Examination of the Traumatic Brain Injury Patient

Today’s article is written by Dr. Carl Garbus who is president of NORA. Antonio Chirumbolo, an OptometryStudents.com Team Member, met Dr. Garbus during an OS.com function and they are now working together to crank out some great information for optometry students. Keep a lookout for more insightful articles from Dr. Garbus in the near future!

Examination of the Traumatic Brain Injury Patient
Key Elements
Carl Garbus, O.D., FAAO
NORA President

As more optometrists are becoming interested in the diagnosis and treatment of brain injury patients, there are a few key concepts that should be considered in the assessment.


Initially, the patient questionnaire is extremely important to probe for specific details and deficits. The history should include questions about sensitivity to light, dry eyes, balance, dizziness, reading and disorientation with movement. It should also question how they feel in crowded or busy environments, such as the market. Take a complete medical and social history. When available obtain reports prior to the examination from co-managing providers such as the neurologist, neuro-psychologist, physiatrist, occupational and physical therapist. It is important to review visual pathways and brain function, so that a lesion in a specific area is identified with the functional deficit.


The examination takes longer than a primary care exam. Often two evaluations are needed to complete the necessary testing. During the evaluation, the office setting should be quiet with minimal distractions. Many TBI patients are sensitive to fluorescent lighting, so when possible turn off the fluorescent lighting


A high percentage of these patients have visual field defects. It is recommended to complete the visual fields in the beginning of the examination before the patient fatigues.  Confrontation fields do not provide enough information for this patient population. Goldmann visual fields are easier to administer and offer additional information related to function.


In addition to your normal examination, special testing should include some of the following:

l. Line Bisection test – for assessing visual inattention

2. Developmental Eye Movement Test (DEM) to check oculomotor function

3. Spatial Localization to evaluate visual spatial interpretation

4. Visual Midline Shift to check for egocentric orientation of space

5. Sensory Motor testing for binocular control

6. Contrast Sensitivity for potential visual problems under low illumination

7. Near-Point Retinoscopy (Book, Bell)

8. Visual Balance to evaluate body position against gravity

9. Mobility screening to look at balance, posture and gait from the vision side


Once the comprehensive evaluation is completed reports need to be sent to referring doctors and other members of the rehabilitation team.

There are many optometric therapeutic interventions that can help these patients. If you would like more information on this subject please email Carl Garbus at cgarbusod@yahoo.com or contact my office at 661-775-1860. The NORA website is also a good source for information at nora.cc.

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