What causes visual floaters post Traumatic Brain Injury (TBI) and how are they treated?

Management of Visual Floaters Post-Traumatic Brain Injury

Causes of Visual Floaters After TBI

Visual floaters after traumatic brain injury are primarily caused by vitreous changes, retinal damage, or neurological disruption, and require ophthalmological evaluation for proper diagnosis and treatment. 1

Visual floaters following TBI may result from:

• Vitreous changes: Trauma can cause posterior vitreous detachment (PVD), vitreous hemorrhage, or vitreous syneresis with collagen fibril clumping 2
• Retinal damage: Retinal tears, holes, or detachment may occur following trauma 3
• Neurological disruption: TBI can affect visual processing pathways, causing visual perceptual deficits 4
• Vascular injury: Retinal ischemia may occur as a stroke equivalent following trauma 5

Diagnostic Approach

A thorough ophthalmological examination is essential and should include:

• Comprehensive dilated fundus examination with scleral depression to identify retinal holes, tears, or detachment 3
• B-scan ultrasonography if media opacity prevents adequate examination 3
• Optical Coherence Tomography (OCT) to evaluate retinal architecture 3
• Visual field testing to map any scotomas 3
• Assessment of eye movements, including versions, ductions, saccades, pursuit, vergence, and near reflex 5
• Forced duction and forced generation testing to distinguish restriction from paresis of extraocular muscles 5

Treatment Options

For Vitreous Floaters

1. Observation and reassurance for mild, non-sight-threatening floaters

   • Many floaters resolve spontaneously over time
   • Patient education about the benign nature of most floaters

2. Surgical intervention for severe, persistent, vision-affecting floaters:

   • Pars plana vitrectomy (PPV) may be considered for debilitating floaters 3
   • Risk of complications includes retinal tears (1-3.5%), retinal detachment, endophthalmitis (<0.05%), and macular hole formation 5

For Retinal Pathology

1. Laser photocoagulation or cryotherapy for retinal holes without detachment 3

   • Creates chorioretinal adhesion to prevent progression to detachment

2. Surgical intervention for retinal detachment:

   • Scleral buckle, pars plana vitrectomy, or combination 3
   • Early intervention recommended for better outcomes

For Visual Processing Deficits

1. Vision therapy for anomalies of accommodation, vergence, version, photosensitivity, and visual field deficits 1, 6

   • Office-based and home-based vision therapy to maximize visual potential

2. Compensatory strategies:

   • Compensatory scanning training for improving functional activities of daily living 5
   • Eye exercises for treatment of convergence insufficiency 5

3. Optical devices:

   • Fusional prism spectacles for diplopia 1
   • Tinted spectacles for photosensitivity 1
   • Yoked prism spectacles for visual-spatial hemispheric inattention 1

Follow-up Care

• Examination on day 1 post-surgery and again 1-2 weeks following surgery 5
• Additional follow-up based on findings and treatment provided
• Long-term follow-up every 3-6 months for patients with retinal pathology 3
• Patient education on symptoms requiring immediate attention (new flashes, floaters, visual field loss, decreased acuity) 3

Special Considerations

• Visual rehabilitation should be considered early in TBI recovery 6
• Multidisciplinary approach involving ophthalmologists, optometrists, and rehabilitation specialists may be necessary 7
• Patients should be informed to promptly notify their ophthalmologist if they experience an increase in floaters, loss of visual field, metamorphopsia, or decreased visual acuity 5

Referral Guidelines

Referral to an ophthalmologist with expertise in vitreoretinal surgery and disease is recommended for:

• Persistent, vision-affecting floaters
• Suspected retinal tears or detachment
• Complex visual symptoms following TBI

Visual rehabilitation specialists should be involved for patients with persistent visual processing deficits 5, 6.