Neuro-visual pathway after mild traumatic brain injury: a systematic scoping review of symptoms, objective testing, and rehabilitation

Abstract

Visual complaints are common after mild traumatic brain injury (mTBI), yet the scope, assessment approaches, mechanisms, and rehabilitation strategies reported in the literature remain heterogeneous. To synthesize evidence on post-concussive visual symptoms, diagnostic/assessment approaches, treatment/rehabilitation strategies, and putative mechanisms. Relevant studies published between 1997 and 2025 were identified and screened; 57 studies reporting visual outcomes following mild traumatic brain injury were included. The literature comprised cohort and cross-sectional studies, randomized and non-randomized intervention studies, case series and case reports, as well as selected guidelines and reviews. Studies were tagged to five domains (Symptoms; Diagnosis/Assessment; Treatment/Rehabilitation; Pathophysiology/Mechanisms; Epidemiology). We performed narrative synthesis with quantitative tabulation and co-occurrence mapping (symptom-test; symptom-treatment). Frequencies of symptom types, assessment modalities, intervention categories, mechanistic signals, and their co-occurrences. Publications spanned 1997-2025, with 56.1% appearing in 2021-2025. Symptoms were reported in 49 studies, dominated by oculomotor disturbances (46.9%) and photophobia (36.7%); binocular anomalies were frequent (diplopia 18.4%; convergence insufficiency 16.3%; accommodative insufficiency 14.3%). Among 21 assessment papers, clinical tests used to assess binocular-vision metrics predominated (accommodation 57.1%; vergence 38.1%; NPC 19.0%), with selective device-based testing (VEP 19.0%; eye-tracking 14.3%; OCT 9.5%). Twenty-one treatment studies most often described vision/orthoptic therapy (47.6%) and vestibular-oculomotor rehabilitation (42.9%); prisms (19.0%) and tinted lenses (14.3%) were used in targeted subgroups. Mechanistic reports (n = 29) emphasized oculomotor control abnormalities (79.3%), with smaller contributions from VOR and VEP findings; structural correlates (DTI/OCT) were less common. Co-occurrence analyses showed dense links between oculomotor symptoms and accommodation/vergence/NPC testing, and between photophobia and spectral filters. Post-concussive visual sequelae are clinically coherent and largely reflect neuro-oculomotor dysfunction with frequent binocular anomalies and photosensitivity. High-yield assessment centers on vergence, accommodation, and NPC, optionally augmented by screening tools and selective device-based measures. The most consistent therapeutic signals favor vision/orthoptic and vestibular-oculomotor rehabilitation, with prisms and tinted lenses for select indications. Standardized outcomes and well-powered comparative trials are needed to strengthen recommendations. This review integrates symptoms, objective testing approaches, and rehabilitation outcomes across the neuro-visual sequelae of mTBI and provides a structured clinical mapping of symptom-test and symptom-treatment linkages.

Keywords: Accommodation; Concussion; Convergence insufficiency; Mild traumatic brain injury; Oculomotor; Photophobia; Vestibular-oculomotor rehabilitation; Vision therapy; Visual symptoms.