Brain Injury Awareness Month - Marcia
This is my final story for Brain Injury Awareness Month. Marcia is not the typical acquired brain injury patient. She actually has Multiple Sclerosis, but has many of the same visual issues as those suffering traumatic brain injuries. Since MS is a disease of the central nervous system and certainly involves the brain, I thought I’d include Marcia in this month’s theme.
Marcia was a vibrant and engaging 64 year old when we met in September 2011 after she had been referred by another patient. On the phone she complained about having nystagmus and convergence insufficiency (her words) which she felt resulted from multiple sclerosis. I learned that her first symptoms of multiple sclerosis appeared in 1972 when she suffered through six months of vertigo. This became an intermittent occurrence as did a dropped foot and balance problems. Marcia was not diagnosed with multiple sclerosis until 1999. She essentially stopped reading in the mid 1980s because it would get blurry and cause vertigo. At her initial visit, Marcia also reported bouts of eye fatigue, double vision, discomfort at the computer, myriad reading issues, and motion sickness.
After greeting Marcia in my waiting room and giving her an intake interview form, we spoke briefly. I asked Marcia how she was feeling and she said that she was having a fairly normal day for her, which meant her vertigo and headache were weighing in at a four-out-of-ten. This had been her default setting for many years, with periodic elevations ranging from five to nine.
I asked to briefly borrow Marcia’s glasses while she was in the waiting room, placed narrow binasal occlusion on her glasses and returned them to her asking her to wear them while she finished the interview form. There was nothing particular about Marcia that indicated beyond a doubt that this would do anything. Sometimes intuition guides you to move in a certain direction. Intuition, informed by knowledge and experience, is a tremendous ally and should not be undervalued in my opinion. However, I have had enough experiences with narrow binasal occlusion to realize that it is generally worth trying, especially when multiple complaints like Marcia’s are in play.
I returned to the waiting room about five minutes later just to check in and to my surprise and delight, Marcia reported that her vertigo and headache had gone from a four to a one. I was not expecting this and I suppose neither was she. She was absolutely thrilled and so was I.
Marcia’s evaluation revealed below expected quality of eye movements and slightly reduced stereo acuity (a test of depth perception) at her reading distance - the testing of which made her “want to throw up.” Marcia had two pairs of bifocals: one with the top set for the computer and one with the top set for far distance. During the evaluation it was determined that Marcia saw just as well at far distance with her computer bifocals as she did with her far distance bifocals. I applied narrow binasal occlusion to her computer glasses, which improved the distance acuity even more, and suggested that she try wearing the computer glasses (with the binasal occlusion)as much as possible. I followed up with Marcia after two weeks and learned that she was no longer using her distance glasses at all and continued to be almost symptom free. Marcia came in to start vision therapy one month after our initial meeting. She continued to be thrilled by the improvement. She started reading again and was very happy about it.
Due to her schedule and travel distance, vision therapy was sporadic, but Marcia continued reading free of vertigo or focus changes. While Marcia was away for the holidays (the start of a three-month gap in therapy) she decided she was cured and took the binasal occlusion off her glasses. I learned this during a follow-up call to see when she would return. She questioned the need to return and told me she had removed the binasal occlusion. I suggested that she at least return for a progress evaluation. The morning of that appointment Marcia ended up cancelling due to severe vertigo which had returned the night before. She said that she put the occlusion back on the glasses and felt somewhat better and came in the following week to resume vision therapy. I reapplied the occlusion the way I had originally intended and Marcia said this felt much better than her attempt. We completed five more vision therapy sessions through May 2012.
I followed up with Marcia in September 2012, having not seen her since May. She reported that she was still happily reading five to six hours a day. She still has the binasal occlusion on her glasses. Marcia still seems to need the narrow binasal occlusion to remain comfortable. It is always my hope that the narrow binasal occlusion will be temporary and that vision therapy will eventually remove the need for them. However, Marcia is very happy with the dramatic reduction in her symptoms and her renewed ability to read comfortably. I would prefer to continue the vision therapy but you can’t always get what you want. I last saw Marcia in January 2013. She reported that she tried going without the occlusion but feels much better with it.
You might be wondering: What is this binasal occlusion? Why have I never heard of it before? Binasal occlusion has been around for over 100 years. It remains kind of a specialty treatment. It is mostly used by behavioral optometrists. I have written and lectured extensively about binasal occlusion and use it frequently in my practice. Binasal occlusion was originally intended for people with strabismus. Over the years I have also found it very useful for many other types of visual disturbances, including symptoms resulting from concussions and other brain injuries such as headaches, dizziness, nausea, vertigo. If you or someone you know has these symptoms, especially if other approaches have been attempted unsuccessfully, find a behavioral optometrist who is familiar with this treatment. It’s safe, non-invasive and often successful. To find a behavioral optometrist near you contact OEPF.