Your client passed a CT scan. Their neurologist found nothing remarkable. Yet months later, they still can’t drive, concentrate, or walk down a crowded hallway without triggering symptoms. Their employer is skeptical. The defense calls it exaggeration.
What’s actually happening? In a significant number of mild traumatic brain injury (mTBI) cases, the underlying dysfunction isn’t being tested for. Why? Because the standard eye chart doesn’t capture it.
This post is based on a presentation by Dr. Amy Pruszenski, delivered during a Medical and Life Care Consulting Services medico-legal webinar. Dr. Amy Pruszenski, OD, FOVDR, FNAP graduated from the Massachusetts Institute of Technology in 1989 with a Bachelor of Science degree in Cognitive Science. She received her Doctorate in Optometry from the New England College of Optometry in 1993.
Dr. Pruszenski is a Fellow of the Opto-metric Vision Development and Rehabilitation Association and serves on the Optometry/Ophthalmology subcommittee of the Society for Brain Mapping and Therapeutics. She is director of medical education for the Neuro-Opto-metric Rehabilitation Association. She has been providing help for brain injury patients for over 20 years, collaborating with other health care providers to ensure a coordinated approach to rehabilitation to achieve best outcomes.
The Core Misconception: 20/20 Does Not Mean Functional Vision
The most damaging myth in concussion litigation isn’t that the injury didn’t happen. It’s that a normal eye exam proves vision is fine.
20/20 acuity measures only one thing: whether a patient can distinguish a specific letter size at 20 feet. It says nothing about how the brain processes, integrates, or acts on visual input. Dr. Pruszenski describes it plainly: the eyes are not a camera. Vision is created in the brain, across at least 70 distinct neural regions, not in the eyeball.
“If we take their eyes out and put them in a jar, their eyeballs are just as good as before they fell. It’s the signal between the eyes and how the brain is using that information that is the problem.”
After a brain injury, patients may experience eye tracking disorders, convergence insufficiency, poor depth perception, light sensitivity, and spatial disorientation. None of this shows up on a standard eye chart. These deficits are measurable with the right evaluation, which means they are also defensible in litigation when properly documented.
What Standard Exams Miss
- Ocular motor dysfunction (inability to smoothly track or shift gaze)
- Convergence insufficiency or convergence excess
- Post-trauma vision syndrome: eyes that appear aligned but fail under load
- Visual-vestibular mismatch causing dizziness and balance problems
- Spatial disorientation: the patient literally doesn’t know where objects are in space
For background on how these evaluations fit into broader injury assessment, the MLCC Insights page covers a range of medico-legal topics relevant to claims professionals.
Five Myths About Concussion That Affect Case Outcomes
Myth 1: If the Scan Is Clear, the Brain Is Fine
The American Congress of Rehabilitative Medicine (ACRM) stated in their 2023 guidelines that neuroimaging is not necessary to diagnose mild TBI. Its primary role is to rule out hemorrhage or structural damage requiring surgical intervention, not to confirm or deny mTBI. A negative CT or MRI does not rule out a brain injury.
For litigation purposes: normal imaging does not undermine a mild TBI claim. Defense arguments built on clean scans rely on outdated medicine.
Myth 2: Balance and Dizziness Mean an Inner Ear Problem
Vestibular dysfunction is a real and common post-concussive complaint—but attributing all dizziness to the inner ear misses the visual component. Research by Clark Elliott and optometrist Bill Padula has identified that the visual ego center (the brain’s spatial orientation system) can be disrupted after injury, causing gate abnormalities and dizziness that don’t respond to vestibular therapy alone.
Dr. Pruszenski describes patients who couldn’t walk a straight hallway. This is not because of an ear problem, but because the brain had lost its spatial map. Corrective prism lenses provided measurable improvement within a single visit.
Myth 3: Complete Rest Speeds Recovery
The standard of care has changed. The ACRM guidelines now state that prescribing strict rest until symptom resolution was once standard. But, current evidence supports a gradual return to activity within 48 hours of injury. Prolonged rest may actually slow recovery and increase risk of mental health complications.
This matters for claims: documenting appropriate, evidence-based activity protocols (rather than enforced inactivity) strengthens medical necessity arguments and supports return-to-function timelines.
Myth 4: 20/20 Vision Equals Good Vision
A patient who reads 20/20 on an eye chart can still have significant post-trauma vision syndrome. If opposing experts rely solely on visual acuity to dismiss visual complaints, that argument does not reflect current clinical standards.
Myth 5: Glasses Only Correct Clarity
Therapeutic lenses do far more than sharpen an image. Prescribing specific prisms, tints, or modified refraction changes the light signal reaching the retina and affects how the brain creates spatial awareness. In Dr. Pruszenski’s practice, lens modifications have reduced dizziness, improved gait, and lowered headache frequency in post-concussive patients.
Medico-Legal Implications: Causation, Damages, and Defensibility
Visual dysfunction after brain injury creates specific medico-legal considerations that go beyond general damages.
Causation
Visual deficits following mTBI are well-documented in peer-reviewed literature and supported by ACRM guidelines. When a patient presents with post-trauma vision syndrome after a documented incident—motor vehicle collision, slip and fall, sports injury, domestic violence—the causal chain is traceable and measurable. Objective testing (such as eye tracking metrics) can demonstrate the deficit and improvement over time, providing before-and-after evidence.
Functional Impact and Damages
The real-world consequences of undiagnosed visual dysfunction are significant and translate directly into damages:
- Inability to drive: loss of independence, employment, and daily function
- Screen intolerance: inability to work remotely, use computers, or read
- Balance and gait problems: increased fall risk, restricted mobility
- Cognitive fatigue: brain bandwidth consumed by compensating for spatial disorientation, leaving nothing for work tasks
- Social and psychological impact: anxiety, isolation, and emotional dysregulation as secondary consequences of being “lost in space”
Defensibility of Treatment Recommendations
Neuro-optometric rehabilitation is not experimental. It is interprofessional, evidence-based, and backed by major rehabilitation medicine organizations. When life care plans include neuro-optometric evaluation and treatment, those recommendations can be defended with reference to ACRM guidelines, peer-reviewed literature, and clinical outcomes data.
Case Management and Life Care Planning Implications
For case managers and life care planners, post-trauma vision syndrome adds a recoverable cost category that is frequently overlooked in initial assessments. Comprehensive medico-legal services that incorporate neuro-optometric needs produce more accurate—and more defensible—projections.
What Should Be Included in a Life Care Plan
- Neuro-optometric evaluation (initial and follow-up)
- Therapeutic lenses and tinted spectacles
- Optometric phototherapy sessions
- Neuro-visual rehabilitation activities
- Coordinated vestibular and vision therapy
- Osteopathic or upper cervical chiropractic evaluation if neck involvement is suspected
- Neuropsychological testing to establish cognitive baseline
Treatment Sequencing
Dr. Pruszenski emphasized in the Q&A that treatment order matters. Rule out life-threatening conditions first. Then address the autonomic nervous system. If the patient is stuck in sympathetic overdrive, no rehabilitation will be effective. Foundation elements (sleep, hydration, nutrition, and neurological calm) must precede active rehabilitation. Aggressive protocols designed for teen athletes are often inappropriate for older patients or those with chronic presentation.
For case managers: this sequencing rationale should be reflected in the life care plan to preempt challenges about the timing or pace of treatment.
Practical Applications for Attorneys and Claims Professionals
For Plaintiff Attorneys
- Request a neuro-optometric evaluation when clients report dizziness, headaches, screen intolerance, or spatial difficulties—even if standard vision exams are normal
- Use objective eye tracking data (such as fixation stability and smooth pursuit metrics) to demonstrate functional deficits over time
- Challenge defense arguments that rely on clean neuroimaging or normal acuity to dismiss visual complaints
- Ensure life care plans include the full spectrum of neuro-visual rehabilitation costs
For Defense Attorneys and Adjusters
- Verify whether the claimant has received a neuro-optometric evaluation—its absence may indicate undertreated injury and future cost exposure
- Evaluate whether treatment protocols match the severity and chronicity of the injury—aggressive programs designed for acute athletes may be inappropriate and non-compensable
- Ensure IME examiners are qualified to assess post-trauma vision syndrome, not just standard acuity
- Review reserves to account for the full scope of visual rehabilitation when the injury profile warrants it
Key Takeaways
- A normal CT scan or 20/20 eye chart result does not rule out brain injury or visual dysfunction
- Post-trauma vision syndrome causes measurable, documentable impairment—including spatial disorientation, dizziness, and cognitive fatigue
- Visual deficits are a distinct and recoverable category of damages with objective clinical support
- Prolonged rest is no longer standard of care; graduated activity within 48 hours is the evidence-based approach
- Life care plans should include neuro-optometric evaluation, therapeutic lenses, and visual rehabilitation for appropriate mTBI cases
- Interprofessional coordination—neuro-optometry, OT, PT, speech, osteopathy—produces better outcomes and stronger legal defensibility
Frequently Asked Questions
Can visual dysfunction after a concussion be objectively measured?
Yes. Eye tracking technology (such as fixation stability testing and smooth pursuit measurement) provides objective, reproducible data on visual-motor deficits. These metrics can show baseline impairment and improvement over time—making them useful in both treatment and litigation.
Does a normal neuroimaging result weaken a brain injury claim?
No. The American Congress of Rehabilitative Medicine (ACRM) states explicitly that neuroimaging is not required to diagnose mild TBI. Its role is to rule out surgical emergencies, not to confirm or deny mTBI. Defense arguments built on clean scans are not consistent with current clinical guidelines.
How does post-trauma vision syndrome differ from standard vision problems?
Standard vision problems typically involve optical clarity—can the eye focus light correctly? Post-trauma vision syndrome involves how the brain processes spatial information, integrates visual and vestibular input, and uses that data to orient the body in space. A patient can have 20/20 acuity and still be functionally impaired by post-trauma vision syndrome.
What triggers a referral for neuro-optometric evaluation?
Dr. Pruszenski recommends referral when: visual acuity is normal but the patient reports visual symptoms; headache or dizziness treatment is not responding as expected; the patient has balance or movement difficulties; or there is a suspected concussion or neck injury. Early referral prevents misattribution of symptoms and delays in appropriate treatment.
Are neuro-optometric rehabilitation costs defensible in life care plans?
Yes, when properly documented with clinical rationale, evidence-based standards, and appropriate specialist credentials. Life care planning and litigation support from qualified nurse consultants ensures these cost projections are grounded in current standards of care and can withstand scrutiny.
Conclusion
Brain injury claims fail (or settle for less than they’re worth) when functional impairments go unmeasured. Post-trauma vision syndrome is one of the most commonly overlooked consequences of mTBI, yet it is among the most documentable.
For attorneys, the takeaway is straightforward: if your client’s recovery is stalled and standard evaluations have been inconclusive, vision function should be assessed by a neuro-optometrist. The clinical evidence is there. The testing methodology is objective. The damages are real.
For claims professionals and case managers, incorporating neuro-optometric needs into cost projections produces more accurate reserves, more defensible plans, and better outcomes for everyone involved.
