network with those already practicing neuro-optometry and find an experienced mentor who is willing to help.
- The American Optometric Association offers a Brain Injury Electronic Resource Manual (BIERM) that is available to members and nonmembers, as well as related EyeLearn lectures that are available to members.
- The Optometric Extension Program Foundation offers several multi-day curricula on topics related to neuro- optometric rehabilitation.
- Consider a higher learning fellowship program which incorporates learning through research, case analysis, and sometimes publication. The Neuro-Optometric Rehabilitation Association (NORA) includes a focus on behavioral optometry, and their website offers a video/audio reference library. The College of Optometrists in Vision Development (COVD) offers a fellowship with a focus on developmental optometry.
- For more intense training, consider a residency program designed to manage neuro-optometric rehabilitation patients. Many of these residencies have multiple areas of emphasis, which may include neuro-optometric rehabilitation along with brain injury vision rehabilitation, ocular disease, pediatrics, or low vision. Search for one that meets all interests at the ASCO Residency Program Directory.