An Acquired Brain Injury is an insult to the brain. It can result from trauma to the head, stroke, or neurological dysfunction. This may produce a diminished or altered state of consciousness and may result in impairment in cognitive abilities, sensory processing and/or physical function. Impairments may be mild or severe; most are amenable to rehabilitation. A concussion is medically defined as a mild form of brain injury, but often times the symptoms and issues are not so mild. A concussion will typically not be detected by standard brain scans, but that does not mean there was no damage or disruption to brain functioning.



Visual problems resulting from concussion and more severe brain injury are often overlooked during initial treatment of the injury. Frequently these problems are hidden and neglected, lengthening rehabilitation and impairing full recovery. Vision is one of the most important sources of sensory information, consisting of a sophisticated complex of subsystems involving the flow and processing of information to the brain. Because there is a close relationship between vision and the brain, a concussion will often disrupt the visual process, interfering with the acquisition and processing of information, and resulting is a brain-based vision problem. These problems go beyond normal eyesight and impact many life skills.

Symptoms indicating a neurological vision problem following concussion are:

Blurred vision
Double vision
Tired, achy eye
Headaches with visual tasks
Loss of visual field/peripheral vision
Difficulty with balance, vertigo, car sickness
Sensitivity to light, photophobia
Reading difficulties; words appear to move
Poor comprehension
Attention and concentration difficulty
Difficulty with memory

Good visual skills are necessary for efficient information processing. When there is a deficiency in processing visual information, one may “try harder,” thus straining without even knowing it as the effort is subconscious. If the visual system is inefficient, every task can seem difficult, using more energy than required.

Visual skills affected by Concussion and Brain Injury include:

Tracking: the ability of the eye to move smoothly across a printed page or while following a moving object.

Fixation: quickly and accurately locating and inspecting a series of stationary objects, such as words while reading.

Focus change: looking quickly from far too near and back without blur or delay.

Depth perception: judging distance of objects – how far or near they are relative to self.

Peripheral vision: monitoring and interpreting what is happening in the surrounding field of vision.

Binocularity: using both eyes together as a team – smoothly, equally and accurately- allowing for appropriate distance spatial estimates and depth.

Sustained attention: keeping focused on a particular activity while interference, such as noise, may be present.

Visualization: accurately picturing images in the “mind’s eye,” and storing them for future recall in cognitive processing.

Near vision acuity: clearly seeing, inspecting, identifying and understanding objects viewed within arm’s length.

Distance acuity: clearly seeing, inspecting, identifying and understanding objects viewed at a distance.

Visual perception: gathering appropriate information from what is seen allowing for accurate understanding and meaning


Few in the health care professions, including head trauma rehabilitation centers, are adequately aware of visual problems resulting from Concussion and Acquired Brain Injury and the visual-perception consequences. Unfortunately, this creates a gap in rehabilitative services, resulting in incomplete treatment and frustration for the patient, as well as the family and treatment team. The vision care professional can play an incredibly important role in the rehabilitation effort. Through vision rehabilitation therapy, an optometrist specifically trained to work with concussion and brain injury patients can help improve the acquisition and processing of information between the eyes and the brain. Vision therapy can be very practical and effective. After examination and consultation, the optometrist determines how a person processes information after an injury and where that person’s strengths and weaknesses lie. The optometrist then prescribes a treatment regimen of vision therapy incorporating lenses, prisms, and specific activities designed to improve control of a person’s visual system and increase visual efficiency. This in turn can help support many other activities in daily living and allow for optimal rehabilitation.


Neuro-optometry is based on the core principle that vision is a learned process and can be rehabilitated at any age following concussion or brain injury. Eye doctors working with concussion and brain injury patients have advanced education in the use of lenses, prisms, and vision therapy to enhance a patient’s visual capabilities, reduce visual stress, prevent and rehabilitate vision problems. As a member of the rehabilitative team, neuro-optometrists have extensive experience treating the vision problems stemming from concussion and brain injury.

Nebraska Visual Integration Center is a specialty vision care office in Omaha that provides vision therapy / rehabilitation to patients following concussion and brain injury. Our eye doctors have extensive training in providing the best rehabilitative vision therapy to patients of all ages. Dr. Gates serves as the Director of Vision Rehabilitation at Madonna Rehabilitation Hospitals and is a rehabilitative optometric consultant to various other brain injury rehabilitation centers in the Omaha and Lincoln area.

If you or a loved one has suffered a Concussion or Brain Injury and may have undiagnosed neurological vision problems, please contact our office at (402) 502-0043 or email [email protected] so we can provide the necessary information to begin the steps to vision rehabilitation recovery.

Attention Problems:

Are They Due to Vision, ADHD, or Both?

At Nebraska Visual Integration Center, many of the children and adults we see in Vision Therapy suffer from attention problems.

It is very important to understand that if your child enjoys being read to, will sit and listen for long periods of time, but demonstrates attention problems when reading or doing homework, there is an excellent chance that your child’s attention problem is caused by an inability to use his eyes. There is no “biochemical imbalance” which allows children to be attentive when information comes in though the ears, but distracts children when information come in through the eyes. It is not uncommon for problems with visual abilities to masquerade as ADHD.

Similarly, if a child can pay attention for math, but not pay attention for reading, there is no “biochemical imbalance,” which occurs when the child looks at numbers, that then disappears when the child looks at words. In math, excluding story problems, there is less visual information to cope with. The child looks at individual numbers and copies them one at a time. In reading, the letters are crowded together so visual problems can more easily cause the letters to run together. Children who can pay attention for math but lose attention for reading frequently have a visual problem masquerading as an attention problem.

However, if when you read to your child, his attention is better although still a problem, then a number of causes–along with vision–could be contributing to the attention problem. For instance, your child might not understand the words, or there could be some other problem affecting attention. Whatever the reason for your child’s struggle with attention or behavior, untreated vision problems will only increase frustration, trigger behavior problems, and make things worse.

Visual Abilities for Success in School, Sports & Life

At Nebraska Visual Integration Center, our Vision Therapy allows an individual to train and improve these visual abilities:

1. 20/20 Eyesight

This is the best known visual ability. If you have 20/20 eyesight, all it means is that at twenty feet, you can see the same letters that people with normal eyes can see at twenty feet. Unfortunately, 20/20 eyesight–with or without new glasses– does not mean that during reading, computer, or desk work you can see clearly for more than a few minutes. Having 20/20, does not mean you can “sustain focus,” enjoy reading, have depth perception and localization skills to drive at night, or that you are free from vision-caused headaches and general fatigue. All 20/20 eyesight guarantees is that you can see clearly long enough to call out the small letters on a dotor’s eye chart. In addition to “20/20 eyesight” we have to consider other visual abilities often ignored during routine eye exams.

2. Eye Teaming

Using the two eyes together as a team is the second visual ability. We have fourteen eye muscles. The brain must coordinate these muscles perfectly if we are to see comfortably and efficiently. If this coordination is reduced as in Convergence Insufficiency, eyesight can be clear at times, but blurred or double at other times. When eye teaming is inaccurate seeing is inaccurate. Eye teaming is a direct measure of how vision affects our attention and this lack of efficient eye control can cause a child to be mislabeled as having ADHD. The effort to prevent such blurred or double vision can cause premature fatigue, or loss of attention and comprehension during reading, desk or computer work. Certain types of eye muscle coordination problems can reduce depth perception for driving and sports. In more severe cases, poor eye muscle coordination can cause crossed eyes (Strabismus) or lazy eye (Amblyopia).

3. Eye Tracking

Accurate eye tracking allows a person to quickly and precisely move their eyes across a line of print to look at the symbols (numbers, letters or words) and process the written text for meaning. During reading, poor eye tracking causes loss of place, confusing one word with another, careless errors, and problems breaking words down into their parts. A common adaptation of poor eye tracking is the use of a finger as a guide when reading. This may help serve as a crutch for eye tracking, but will slow down fluency and restrict peripheral vision of upcoming words reducing anticipation of the text. Appropriate eye tracking also allows us to accurately move our eyes when tracking a ball in a variety of sports.

4. Eye Focusing

Eye focusing, also known as accommodation, is a visual skill that allows us to have clear focus when looking at targets up close, as well as when shifting focus from close to far. Close to far focus is necessary when looking from the board back to desk notes in class. Eye focusing strongly overlaps with eye teaming and plays a large role in maintaining attention during visual tasks. If eye focusing is poorly controlled, it can increase the time it takes to copy notes and make it extremely difficult to maintain concentration and attention on sustained up-close tasks.

5. Eye-Hand Coordination

The visual information taken in through our eyes helps to guide our hands with fine motor or “little” coordination and gross motor or “big” coordination. We need “little” coordination to copy sentences and keep words equally spaced and on the line. We need “big” coordination to throw or catch a ball or to guide a steering wheel. The “big” type of eye-hand coordination is also very much linked with balance and general coordination.

6. Visual Perception

“Visual Perception” is the ability to organize visual images and ideas and to understand what is seen by the eyes. It’s useful to help understand how things are alike and different and how the pieces fit together to make up the whole. At one extreme we have the artist who can  look at a scene and “see” the relationships between the shapes and colors well enough to reproduce them with paint on canvas. On the other extreme we have the child who cannot tell the difference between a “b” and a “d” or  “was” and “saw”. Visual perception problems can make it difficult to recognize words, complete puzzles, align columns in math or–for adults– read a roadmap.

7. Visualization

Visualization, or Visual Imagery can be explained as, “seeing with the mind’s eye.” If visualization is good, a child or adult can “see” words in the mind to spell them. They can “see” the story when they are reading. They can picture their goal in their minds and they have the ability to picture the consequences of their actions. Visualization allows us to learn from the past and plan for the future. All reluctant readers should be tested for these important visual abilities.

The Solution

At Nebraska Visual Integration Center, we work with children and adults in Vision Therapy whose attention problems are caused by vision. If a child who has vision problem affecting attention in school is never diagnosed, chances are they will not outgrow it, but rather simply become an adult with a vision problem affecting attention in the workplace and life. Vision therapy treats the vision problems that interfere and prevent an individual from functioning at the highest level which can impact learning, attention, and behavior. Some patients may have vision problems that mimic learning disabilities and may be misdiagnosed and this is where specialized vision testing is necessary and very important. Other patients may have co-existing vision problems and learning disabilities where the visual issues should still be addressed.


Our Vision Therapy office in Omaha specializes in testing, diagnosing and treating these visual issues. If you have any questions about Vision Therapy and how it may impact your/or your child’s life, please call our office at 402.502.0043 or email us at [email protected].



How Accurate are Vision Screenings?

If you have a child in school they have probably had a vision screening. These are generally performed by a pediatrician, or a nurse if done at school. It’s important to note that these are rarely performed by a vision specialist or optometrist.  A vision screening is usually part of a school general physical. This is an opportunity to note any physical issues and may lead to a referral to an eye doctor, although they do not offer a diagnosis or treatment plan.

The Good and Bad of School Vision Screenings

The American Optometric Association says:

  1. Schools screenings provide <4% of the vision tests needed to help a child see.
  2. Miss up to 75% of children with vision problems.
  3. Of the children found to have eye problems through screening, 61% never visit the eye doctor.

School vision screenings are limited, but are typically able to detect issues such as myopia (nearsightedness) and amblyopia (lazy eye). Amblyopia is a visual issue that requires an optometrist with specialty training. Vision screenings often fall short diagnosing visual issues that have an impact on learning, reading and classroom performance. Issues like hyperopia (farsightedness), binocular vision (eye teaming) disorders, eye tracking and eye focusing can have a significant impact on visual functioning for learning.

What to do after a Vision Screening

Your child has had a vision screening so what now?

If your child has failed any portion of the vision screening, it’s necessary for them to see an optometrist or other eye care specialist. If there is suspicion of a visual issue impacting learning, your child may likely need to see an optometrist who specializes in vision therapy and binocular vision. Optometrists who specialize in treating visual issues that affect learning are called developmental or functional optometrists.

What does a Developmental Optometrist Do?

A developmental optometrist specializes in vision therapy. Vision therapy has been scientifically proven to treat and remediate a number of learning-related vision issues. COVD is a website dedicated to the advancement of vision therapy and the prevention, enhancement, and rehabilitation of functional visual issues.

Below you’ll find the full article on vision screenings and how they are insufficient in detecting a number of significant visual issues.

HPI American Optometric Association Issue Brief: “Vision Screen: Should Be Called “Amblyopia Screening” 

Vision is more than seeing clearly! It’s the ability to obtain meaning and understanding from what we see with our eyes. Vision is a complex combination of learned skills including eye movement coordination, binocular fusion (eye teaming), accommodation (eye focus), and visual form perception.

Visual Skills for the Classroom, Learning & Life

Eye Tracking – the ability to keep the eyes on target when looking from one object to another, moving the eyes along printed page, or following a moving object like a thrown ball.


Eye Teaming – the ability to coordinate and use both eyes together for spatial orientation and to be able to judge distances and see depth (3D Vision).


Eye Focusing – the ability to quickly and accurately maintain clear vision when looking from the board to the desk and back. Eye focusing allows you to easily maintain clear vision over the time like when reading a book or writing a report.


Eye-Hand Coordination – the ability to use visual information to monitor and direct the hands when drawing a picture or trying to hit a ball.


Visual Perception the ability to organize visual images and ideas and to understand what is seen by the eyes.



Please feel free to contact our Omaha Vision Therapy office at (402) 502-0043 with any questions. We love to explain how vision goes way beyond 20/20. 

What About Insurance?

Individuals and families come to us seeking professional help with vision therapy, but may find medical insurance will not readily help cover the out of pocket costs. We’ve learned ways of working with medical insurance providers on your behalf and would welcome the opportunity to serve you.

We understand the commitment required of Vision Therapy, but we are also aware of the truly life-changing impact Vision Therapy can have on children and adults of all ages. Our goal is to ensure insurance or any financial reason is not the barrier preventing you / your child from receiving the necessary life-changing care.

It’s important to understand the unwillingness of your insurance company to pay for services does not reduce the need for obtaining treatment. While Vision Therapy is not inexpensive, it can be seen as an investment in yourself or your child’s future.

What Options Are Available?

If you find yourself stuck between much needed care and the potential cost, these creative suggestions to cover out of pocket expenses are for you.

Vision Therapy costs estimate around $2,000 – $6,000 for all evaluations, therapy, progress examinations, and follow-up post-therapy visits.

1.Finance through Advance Credit

Advance Care is a known, reputable company that can help you finance Vision Therapy costs and offers up to 14-month no interest financing plans. Nebraska Visual Integration Center has developed a relationship with Advance Care allowing families the financing to ensure appropriate care is option for them. Advance Care provides you with a line of credit with no interest that you can use for Vision Therapy treatment. Many families take advantage of the benefits of Advance Care for orthodontics (braces) as insurance often deems braces as an elective procedure similar to Vision Therapy. 

Affordable monthly payment plans allow additional time to pay and often put costs below $300 a month.

2. Use your Flex Spending or Health-Savings Account

This is another very popular approach. Vision Therapy at Nebraska Visual Integration Center fully qualifies as an approved use of Flex Spending or Health-Savings Account. Based on your tax bracket, this is a way to save significantly on your costs by spending the money on a pre-tax basis.

3. Reach out to churches, community groups (Lion’s Club, etc), friends and family

Patients often reach out to their community for help. You’ll be surprised how receptive people will be when they understand the need.  Don’t be afraid to reach out.

4. Appeal to your employer

Try contacting your employer and ask them to make an exception for your child’s vision care in your insurance plan.  If they understand the importance and value of the therapy, they may be willing to make an exception and provide coverage.


Our goal is to ensure every patient who requires Vision Therapy is able to find a way to begin receiving the needed care.

Please contact our Omaha Vision Therapy office (402) 502-0043 or email: [email protected] with any questions and we’d love to help.

Primitive Motor Reflexes and their Role in Vision Development

Most people are familiar with retained motor reflexes, they just may not know it. They can be witnessed when: a baby’s head is turned to one side and the arm and leg on that side turn out and the baby assumes a ‘fencer’ pose; or if a baby, when startled by a loud sound, extends his head back and spreads arms out; or if you touch a baby’s palm, a reflexive gripping of your finger will occur.

Doctors often assess the development of a child based on the progression and integration of these reflexes.

Primitive reflexes are involuntary movement patterns directed by the brainstem, meaning they are not under conscious control. They emerge in-utero and during the early months of life play an essential role in infant survival and development.

These reflexes have a limited life span and lay the foundation for more precise movement. For ideal development, they should become integrated during the first year of life to allow for more complex movement patterns controlled by higher levels of the brain.

What if these Reflexes are retained (stay around too long) or re-emerge after a brain injury?

The persistence of these reflexes can indicate poor neurological development and immaturity within the nervous system. They can interfere and prevent the development of succeeding postural reflexes.

Postural reflexes are necessary to support control of balance, posture and movement. Because eye movements are often considered the most precise and neurologically demanding motor skills initiated by the brain, when earlier movement patterns do not develop appropriately, visual skills tend to be poorly controlled and integrated.

The brain possesses a finite amount of energy, and when we are required to compensate for retained reflexes, this takes a toll on the brain and nervous system, and limits the amount of remaining energy available for other necessary cognitive action.

One of the possible underlying causes of academic and/or visual problems may be the retention or inadequate integration of one or more of the primitive reflexes.

Why Test for Retained Primitive Reflexes during a Vision Evaluation?

Integrating primitive reflexes can help patients progress faster during their Vision Therapy program because the visual skills are built on a more secure neurologic foundation. If the brain has better control over the large movements of the body, this frees up mental resources that can be dedicated for learning and thinking, much of which depends on visual skills and visual information processing. Depending on the individual, Dr. Gates works closely with occupational therapists providing collaborative care.

Below you’ll find a brief overview of symptoms of retained primitive reflexes:

Moro Reflex:

poor eye movement control; visual-perceptual problems; difficulty ignoring irrelevant visual material; difficulty with black print on white paper; motion sickness; poor balance and coordination (commonly during ball games); physical timidity; dislike of change/surprises; poor auditory discrimination; hyperactivity; mood swings; tense muscle tone

Asymmetrical Tonic Neck Reflex:

poor balance with head movement to either side; poor smooth tracking eye movements (especially when crossing the midline); mixed laterality (uses right/left hands interchangeably); poor handwriting; difficulty shifting focus from near to far; difficulty keeping place when copying from the board; difficulty catching and throwing a ball; hard to tell right from left

Symmetrical Tonic Neck Reflex

poor eye-hand coordination; difficulty adjusting binocular vision from distance to near; poor posture; tendency to slump when when sitting (especially at desk/table); ‘W’ position when sitting on the floor; poor depth perception; poor balance

Spinal Galant Reflex

bedwetting; fidgety and wiggly (especially when seated); poor short-term memory; poor concentration; hip rotation to one side when walking; ADHD characteristics

Tonic Labyrinthine Reflex

eye movement, visual-perceptual, spatial awareness problems; poor posture; toe walking; vestibular related problems —poor balance, car/motion sickness; dislike of sporting activities, running; poor sequencing skills; poor sense of time

Nebraska Visual Integration Center is one of the only vision clinics in the region to combine Vision Therapy with primitive reflex integration to treat the whole person.

After all, vision is a brain-based process and requires interaction with many other neurological systems to be efficient. It only makes sense to treat the entire brain as there is no way to isolate vision from other brain-based actions.

Dr. Gates Bio

Dr. Gates bio information here

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