Double Vision

Light Sensitivity - Headlights

Glow, Visual Aura, and Migraine

Double or Triple?

Stars/Sparkles or Visual Snow

Washed Out - Lack of Contrast and/or Glare Sensitivity/Light Sensitivity

Pixilated

Reading

Tilted

Dark and/or scratchy around the edges, peripheral vision distortion, vision lag with motion

Swirl

Blur

Patterns

Picasso Face

Cogs and Circles

Floaters and Squiggles

Inverse Image/Afterimage

Videos

In general double vision can be because the eyes are not working together as a team, in which case it occurs when both eyes are open, but improves when either eye is closed. This is called binocular double vision. This could be due to an oculomotor/vergence dysfunction, or ocular misalignment due to a strabismus or cranial nerve palsy.

TRIAGE:

This should be triaged to an eyecare provider for a binocular vision/oculomotor examination like a neuro-optometrist/ophthalmologist or pediatric optometrist/ophthalmologist, if they are available in your area.

H53.2 Diplopia/double vision

Double vision that is present with each eye on its own (still present with one eye covered) is called monocular double vision and can be due to uncorrected refractive error like astigmatism, accommodative dysfunction or an ocular (eye) health condition like dry eye, cataracts or maculopathy.

TRIAGE:

This should be triaged to a primary care optometrist/ophthalmologist.

H53.2 Refractive diplopia/double vision

In general reduced night vision, glare sensitivity, and light sensitivity can be complicated to diagnose.

Night vision complaints most often occur due to uncorrected refractive error or an ocular health problem like dry eye, pupil problems or cataracts.

H53.60 Vision loss at night

Glare sensitivity is most commonly due to an ocular health condition like dry eye or cataracts, but can occur in patients who are overall light sensitive after brain injury.

H53.71 Glare sensitivity

Light sensitivity after brain injury has a vast differential diagnosis including an eye health problem like dry eye or inflammation inside the eye, while others have light sensitivity due to a neurologic or psychiatric condition. Some patients benefit from specialty tinted lenses, while others are worse with tinted lenses and need vision rehab.

H53.141 Photophobia/Visual discomfort - right eye

H53.142 Photophobia/Visual discomfort - left eye

H53.143 Photophobia/Visual discomfort - both eyes

H53.149 Photophobia/Visual discomfort - unspecified eyes

TRIAGE:

These patients should be referred to optometry/ophthalmology to rule out ocular health etiology (ex: cataracts, dry eye, etc.) and if persistent may benefit from further evaluation for a tint assessment or vision rehab with a low vision or neuro-optometrist. Be aware that prolonged use of dark tinted lenses indoors chronically may exacerbate light sensitivity. It is important that these patients see a specialist if their complaints are persistent.

H53.141 Photophobia/Visual discomfort - right eye

H53.142 Photophobia/Visual discomfort - left eye

H53.143 Photophobia/Visual discomfort - both eyes

H53.149 Photophobia/Visual discomfort - unspecified eyes

Some patients may have atypical visual symptoms that last 10-60 minutes which precede a migraine. This is called a migraine aura and can include abnormal “glow” of objects, light sensitivity, zig zag lights in their central or peripheral vision and temporary peripheral vision loss. Some patients can experience this visual aura without a subsequent migraine in which case it is called a retinal or ocular migraine or an acephalgic migraine.

TRIAGE:

These ultimately improve with treatment of the migraine by a neurologist or physiatrist/physician that is specialized in brain injury medicine However, a patient may benefit from some types of tinted lenses. A consultation with an optometrist/ophthalmologist may also be helpful. In the case of flashing lights and vision loss, patients should have a dilated eye exam with an optometrist or ophthalmologist to rule out a retinal defect like a retinal tear that can occur in patients who have suffered head trauma.

G43.109 Migraine with aura/retinal migraine

R44.8 Aura - other symptoms and signs involving general sensations and perceptions

H53.10 Flashes of light/subjective visual disturbance

TRIAGE

****Please note: If a patient reports bright flashes of light in the peripheral vision of one eye that is new to them that lasts for a few seconds and occurs at random, they may have a retinal tear/detachment and they should be referred URGENTLY to an eyecare provider for a dilated eye exam.

If a patient has both monocular (one eyed) and binocular (two eyed) double vision, they may complain of “triple” vision. If they notice the double/triple only when an object is moving, it may be due to an oculomotor dysfunction like difficulties with vergence or smooth pursuits.

In general double vision can be because the eyes are not working together as a team, in which case it occurs when both eyes are open, but improves when either eye is closed. This is called binocular double vision and could be due to an oculomotor/vergence dysfunction, or ocular misalignment due to a strabismus or cranial nerve palsy.

TRIAGE:

This requires a binocular vision/oculomotor examination by a neuro-optometrist/ophthalmologist or pediatric optometrist/ophthalmologist, if they are available in your area.

H53.2 Diplopia/double vision

H55.82 Deficient smooth pursuit eye movements

Double vision that is present with each eye on its own (still present with one eye covered) is called monocular double vision and can be due to uncorrected refractive error like astigmatism, accommodative dysfunction, or an ocular (eye) health condition like dry eye, cataracts or maculopathy.

TRIAGE:

This should be triaged to a primary care optometrist/ophthalmologist.

H53.2 Refractive diplopia/double vision

Some patients may get visual disturbances like panfield dots in their vision described as “TV static” or bright white spots throughout their vision. 

TRIAGE:

These patients need to have a dilated eye exam with an optometrist/ophthalmologist to rule out a retinal defect like a retinal tear or detachment or disorder of the macula. Often this is due to cortical hyperexcitability in the occipital lobe or other neurological disorder. The patient may benefit from seeing a provider with experience treating visual snow syndrome, including, but not limited to, a neuro-optometrist/neuro-ophthalmologist/neurologist as well as other providers, who may treat some of the other symptoms that go along with visual snow like tinnitus (ENT, orthopedic/cervical physical therapist, etc).

H53.10 unspecified subjective visual disturbances (flashes of light/sparkles)

H53.8 other vision disturbances (visual snow syndrome)

Contrast sensitivity or the ability to see differentiation in various shades of gray/contrast is a common problem in patients with brain injury or neurological visual field loss, like hemianopsia, as well as ocular health/retinal conditions, like glaucoma, cataract, diabetic retinopathy. These patients may see 20/20 on the high contrast visual acuity charts but complain that their vision seems dim, muted, washed out. Reduced contrast has a large impact on visual function in daily life and puts patients at a higher risk of falls (since they can’t see the differentiation between the gradation of stairs).

TRIAGE:

These patients need to see a primary care optometrist/ophthalmologist to determine the cause of the contrast loss. They may also need to see a low vision optometrist to prescribe specialty tinted lenses to improve their vision.

H53.72 Impaired visual contrast sensitivity

Glare sensitivity occurs when patients have a hard time looking at lights or bright surfaces from which light is reflected. It is most commonly due to an ocular health condition like dry eye or cataracts, but can occur in patients who are light sensitive after brain injury.

H53.71 Glare sensitivity

Light sensitivity after brain injury has a vast differential diagnosis including an eye health problem like dry eye or inflammation inside the eye, while others have light sensitivity due to a neurologic or psychiatric condition. Some patients benefit from specialty tinted lenses, while others are worse with tinted lenses and need vision rehab.

TRIAGE:

These patients should be referred to optometry/ophthalmology to rule out ocular health etiology (ex., cataracts, dry eye, etc.). If persistent, the patient may benefit from further evaluation for a tint assessment or vision rehab with a low vision or neuro-optometrist. Be aware that prolonged use of dark tinted lenses indoors chronically may exacerbate light sensitivity. It is important that these patients see a specialist, if their complaints persist.

H53.141 Photophobia/Visual discomfort - right eye

H53.142 Photophobia/Visual discomfort - left eye

H53.143 Photophobia/Visual discomfort - both eyes

H53.149 Photophobia/Visual discomfort - unspecified eyes

While not unknown as to a cause or diagnosis, some patients may describe their vision as pixelated.  

TRIAGE:

It is important that they see a primary eye care provider like an optometrist/ophthalmologist to ensure there is not a problem in the retina/macula. However, it is possible that like visual snow complaints, it is an unknown subjective visual disturbance of neurological origin.

H53.10 Unspecified subjective visual disturbance

Difficulties with blur/double vision/words moving on the page can be due to oculomotor dysfunction like convergence insufficiency, accommodative insufficiency, saccadic dysfunction, uncorrected refractive error or an ocular health problem like dry eye or cataracts.  

TRIAGE:

This should be triaged to optometry/ophthalmology to ensure normal glasses prescription/eye health. If those are normal, further referral to a neuro-optometrist may be warranted to perform a comprehensive oculomotor evaluation and provide vision rehabilitation.

There is no specific CPT code for difficulties with reading. However, the following are the most common causes of reading difficulties post brain injury.

H51.11 Convergence insufficiency (inability to cross eyes at near causing intermittent horizontal double vision at near)

H50.52 Exophoria (eyes drift outwards)

H50.51 Esophoria (eyes drift inwards)

H55.81 Saccadic eye movement dysfunction

H52.6 Accommodative insufficiency (inability for eyes to focus at near causing intermittent or constant blurred vision at near)

H55.89 Irregular eye movements

H55.82 Smooth pursuit dysfunction

Some patients may notice that their vision is tilted. This may occur particularly if one of their oblique eye muscles is impaired due to a cranial nerve palsy/strabismus or restricted strabismus or cerebellar/vestibular dysfunction causing the images to tilt. 

TRIAGE:

These patients need to see an optometrist/ophthalmologist who specializes in double vision or a neuro-optometrist/developmental optometrist or a pediatric/neuro-ophthalmologist.

H53.2 Double vision

H53.10 Unspecified subjective visual disturbance

H51.8 Other specified disorders of binocular movement (ocular tilt reaction)

Some patients may have stable vision when their head or eyes are stable, but notice the edges of their vision is distorted/blurry especially when they/their head or eyes are in motion or the object is in motion. This may be due to an eye movement/eye focus disorder or a vestibular dysfunction.  

TRIAGE:

These patients would benefit from a workup with a neuro-optometrist/vestibular physical therapist and may require both providers for full remediation of their symptoms.

R42 - Vertigo/dizziness/giddiness

H53.10 Unspecified subjective visual disturbances - palinopsia

If a patient has vertigo or dizziness due to vestibular, oculomotor disorder or nystagmus, they may complain that the world is moving when they are stable or in motion. This can be described as oscillopsia or vertigo or dizziness or that their vision is “swirled.”

R42 - Vertigo/dizziness/giddiness

H53.10 Unspecified subjective visual disturbances - palinopsia

Blurred vision is the most common visual description used when vision isn't “normal.” However, some patients describe images as blurry when they are actually double or areas of vision loss (scotoma). It is important to ask patients if the blur is the entire visual field or just a part/spot. Is it constant or does it fluctuate? Is it only at distance or near or is it everywhere?

• The most common cause of blurred vision is uncorrected refractive error (myopia, hyperopia, astigmatism, presbyopia) or ocular health conditions like dry eye or cataracts.

• It is imperative that the provider figure out if it is “blur” versus vision loss - areas of vision that are gone/missing. Vision loss should be referred promptly to an eyecare provider.

TRIAGE:

This patient should be referred to a primary eye care provider - optometrist and/or ophthalmologist first. If their blur is not improved/resolved with a comprehensive primary eye care exam, they may need further referral to a neuro-optometrist/ophthalmologist.

ICD-10 codes: Differential diagnosis for blurred vision is too vast to isolate.

Patterns of vision can occur in patients with neurological dysfunction. It is rarely caused by the eye itself and is more often a cortical phenomenon.

TRIAGE:

These patients should see an eye care provider to rule out any ocular health pathology, but know that the dysfunction may persist and they may need to see a neuro-optometrist/neuro-ophthalmologist/neurologist.

H53.10 - Unspecified subjective visual disturbance

Information coming soon.

Some patients may describe objects that are white or colored lights (positive photopsias) that are spin wheels or cogwheels in shape or dark (negative photopsias). They should get a dilated eye exam to rule out eye health problems, but normally this is a cortical (brain) phenomenon in the visual cortex).

TRIAGE:

Patient should have a dilated eye exam with an eyecare provider - optometrist or ophthalmologist. It is possible to be part of a migraine aura, so may warrant referral to a neurologist.

H53.10 - Unspecified subjective visual disturbance

Floaters or “spots” in front of the eyes can be normal or a sign of an ocular emergency like a retinal tear or detachment.  

TRIAGE:

If the patient has floaters AND flashing If the patient has floaters AND flashing lights AND/OR a missing piece of their peripheral vision they need to be urgently referred to an ophthalmologist/optometrist for a dilated eye exam to ensure ocular health/absence of a retinal tear or detachment.

• Some floaters can be normal due to the natural aging process of the vitreous gel in the eye, or can be traumatic in origin due to a retinal or vitreous detachment, or if there is a bleed somewhere inside of the eye.

If you cannot decipher the type of floaters, you can code H53.8 other visual disturbances and the eyecare provider can decipher what type of floater they are.

H43.391 Vitreous floaters, right eye

H43.392 Vitreous floaters, left eye

H43.393 Vitreous floaters, both eyes

H43.399 Vitreous floaters, unspecified eye

Some patients may notice persistent afterimages. When they look at an object (lit or not) and then look away and the previous object persists in their vision as a clear tracing of it.

H53.10 Unspecified visual disturbance