What an Optometrist Needs to Know When a Patient With a Recent Concussion Presents for an Eye Exam

A recent concussion can change the way a patient sees, focuses, tracks, reads, and tolerates light. Even when visual acuity is still 20/20, the patient may struggle with headaches, eye strain, dizziness, blurred vision, double vision, light sensitivity, or difficulty reading. The optometrist’s role is not only to check the eyes, but to evaluate how the visual system is functioning after the brain injury.

Concussion symptoms commonly include headache, dizziness or balance problems, nausea, fatigue, light/noise sensitivity, trouble concentrating, memory difficulty, and vision problems. The CDC lists vision problems, light sensitivity, dizziness, slowed thinking, and concentration issues among common concussion symptoms.

Doctor discussing common problems that occur after a concussion.

Why Vision Problems Are Common After Concussion

A concussion is a mild traumatic brain injury, but “mild” does not always mean simple. The visual system uses a large portion of the brain, so even a relatively mild head injury can affect focusing, eye teaming, eye tracking, visual motion sensitivity, and reading comfort.

After concussion, common visual findings include:

• Convergence insufficiency

• Accommodative insufficiency

• Accommodative infacility

• Saccadic dysfunction

• Smooth pursuit abnormalities

• Photophobia

• Visual motion sensitivity

• Intermittent diplopia

• Reading difficulty

• Headache or eye strain with near work

The American Academy of Ophthalmology notes that accommodative insufficiency can occur after concussion and may cause near blur, headaches, fatigue, and reduced interest in reading or near work. Research and clinical reviews also describe accommodation, convergence, saccades, and smooth pursuits as commonly affected after concussion.

Start With Safety: Red Flags First

Before focusing on refraction or binocular vision, the optometrist should make sure the patient does not have signs that require urgent medical or emergency referral.

Red flags include:

• Worsening headache

• Repeated vomiting

• Increasing confusion

• Loss of consciousness

• Seizure

• New weakness, numbness, slurred speech, or facial droop

• Unequal pupils

• New constant double vision

• New visual field loss

• Severe eye pain

• Papilledema or optic nerve swelling

• Suspected orbital trauma, hyphema, retinal tear, retinal detachment, or cranial nerve palsy

Patients with progressive neurologic symptoms, worsening mental status, or acute neuro-ophthalmic signs should be referred urgently. The eye exam should not delay emergency evaluation when the history or findings suggest a more serious injury.

History: Questions the Optometrist Should Ask

A good concussion eye exam starts with a detailed history. Important questions include:

Injury details

• When did the concussion happen?

• What caused it: fall, sports injury, car accident, assault, blast injury?

• Was there loss of consciousness?

• Was there amnesia before or after the injury?

• Has the patient already been evaluated by primary care, neurology, emergency medicine, sports medicine, or concussion clinic?

• Was imaging performed?

• Is the patient cleared for school, work, driving, or sports?

Visual symptoms

• Blurred vision at distance or near?

• Double vision: constant or intermittent?

• Trouble reading?

• Losing place while reading?

• Words moving, swimming, or overlapping?

• Eye strain or headaches with near work?

• Light sensitivity?

• Dizziness in grocery stores, crowds, or while scrolling?

• Difficulty with screens?

• Trouble shifting focus from distance to near?

Functional impact

• Can the patient tolerate school or work?

• How long can they read before symptoms start?

• Are symptoms worse later in the day?

• Are screens worse than paper?

• Are they avoiding driving?

• Are fluorescent lights a trigger?

Baseline risk factors

• Prior concussion

• Migraine history

• ADHD or learning difficulties

• Anxiety

• Motion sickness

• Strabismus or amblyopia history

• Prior binocular vision disorder

• High prescription, anisometropia, or poor spectacle correction

Examination Priorities

A standard eye exam is not enough. A patient with recent concussion needs both ocular health evaluation and visual function testing.

1. Visual Acuity and Refraction

Check best-corrected visual acuity, but remember that 20/20 does not rule out concussion-related visual dysfunction. Perform a careful refraction, especially if the patient has new blur, eye strain, or difficulty with screens.

Consider whether a temporary near prescription may help during recovery, particularly if accommodation is reduced.

2. Pupils

Check for:

• Anisocoria

• Relative afferent pupillary defect

• Sluggish reaction

• Light sensitivity

• Abnormal near response

Unequal pupils after head trauma, especially with headache, neurologic changes, or mental status changes, should raise concern.

3. Ocular Motility

Evaluate:

• Extraocular muscle range

• Versions

• Ductions

• Pain with eye movement

• Nystagmus

• Cranial nerve palsy patterns

• Comitant vs incomitant deviation

A new incomitant deviation, limited eye movement, or constant diplopia may require urgent referral.

4. Cover Test

Perform distance and near cover testing. Look for:

• Exophoria greater at near

• Decompensated phoria

• Intermittent tropia

• Vertical deviation

• Comitant vs incomitant pattern

Concussion may not create a large eye turn, but it can reduce the patient’s ability to compensate for a pre-existing phoria.

5. Near Point of Convergence

Near point of convergence is one of the most important concussion-related tests. Measure break and recovery. Repeat it more than once because some patients fatigue quickly.

Findings may include:

• Remote break point

• Poor recovery

• Symptom reproduction

• Eye strain or headache during the test

• One eye drifting outward

Convergence insufficiency is one of the most commonly reported binocular vision issues after concussion.

6. Accommodation Testing

Evaluate accommodation carefully, especially in students and working adults who complain of reading difficulty.

Useful tests include:

• Monocular accommodative amplitude

• Binocular accommodative amplitude

• Accommodative facility

• MEM retinoscopy or NRA/PRA when appropriate

• Near blur point

• Symptom reproduction with sustained near work

Accommodative insufficiency can cause near blur, headaches, fatigue, and avoidance of reading after concussion.

7. Vergence Ranges

Test positive and negative fusional vergence at distance and near. This helps determine whether symptoms are due to poor eye teaming, poor stamina, or decompensation under visual demand.

Document:

• Base-out ranges

• Base-in ranges

• Recovery values

• Symptoms during testing

• Whether the patient fatigues quickly

8. Saccades and Pursuits

Patients may complain that they lose their place while reading, skip lines, feel dizzy while scanning, or cannot tolerate busy environments.

Assess:

• Horizontal and vertical saccades

• Accuracy

• Speed

• Fatigue

• Symptom provocation

• Smooth pursuit quality

• Head movement compensation

Saccadic and smooth pursuit problems are commonly described after concussion and can contribute to reading difficulty and visual discomfort.

9. Photophobia and Visual Comfort

Ask about indoor lights, sunlight, headlights, screens, and fluorescent lighting. Consider trialing lens options carefully, but avoid over-darkening the patient indoors long-term unless clinically needed.

Options may include:

• Temporary tint

• FL-41 style tint

• Anti-reflective coating

• Blue-control options when screen glare is a trigger

• Hat/brim recommendations

• Screen brightness and contrast adjustments

The goal is symptom control while avoiding unnecessary dependence on very dark lenses indoors.

10. Ocular Health Examination

A dilated exam should be considered, especially after head trauma or if the patient reports flashes, floaters, visual field defects, pain, or decreased vision.

Evaluate for:

• Retinal tears or detachment

• Commotio retinae

• Vitreous hemorrhage

• Traumatic optic neuropathy

• Papilledema

• Optic nerve pallor or edema

• Cranial nerve involvement

• Orbital injury signs

What to Document

Good documentation is critical. Include:

• Date and mechanism of concussion

• Other providers involved

• Current restrictions: school, work, sports, driving

• Visual symptoms and triggers

• Best-corrected acuity

• Pupils

• EOMs

• Cover test distance/near

• Near point of convergence

• Accommodation findings

• Vergence ranges

• Saccades/pursuits

• Photophobia

• Ocular health findings

• Impression

• Patient education

• Referral plan

• Follow-up interval

Also document whether testing reproduced symptoms. This can help guide rehabilitation and communicate clearly with the concussion care team.

Management: What the Optometrist Can Do

Treatment depends on the findings. The goal is to reduce symptoms, improve function, and coordinate care.

Optical Management

Possible options include:

• Updating the full-time prescription

• Temporary near add

• Computer prescription

• Prism when appropriate

• Tints or glare-reduction lenses

• Anti-reflective lenses

• Contact lens modification if symptoms are worsened by dryness or poor correction

For some patients, a small near add can reduce accommodative demand during recovery. Prism may help selected patients with symptomatic binocular dysfunction, but it should be prescribed carefully and reassessed as recovery changes.

Visual Hygiene and Activity Modification

Patients may need practical guidance such as:

• Shorter reading sessions

• Frequent visual breaks

• Reduced screen brightness

• Larger font size

• Printed material instead of screens when needed

• Avoiding visually busy environments early in recovery

• Gradual return to near work

• Good sleep and hydration

• Coordinating return-to-learn or return-to-work accommodations

Vision Therapy / Neuro-Optometric Rehabilitation

When symptoms persist or testing shows measurable dysfunction, vision therapy may be considered. Therapy may target:

• Vergence

• Accommodation

• Saccades

• Pursuits

• Visual-vestibular integration

• Reading stamina

• Visual motion sensitivity

There is clinical support for evaluating and managing post-concussion visual dysfunction, but treatment plans should be individualized and coordinated with the patient’s broader medical team. The AAO consensus statement notes that tools such as the Convergence Insufficiency Symptom Survey may be useful for following symptoms, while also emphasizing the need for careful diagnosis and evidence-based management.

When to Refer

Refer to the appropriate provider when findings suggest problems beyond routine optometric management.

Refer urgently / emergency care

• Worsening neurologic symptoms

• Unequal pupils with concerning history

• New constant diplopia

• Cranial nerve palsy

• Visual field loss

• Papilledema

• Retinal tear/detachment symptoms

• Severe headache with vomiting or confusion

• Suspected orbital fracture or significant ocular trauma

Refer to neurology, sports medicine, or concussion clinic

• Persistent headaches

• Dizziness or balance issues

• Cognitive symptoms

• Multiple concussions

• Delayed recovery

• Return-to-play concerns

• Symptoms not matching ocular findings

Refer to neuro-ophthalmology

• Optic nerve swelling

• Unexplained vision loss

• Cranial nerve palsy

• Visual field defect

• Nystagmus

• Suspected traumatic optic neuropathy

• Incomitant diplopia

Refer for vestibular therapy / physical therapy

• Dizziness triggered by movement

• Balance problems

• Visual motion sensitivity

• Neck injury component

• Symptoms in busy visual environments

Patient Education: What to Tell the Patient

A helpful explanation might be:

“After a concussion, your eyes may still be healthy, but the way your brain controls focusing, eye teaming, and tracking can be disrupted. That can make reading, screens, bright lights, and busy environments uncomfortable. Today we are checking both the health of the eyes and how the visual system is functioning.”

Patients should also understand that symptoms may improve gradually, but worsening symptoms should not be ignored.

Clinical Pearl

A concussion patient can have 20/20 vision and still have significant visual dysfunction. Do not stop the exam after visual acuity and refraction. Near point of convergence, accommodation, vergence ranges, saccades, pursuits, pupils, ocular motility, and ocular health evaluation are all important pieces of the post-concussion eye exam.

Summary

When a patient with a recent concussion presents for an eye exam, the optometrist should think beyond glasses. The exam should screen for urgent neurologic or ocular red flags, evaluate ocular health, and carefully test binocular vision, accommodation, eye tracking, and light sensitivity.

The optometrist plays an important role in identifying post-concussion visual dysfunction, helping the patient return to school, work, reading, screens, and daily activities, and coordinating care with the broader concussion management team.