Volume 40/Number 1/2009

45

Article

Traumatic Brain Injury and Binasal Occlusion

Alissa Proctor, OD

Northeastern State University Oklahoma College of Optometry, Tahlequah, OK

Correspondence regarding this article can be emailed to [email protected]

or sent to: Dr. Alissa Proctor at Northeastern State University Oklahoma

College of Optometry, 1001 N Grand Avenue, Tahlequah, OK 74464.

Online access is available at http://www.covd.org.

Proctor A. Traumatic brain injury and binasal occlusion. Optom Vis

Dev 2009;40(1):45-50.

ABSTRACT

Background: Most individuals who have

experienced a traumatic brain injury (TBI) have some

degree of visual, physiological and/or behavioral

change that accompanies the injury. Symptoms vary

from diplopia to vertigo and from reading problems

to memory loss. For many patients with TBI, using

vertigo, he also exhibited poor depth perception. All

prior examinations, including visits to his primary

care physician, the emergency room, a neurologist,

an otologist, and an optometrist were unremarkable.

No interventions were offered to relieve the patient’s

symptomology. Upon the completion of the

evaluation an oculomotor dysfunction and exophoria

were diagnosed. Base-in prism was prescribed and

optometric vision therapy was initiated. ree

months after his first examination, binasal occlusion

spatial information. is may reduce the focal system’s

processing ability. Binasal occlusion provides the brain

with an opportunity to process information differently.

is alteration in visual input may improve vision

function and relieve visual symptoms for patients who

are post TBI as noted in this case report.

Keywords: ambient vision, binasal occlusion,

optometric vision therapy, TBI, traumatic brain

injury

Introduction

unilateral strabismus into a patient with alternating

strabismus.

Jacques felt that binasal occlusion worked

because it removed visual inhibition and suppression

and allowed “the opportunity to establish the basic

vision patterns of the normal human being.”

Binasal occlusion is considered a form of sector

occlusion.

Depending on the condition being treated, symmetry

may or may not be indicated. Others felt that the tape

should be placed nasal to the limbus.

have found the opaque or translucent Streff Wedge

to be helpful in finding the best placement for the

binasal occlusion. After initial placement, changes

may be made based on the patient’s perception or

performance while wearing the occlusion.

been recommended for many vision disorders. e

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Optometry & Vision Development

following case report is a demonstration of the use of

binasal occlusion for something other than esotropia.

Case Report

A forty-six year old Caucasian male was referred

to the Traumatic Brain Injury (TBI) Clinic at

Northeastern State University’s Oklahoma College

of Optometry because he was experiencing dizziness

e referring clinic noted that the patient had

difficulty maintaining fixation and concluded that

he would benefit from an optometric vision therapy

evaluation. A review of the medical history, including

copies of his medical records, showed that he had not

suffered overt head trauma. He had, however, been

involved in approximately 13 minor motor vehicle

accidents as a regional driver for a car rental company.

After multiple medical evaluations, including a full

neurological evaluation with neuroimaging and an

A College of Optometrists in Vision Development

Quality of Life (COVD-QOL) 30 Item Checklist

was given producing a score of 49. A score of 20 or

above is considered indicative of a binocular vision

or perceptual dysfunction. e items checked ‘always’

included “words run together when reading”, “skips/

repeats lines reading”, “dizzy/nausea with near work”,

“avoids near work/reading”, “holds reading too close”,

and “poor hand/eye coordination.”

fields and versions being full. e cover test with his

habitual correction in place showed a 6

exophoria at

distance and 8

exophoria at near. NSUCO saccades

were 5/3/4/0 and pursuits were 1/1/1/0 with so much

body movement he had to be seated during both

procedures.

to assess as the patient jerked his head away as the

target approached and had to close his eyes for several

moments between tests.

e manifest refraction showed myopia,

astigmatism, and presbyopia that was minimally

different from his habitual worn spectacles (-3.25

-2.25 x 051 OD and -3.25 -2.00 x 141 OS with a

+1.75 add). Dissociated and fused cross cylinder

base-in vergence ranges at near were 20/28/16 and his

base-out ranges were x/18/12. His vergence facility

with the VO Series was 16 seconds with slide 6; 18

seconds with slide 7; unable to fuse slide 8 on the

bottom; 12 seconds with slide 11; and unable to fuse

slide 12 on the bottom.

e vectographic slide at distance confirmed the

exophoria and measured 6

on the measurement, horizontal prism (3

OS) was trial framed with the new refractive findings.

scheduled for additional testing.

Two weeks later the patient returned for further

evaluation. He had not yet obtained the updated

spectacle lenses so their benefit could not be ascertained.

Additional case history information included

worsening symptoms in the last six months, including

faintness when watching TV and falling down at

home. e Van Orden (VO) Star showed the centers

below the midline with the left point shifted laterally

Volume 40/Number 1/2009

47

toward the right side (See Figure 1).

Stereo acuity was 100 seconds of arc.

When performing any procedure

with moving targets or lights, the

patient became dizzy. Because of his

report of worsening symptoms in

the last six months, a cranial nerve

assessment was performed. All twelve

walk with 8

yoked prism (BU, BD,

BR, and BL) was attempted, but

the patient experienced dizziness.

Moreover, no positive change in

movement, gait or posture was noted

by the examiners or the patient. is

testing ruled out yoked prism as a

treatment option at that time.

e management and treatment

plan following this second evaluation

unremarkable. e treatment plan

at this time included initiation of

an office based optometric vision

therapy program. e therapy goals

included improving fixation ability

at all distances, improving pursuit

and saccade ability, symmetry in the

VO Star, and improving the patient’s

peripheral awareness. (See Table 1

strategy was suggested by optometrists

presenting at the Invitational Lens

Symposium held in Tahlequah, OK

in November of 2007. Scotch® tape

was applied to the nasal portion

of the front surface of the patient’s

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Optometry & Vision Development

on home activities. e patient, unfortunately did not

follow through with this plan of action. After a six

month absence, he was contacted by phone at which

time the patient stated that he was still wearing the

BNO for most activities except driving. e patient

noted that he feels much more comfortable walking

with the binasals on, but that his peripheral vision is

restricted while driving. He will continue to be seen

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49

His second point was that binasal occlusion allows

the temporal visual fields to become more stimulated

causing greater awareness of the environment. If an

incident causes the patient to shut down peripheral

awareness, it reduces the information crucial to

allowing the patient to feel secure about his relationship

between himself and the world around him. is

increases stress, which can be manifested in other

if not consciously noticed, interjected between the

patient and the visual environment to help organize

visual input.

functioning ambient system usually stabilizes images

of the peripheral retina, but in a patient who has had

TBI, this situation may cause complaints of vertigo.

given binocular visual evoked cross-pattern reversal

P-100 evaluations while wearing their best distance

correction. e experimental and control groups were

given the VEP test. Testing was then repeated with

the subjects in the experimental group while wearing

binasal occlusion and base-in prism. e results of

these tests showed an increase in the amplitude of

the VEP in the experimental group while they were

wearing the binasal occlusion and base-in prism. e

authors suggested that by producing a change in the

Binasal occlusion may not be an appropriate

treatment option for all TBI patients. Although

Jacques was not addressing binasal occlusion as a

treatment for brain injury, some of his cautionary

statements apply to these patients as well. He

indicated that some patients may experience feelings

of discomfort as they cannot or will not function with

any type of treatment that obstructs the use of their

central field. Forcing patients to cope with increased

Exophoria Objects Appear to Move

Accommodative Dysfunction Memory Problems

Convergence Insufficiency Staring Behavior

Poor Tracking Ability Asthenopic

Sensitivity to Light Fatigue

Low Blink Rate Difficulty Reading

Spatial Disorientation Irritability

Balance and Postural

Difficulties

Inability to Follow Sequential

Instructions

Visual Memory Problems

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Optometry & Vision Development

with TBI may benefit from smaller sections of binasal

occlusion. Aiming for areas nasal to the limbus rather

than covering the pupil is recommended for optimal

success in treating these patients.

Conclusion

e value of binasal occlusion in treating patients

with brain injury has been demonstrated on an

a change which creates the potential for improved

symptomology and behavior.

is simple procedure

can be utilized alone as a form of effective therapy or

in conjunction with active therapy. It is inexpensive,

easy to apply, and readily available to all practitioners.

e success reported on a case by case basis has

encouraged clinicians to try this technique on similar

patients. Additional case reports, research and

controlled clinical trials are necessary to validate the

use of binasal occlusion. By utilizing BNO as a part

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Padula W, Argyris S. Post-trauma vision syndrome: part I. Centre for 13.

Neuro Skills http://www.neuroskills.com/tbi/vision1.shtml. Last accessed

08/25/2008.

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accessed 08/25/2008.

Materials

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com).

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