Post Trauma Vision Syndrome & Visual

Midline Shift Syndrome

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NeuroRehabilitation 6 (1996) 165-171

By William V. Padula, OD, SFNAP, FAAO, FNORA*, Stephanie Argyris
Abstract
Following a neurological event such as a traumatic brain injury (TBI), cerebrovascular
accident (CVA), Multiple Sclerosis (MS), etc. Vision imbalances can occur between the
focal and ambient visual process that can affect balance, posture, ambulation, reading,
attention, concentration and cognitive function in general. Post Trauma Vision
Syndrome (PTVS) and Visual Midline Shift Syndrome (VMSS) can be the cause of these
difficulties. This paper discusses the symptoms and characteristics of these syndromes
as well as methods of treatment.
Keywords: Post trauma vision syndrome; Visual midline shift syndrome; Vision;
Traumatic brain injury; Cerebrovascular accident
1. Introduction
Following a neurological event such as a traumatic brain injury, cerebrovascular
accident, multiple sclerosis, cerebral palsy, etc., it has been noted by clinicians that
persons frequently will report visual problems such as seeing objects appearing to
move that are known to be stationary; seeing words and print run together; and
experiencing intermittent blurring. More interesting symptoms are sometimes reported
such as: attempting to walk on a floor that appears tilted and having significant
difficulties with balance and spatial orientation when in crowded, moving
environments.
These types of symptoms are not uncommon. Frequently, persons reporting these
symptoms to eyecare professionals (optometrists and ophthalmologists) have been
told that their problems are ‘not in their eyes’ and that their eyes appear to be
healthy. In many instances persons experiencing these difficulties also experience
anxiety with these symptoms and are often referred to psychologists or psychiatrists in
an attempt to treat their anxiety. The referral for psychological or psychiatric care is
sometimes made based on a diagnosis of hysteria without recognizing that many of
these individuals are suffering from syndromes affecting the visual process in the
brain. These syndromes have been called Post Trauma Vision Syndrome (PTVS) and
Visual Midline Shift Syndrome (VMSS) [11].
Recent research has documented PTVS utilizing Visual Evoked Potentials (VEP) [2].
This documentation concludes that the ambient visual process frequently becomes
dysfunctional after a neurological event such as a TBI or CVA. Persons suffering from
a neurological event begin to experience a wide variety of symptoms as a result of
dysfunction in this portion of the visual system. Yet persons who are experiencing
these visual difficulties may frequently have healthy eyes and relatively normal visual
acuity.

2. Vision: the process

The visual system is composed of two separate processes. The process that we are
most familiar with has been called the focal process [3,4]. This process neurologically
is related to the central visual function. The eye represents central vision primarily
through an area called the macula located in the retina. Aiming your eye directly at an
object causes focalization by the brain through the macula.
As noted by Leibowitz and Post [4], the focal process does not have to be delivered
directly by the macula. For example, you can aim your eye at a particular object such
as a doorknob on a door across the room. Fixating on the doorknob represents a
central focalization. However, you can also focalize with your peripheral vision. While
you are aiming your eye at the doorknob, you can use your peripheral vision to
focalize on objects about the room, such as a picture or a chair. The focalization
process, however is most easily delivered through the macula. While you can focalize
in any portion of the visual field, the peripheral vision is primarily used as a general
spatial orientation system. The reason for this is that peripheral vision is mostly a
function of a second visual process called the ambient process.
The ambient process lets you know where you are in space and provides general
information used for balance, movement, coordination and posture. Neurologically,
nerve fibers from the peripheral retina that are part of the ambient visual process
provide axons that are delivered to a level of midbrain where they become part of the
sensory-motor feedback loop. The importance of this system is that it is less
sensorially involved and more motoric in function. It must match information with
kinesthetic, proprioceptive, vestibular, and even tactile systems for the purpose of
orienting and acting as a master organizer of these other processes. Once this is
accomplished, a feed-forward mechanism enables this information to be directed to
higher cortical areas, including the occipital cortex, as well as 99% of the cortex.
The ambient visual process must let you know where you are in space and essentially
where you are looking before you process information about what you are looking at.
Given a neurological event such as a traumatic brain injury (this includes a mild
whiplash) multiple sclerosis, cerebrovascular accident, etc., the ambient visual process
can lose its ability to match information with other components of the sensory-motor
feedback loop. Even a whiplash, as mentioned, can cause significant dysfunction at
the level of midbrain. Thomas [51] has calculated that at the level of the foramen
magnum, as much as 14,000 lbs. of inertial force is exerted on the spinal cord with a
minimal 10 m.p.h. rear-end collision. This can cause a dysfunction in the sensory-
motor feedback loop and more specifically in the ambient visual process. Although this
type of an injury cannot be seen in most cases on a CT scan or MRI, injured
individuals will frequently experience the types of symptoms explained in the
introduction of this paper.

3. Post trauma vision syndrome

Research has been conducted by the authors utilizing Visual Evoked Potentials to
capture this state of dysfunction at the level of midbrain. Subjects were given
binocular visual evoked cross-pattern reversal P-100 evaluation with their best
distance correction.
An experimental group was used in this study. Immediately following phase 1 of the
VEP testing, binasal occlusion and base-in prisms were introduced before both eyes. In
the experimental group there was an increase in the amplitude(N1P1) of the VEP.
This indicates that the ambient process became more organized and provided
appropriate feed-forward spatial information for the higher binocular cortical cells at
the level of the occipital cortex to improve upon states of binocularity and fusion. This
same prism and binasal occlusion for the control group statistically caused a decrease
in the amplitude. In addition for persons without a neurological problem affecting the
ambient visual system, binasal occlusion and base-in prism interferes with visual
processing.
The results of the study along with clinical findings, have led the authors to document
a new syndrome called Post Trauma Vision Syndrome. This syndrome is caused by a
dysfunction of the ambient visual process and has the characteristics, as well as
symptoms, presented in Table 1.
Person’s with PTVS will frequently have characteristics of exophoria or exotropia (a
tendency for the eyes to turn out or an actual eye turned outward), accommodative or
focusing dysfunction, oculomotor dysfunction, convergence insufficiency (a difficulty
converging the eyes and sustaining convergence at a near plane), as well as increased
myopia. The common symptoms frequently include diplopia (double vision), perceived
movement of print or stationary objects, headaches and photophobia (light
sensitivity).
Persons who are not treated for PTVS can experience this syndrome for many years
following a neurological event. Treatment of this syndrome may include binasal
occlusion in conjunction with low amounts of base-in prism and

Table 1
Characteristics and symptoms of Post-Trauma Vision Syndrome
Common Characteristics Common Symptoms
Exotropia Diplopia
Exophoria Blurred near vision
Convergence Insufficiency Perceived movement of print or stationary objects
Accommodative Insufficiency Asthenopia
Oculomotor Dysfunction Headaches
Increased Myopia Photophobia

4. Visual midline shift syndrome

An unusual phenomenon that often occurs following a neurological event, such as
a hemiparesis or hemiplegia, is that the ambient visual process changes its orientation
to concept of the midline. To understand this more completely, let us think for a
moment about the toddler who begins to gain orientation to a standing posture. The
toddler must have organized at various developmental levels concepts of midline that
were established through vestibular, kinesthetic, proprioceptive, and ambient visual
processing. These midlines include but are not limited to a lateral midline, as well as a
transverse midline. The toddler must gain orientation of the midline in order to
develop weight transfer and position sense.
Information from the two sides of the body must be matched through kinesthetic and
proprioceptive systems with ambient and vestibular information. This information
develops experience and creates a set by which the child continues to process
information throughout the developmental years. Given a neurological event such as a
CVA causing a hemiparesis or hemiplegia, information from one side of the body
becomes interfered with. The ambient visual process is a relative processing system. it
attempts to create a relative balance based on the information established. With an
interference of information from one side of the body compared to the other, the
ambient visual process attempts to create balance by expanding its concept of space
on one side of the body compared to the other. In so doing a perceived amplification
of space occurs internally on one side and a perceived compression of space occurs on
the other side. This phenomena causes a shift in concept of midline that usually shifts
away from the neurologically affected side.
The authors have developed a simple test (see Fig. 1) whereby a wand is passed
before the person laterally and the person is asked to state when the wand appears to
be directly in front of the person’s nose. A high correlation has been found with a shift
in midline away from the neurologically affected side. In other words, the person
would frequently report that the object appears to be directly in front of their nose
when in fact it may be shifted to the right (see Fig. 2 and 3). This individual will
frequently have a left hemiparesis or hemiplegia. This shift in concept of midline also
can occur in an anterior posterior axis, causing the individual to experience a midline
shift anteriorly or posteriorly (see Figs. 4-7).
The result is that posture will be affected by either emphasizing flexion as in the
former, or extension in the case of the latter. Combinations of anterior posterior and
lateral shift are quite common. While these individuals do have a neurological problem
such as a paresis to one side, it has been the authors’ experience that frequently
persons involved in physical therapy will not be able to increase weight bearing on
their affected side and/or stand erect without constant reminders from the physical
therapist. The therapist will frequently tell the person to stand straight and the person
will follow these directions. However, after the physical rehabilitation therapy session
is over, a shift away from the neurologically affected side continually occurs,
frequently causing the person to experience a plateau and therapy to be discontinued.

Fig. 1 – Visual midline shift test normal response.

Fig. 2 – Visual midline shift to the right

Fig. 3 – Visual midline shift to the right affecting posture.

Fig. 4 – Posterior visual midline shift

Fig. 5 – Posterior visual midline shift affecting posture

Fig. 6 – Anterior visual midline shift

Fig. 7 – Anterior visual midline shift affecting posture

The authors are stating that there is a visual relationship that occurs through the
ambient visual process. However, it must be understood that there are many
individuals who do benefit from physical therapy programs and can improve function
of their paretic side. Perhaps this is not simply through a strengthening of muscles but
really a total change in neurological processing that occurs at the midbrain level in
relationship to organization of internal space thereby affecting even the ambient visual
process.
Persons with a VMSS will walk as if the plane of the floor is tilted. In fact a number of
individuals with VMSS have reported to the authors that the floor appears to be tilted.
A neuro-optometric treatment approach that works effectively is to utilize prisms
before both eyes positioned in yoked fashion. A prisms is a wedge of glass or plastic.
The thick end is called the base. When the base ends of the prism are positioned in
the same direction for each eye, for example to the right or to the left for both eyes,
this is termed yoked prisms. The effect of the prism is to counter the expansion and
compression of space that is occurring in the ambient visual process. In turn, this
causes the midline to shift to a more centered position.
The authors have noted that clinically persons will frequently shift their weight almost
immediately and increase weight bearing on the affected side. The use of these yoked
prisms is for short durations each day. The reason for this is that prisms provide a
profound change in the ambient visual process and develop a level of experience of
weight bearing in relationship to the ambient system as part of the sensory-motor
system. The effect will be maintained for longer periods of time throughout the course
of rehabilitation. Frequently, the yoked prisms are prescribed to be used in conjunction
with physical and/or certain approaches of occupational therapy. These yoked prisms
are prescribed following a neuro-optometric evaluation.
5. Visual field loss affecting VMSS
Visual field loss following a CVA or TBI often can influence a shift in visual midline
causing a VMSS. A homonymous hemianopsia frequently occurs following a CVA. The
bilateral field loss causes the visual concept of the midline to become centered in the
remaining portion of the visual field. In turn, weight bearing will be shifted away from
the side of the homonymous hemianopsia producing the effect of the VMSS. Yoked
prisms are effective in re-centering the concept of the visual midline and thereby,
increasing weight bearing on the affected side. Eventually, expanded field prisms to
increase the visual awareness into the side affected by the homonymous hemianopsia
can be mounted into the lenses.

6. Conclusion
Persons who have suffered a neurological event have often had visual problems that
have been misinterpreted as well as misdiagnosed. Recent advances in research,
enabling clinicians to gain a better understanding of vision as a process, has
uncovered more then one visual processing system. The ambient visual process is
essentially a silent process. We cannot think in this process. Instead we somehow
develop a level of feeling through this process that establishes one’s organization of
space for balance, movement and coordination, while also providing a spatial net by
which the higher focal process obtains information about detail and identification.
Following a TBI, CVA, or other neurological event individuals frequently lose this
ambient visual process and instead are left with a focal processing system that breaks
up the visual world into isolated parts. This causes individuals extreme difficulty, not
only with balance and movement, but also affects the person in other ways such as in
the person’s tendency to compress and limit his spatial world. This creates experiences
such as an inability to find an object on a shelf in a store. The compression of space
causes a focalization process to function both centrally and peripherally. This has
greater meaning when one thinks of what the experience must be like when all the
bottles, cans and boxes on the shelf suddenly begin to be experienced as massive
amounts of detail causing the persons to be unable to isolate one detail from another.
Movement in a crowded environment also becomes quite disturbing because the
ambient visual process is supposed to assist in stabilizing the image of the peripheral
retina. Without this system the person internalizes the movement that he or she is
experiencing in the peripheral vision. This becomes extremely disturbing and causes
experiences of vertigo, and severe dysfunction. The authors’ have found that the
combination of a low amount of base-in prisms and binasal occlusion have been
extremely effective in almost immediately offering increased stability to the ambient
visual process, thereby reducing the symptoms and enabling the person to re-establish
levels of independence that were otherwise not achieved.
Interference caused by Post Trauma Vision Syndrome can affect higher cognitive
levels of function as well. The focal process is very much related to higher perceptual
and cognitive function. However, the focal process can not function properly unless it
is grounded by the ambient visual system. In turn, this loss of grounding following
PTVS will cause a slowing of responses in general and interference with higher
perceptual cognitive function. Therefore, cognitive therapy should be supported
by neuro-optometric rehabilitation.
Neurological problems affecting states of motor function may be diagnosed and even
related to specific cortical lesions. However, the total impact of function and
performance concerning balance, posture and movement may be interfered with
further by shifts in concepts of the visual midline. The midline with VMSS affects not
only persons who are attempting to ambulate, but also those individuals that are
wheelchair bound causing them to lean to the side, forward or backward. Yoked prism
therapeutic lenses can make significant changes in concept of midline, thereby
affecting posture, balance and movement. The use of these yoked prisms can be
developed in a transdisciplinary approach, so that they may be incorporated into
existing physical and/or occupational therapy programs. The authors again emphasize
that neuro-optometric rehabilitation should support the overall rehabilitation of the
individual prior to and/or concurrently being given physical and or occupational
therapy.
The authors emphasize that these types of neuro-optometric approaches are
rehabilitative in nature and should not be thought of as a cure. As with all
rehabilitation, progress depends on many factors.
The profound affects of dysfunction in the ambient visual system can greatly interfere
with function and performance at all levels for persons with neurological insults.
Neuro-optometric rehabilitation has effectively delivered new approaches toward
treatment regiment in conjunction with treatment already being conducted in hospitals
and clinics. The optometrist who has developed an understanding of neuro-optometric
rehabilitation can be an important member of the multi-disciplinary team who is
serving these special populations.

References
[1] Padula WV. A Behavioral Vision Approach for Persons with Physical Disabilities.
Optometric Extension Publishers, 1988.

[2] Padula W, Argyris S, Ray J. Visual Evoked Vision syndrome (PTVS) in patients with
traumatic brain injuries (TBI), Brain Injury, 1994;8(2):125-133.

[3] Trevarthen CB, Sperry R. Perceptual unity of the ambient visual field in human
commissurotomy patients. Brain 1973;96:547-570.

[4] Liebowitz HW. and Post RB. The two modes of 28: processing concept and some
implications. In: Beck JJ, ed. Organization and Representation in Perception. Erlbaum,
Hillsdale, NJ, in press.

[5] Thomas J. Lecture at the Neuro-Optometric Rehabilitation Association Symposium

in Atlanta, GA, 1992.