Vision Therapy: Ocular Motor Training in Mild Traumatic Brain Injury

Abstract

Vision therapy in the form of ocular motor training is increasingly used to treat visual complaints, particularly in the setting of persistent symptoms after mild traumatic brain injury (mTBI). In this review, we discuss the rationale behind this intervention and the evidence for its utility. Although the efficacy of exercises for primary convergence insufficiency is plausible and supported by data, there is not yet strong evidence of benefit for the post‐traumatic variant. It is not established that abnormalities in fixation, pursuit, and saccades in mTBI are the cause of post‐concussive symptoms, or that these abnormalities arise from ocular motor damage rather than being secondary effects of cognitive problems with attention or executive control. The few studies to date have significant methodological weaknesses. More substantial evidence is required before vision therapy can be accepted as a useful tool in the rehabilitation of patients with brain trauma. ANN NEUROL 2020;88:453–461

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“…These authors attributed observed improvements to stabilization of vergence and accommodation. Nonetheless, in a recent review Barton and Ranalli (2020) referenced a Cochrane review to suggest that the evidence pertaining to the efficacy of oculomotor training in the above studies had a "very low certainty." Some of the specific points of criticism included very small sample sizes, fairly high drop-out rates (between 25 and 45%) as well as the use of a rapid serial visual presentation task during training sessions, a technique that, according to the authors, clearly requires sustained attention, concentration and working memory.…”

“…Some of the specific points of criticism included very small sample sizes, fairly high drop-out rates (between 25 and 45%) as well as the use of a rapid serial visual presentation task during training sessions, a technique that, according to the authors, clearly requires sustained attention, concentration and working memory. Barton and Ranalli (2020) thus contended that observed functional improvements in the mTBI group on the clinical Visual Search and Attention Test (VSAT) in the Yadav et al (2014) study could be attributed to inadvertent training of attention rather than eye movements. The authors further noted that one of the most common oculomotor deficits in mTBI related to version, such as visually guided saccades, typically do not appear anomalous until the patient is placed under conditions of increased cognitive workload with working memory and attentional demands (i.e., antisaccades and memory guided saccades).…”

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