Chronic Neck Pain and Blurred or Double Vision Problems?
Ross A. Hauser, MD.
If you are reading or listening to this article, it is likely that you already know the answer to the question posed: Can a herniated disc in the neck or whiplash cause vision problems? The answer is yes. The next challenge, can it be treated? If you are exploring this article you have probably had treatments with less than hoped-for results. The main reason for your lack of success is that your doctors may have focused solely on the blurry vision and not explored the possibility of a greater problem of the soft tissue damage in your neck causing the blurred, double vision.
Cervical neck instability causes a myriad of symptoms such as pain, dizziness, tinnitus, vertigo, sinusitis, swallowing difficulty, and others. In this article, our focus will be on vision problems.
While vision problems are the focus, it is important to understand that anyone who suffered from a traumatic injury, such as whiplash in a car accident or sports injury, or someone suffering from degenerative problems of the neck, blurred, double vision is only one component of symptoms. Fixing the problems of blurred vision will be difficult to treat when symptoms of cervical neck instability are not treated. We will provide treatment options below. Common eye complaints that occur with patients who suffered neck injuries, including whiplash, include blurry vision, diplopia (double vision), inability to focus clearly, eye pain, photophobia (eye discomfort brought on by exposure to bright light), palinopsia (an image remains “in sight” even though the image has been removed. “I see things that are no longer there., visual distortions, and a feeling of “wooziness” (like being on a boat – Mal de debarquement syndrome.)
Problems of blurred or double vision can be caused by many problems. This article will focus on the cause of neck instability causing pressure on the nerves, arteries, and veins that run through the cervical spine and into the skull.
Introduction: Chronic Neck Pain and Blurred or Double Vision Problems – Is the answer in the neck ligaments and the cervical sympathetic ganglion?
- Chronic Neck Pain and Blurred or Double Vision Problems – Is the answer in the neck ligaments and the cervical sympathetic ganglion?
- The idea of nerve compression from cervical spine instability causing blurry vision.
- The idea that eye movements, gaze stability, and ocular reflexes are hampered by soft tissue neck injuries is a recognized but somewhat controversial subject.
- But is it really the neck causing vision problems? The research and controversy surrounding neck pain and vision problems.
- What does this image show? The superior cervical sympathetic ganglion.
- The wandering vertebra and the pull of these vertebras on the nerve, ganglia and blood vessels that attach to them. Ligament and joint instability and nerve impulse disruption.
- Can a herniated disc in the neck or whiplash cause blurred vision?
- “Characteristics of visual disturbances reported by subjects with neck pain.”
- A swollen optic nerve – “Patients with abnormal visual function most likely have demyelinating optic neuritis”
- Non-arteritic anterior ischaemic optic neuropathy.
- An increase in optic nerve sheath diameter can be due to increased intracranial pressure. Increased intracranial pressure causes the optic nerve to swell.
- “Altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility (eye muscle movement) and coordination should become an essential part of the routine assessment of those with traumatic neck pain.”
- Altered cervical joint position. Can a herniated disc in the neck cause blurred vision?
- Whiplash and cervical ligament damage – can this be the cause of your double, blurry vision?
- Problems of neck stability and movement are caused by muscle atrophy. Can muscle atrophy cause double, blurry vision?
- Our treatments for cervical instability and related challenges of vision – Regenerative Medicine Injections | Caring Cervical Realignment Therapy
- An individualized cervical spine instability and vision problem treatment protocol may include the following:
- A case history using PRP injections with Prolotherapy to alleviate symptoms related to cervical spine instability and vision problems
The idea of nerve compression from cervical spine instability causing blurry vision
Blurred vision, blind spots, water eyes, and difficultly focusing are very common eye complaints that many people are not aware are from cervical instability. The pupil and iris of the eye function as a unit to produce a sharp focus by eliminating or controlling light stimuli. The pupil is the circular colored area of the eye and is responsible for controlling the diameter and size of the pupil, which is the part of the eye that allows light to reach the retina. The iris sphincter muscle (pupillary constrictor) which receives its impulses from the parasympathetic fibers of the third cranial nerve (oculomotor) constricts the pupil; whereas the iris dilator muscle (pupillary dilator) are innervated by sympathetic fibers running from the superior cervical ganglia.
- The various nerve centers of the autonomic nervous system are called ganglia and are located just in front of the vertebral bodies in the cervical, thoracic and lumbar spine.
Cervical instability from ligament damage or injury causes eye symptoms and diseases by two main mechanisms: obstruction of cerebrospinal fluid (CSF) and dysautonomia. (Both of these issues will be discussed below). The assault on eye blood flow, pressure, and homeostatic (balance) mechanisms is enough to not only cause various eye symptoms, including palinopsia (tracers, after image, static, or snow vision), oscillopsia (oscillating vision), entopic phenomena (floaters), but also serious eye conditions, including optic hypertension, glaucoma, and macular and retinal degeneration.
Please see my companion articles:
- Cervical Spine Instability, Vein blockage, fluid build up and intracranial hypertension.
- Visual snow syndrome and neck instability.
- Nystagmus – Oscillopsia caused by cervical spine instability and neck pain
The idea of nerve compression from cervical spine instability causing blurry vision
The idea that eye movements, gaze stability, and ocular reflexes are hampered by soft tissue neck injuries is a recognized but somewhat controversial subject. Controversial in that diagnosis and treatments do not have a standardization. This is pointed out in numerous studies. Here are a brief list:
In 2016 Dutch researchers wrote in the BioMed Central musculoskeletal disorders (10) “Overall the reviewed (previously published research) studies show deficits in eye movement in patients with whiplash associated disorder, but studies and results are varied. When comparing the results of the 14 relevant publications, one should realize that there are significant differences in test set-up and patient population. In the majority of studies patients show altered compensatory eye movements and smooth pursuit movements which may impair the coordination of head and eyes.”
A 2020 case history presented in the medical journal Cureus (11), citing this research in support of treatment suggestions, described the case of a 22 year old woman who was in a high speed car accident.
- A 22-year-old woman presenting with an acute concussion and whiplash secondary to a high-speed motor vehicle collision. Smooth pursuit eye-movement abnormalities were observed in relative cervical rotation in the setting of clinical examination of cervicogenic dysfunction. Treatment was focused on cervical manual therapy. While concussive symptoms resolved after seven days, eye-tracking showed a mild improvement and continued to exist in relationship with cervicogenic dysfunction. After completing physical therapy twice weekly for two weeks and in-home exercises, clinical signs and symptoms of whiplash-associated cervicogenic dysfunction and abnormal smooth pursuit eye-movement resolved across all cervical positions.”
But is it really the neck causing vision problems? The research and controversy surrounding neck pain and vision problems.
A March 2022 paper in the International journal of environmental research and public health (13) examined forty-three patients with neck pain who were referred by orthopaedic outpatient clinics where they were required to fill out 16-item proformas of visual complaints. The aim of the study was to analyze classification accuracy of visual symptom intensity and frequency based on smooth pursuit neck torsion tests results. (Smooth pursuit neck torsion tests look for relationships between neck movement and eye function. They are frequently used in whiplash cases, neck injury, and is cases of suspected cervical spine instability).
The researchers write: “The cervical spine has undergone scientific scrutiny for many years. From university professors to highly skilled clinicians, many attempts have been made to concur about interconnected signs and symptoms, but the overall understanding remains based on the assumptions that “In the cervical spine, everything is possible.” Many unfortunate people, therefore, suffer from a variety of different symptoms attributed to neck pain disorders. While some relationship exists between functional signs and symptoms, such as in cervicogenic headaches, radiculopathy and dizziness, visual disturbances remain poorly understood.”
While there are many controversies surrounding vision and neck movement, the researchers here state: “Our study confirmed the relationship between cervical driven oculomotor deficits measured during the Smooth pursuit neck torsion tests (SPNT) and some of the commonly reported visual complaints in patients with neck pain disorders. Intensity of visual symptoms should be considered in clinical practice as it might show a more pronounced relationship to oculomotor control deficits measured during neck torsion positions. Although some relationship was found between visual complaints and oculomotor deficits related to cervical spine, other potential causes not investigated in our study should be considered.”
There is great confusion about the role of cervical spine instability and vision problems. This is demonstrated in the emails we get from people who are not sure if there is a connection. Here is one such email. It has been edited for clarity:
“Many years ago, I was diagnosed with cervical spinal stenosis and a bulging cervical disc. I ended up getting a cervical spine epidural and having physical therapy and I was able to avoid surgery. My neck has never been great, but does not appear to be my main issue today (unless it’s connected). My main issue is with my vision. For the past couple of years, I have had issues with blurred vision that seem to subside when I lay down and close my eyes for 20-30 min. This happens daily and has increased in frequency to where it is almost constant. I work on a computer all day and at times, can’t even read the screen (blurred vision). This has impacted things like driving and being a spectator at sports.
I have seen a neurologist, cardiologist and ophthalmologist – all say I’m ok. I can’t wondering if the issue is tied to my spine? I feel a lot of tension in my neck and lower rear part of my head as well. I came across your practice on the internet and I thought I’d reach out to see if you had any ideas as to what could be causing this and if there’s a solution out there.”
What does this image show? The superior cervical sympathetic ganglion
This is the superior cervical sympathetic ganglion (in simple terms a nerve relay station that forwards neural messages) in its native habitat. Surrounded by blood vessels (internal carotid artery and internal jugular vein) and nerve networks and near the C2 vertebrae. When a condition of cervical instability exists, the vertebrae wander out of position-taking with them and stretching the area’s veins, arteries, nerves, and nerve bundles. This causes internal compression or cervical stenosis and reduced and distorted nerve messaging (in the case of this article – vision problems).
The superior cervical ganglion is the largest of the cervical ganglia and as we see in the image, is located opposite the second and third cervical vertebrae. It lies in front of the transverse processes of C2 and C3 and the longus capitus muscle and behind the carotid sheath. The branches of the superior cervical ganglion connect with the upper four cervical nerves, the nodose ganglion of the vagus nerve, petrous ganglion of the glossopharyngeal nerve, jugular ganglion of the vagus nerve, hypoglossal nerve, internal carotid nerve, and the left and right superior cardiac nerves. As you can see from all these connections, the superior cervical sympathetic ganglion is the primary messaging relay center.
There are additional communications with the vagus nerve through communicating branches that go to external laryngeal and vagus nerves via the pharyngeal plexus and one that goes directly to the glossopharyngeal nerve. As a side note the middle cervical ganglion has branches that go to C4-and 5 spinal nerves and the stellate ganglion communicates with spinal nerves C6-T3.
The wandering vertebra and the pull of these vertebras on the nerve, ganglia and blood vessels that attach to them. Ligament and joint instability and nerve impulse disruption
An introduction to nerve stretching and compression. This would impact the superior cervical sympathetic ganglion. If the vertebrae are wandering, so would the nerves and the ganglia relay stations. It is important to remember that the SCG is very close to the anterior surface of the C2-C3 vertebra. Cervical instability can pull and tug on the superior cervical sympathetic ganglion and effect it directly. On ultrasound the cervical sympathetic ganglion can be 1mm from the bone. So when a person has cervical instability, most probably, the C2-C3 vertebrae will lay right on the superior cervical sympathetic ganglion and cause compression.
- Proper nerve impulse is key to health. Messages from brain to spinal cord to organs and limbs must be clear and get through.
- Important nerves run extremely close to bone for their protection.
- Spinal cord and cervical nerves and ganglia are within 3 mm of bone. Our necks are a very tight and compacted structural anatomy. The cervical spine provides stability and protection to the nerves, veins, and arteries.
- However, many neck instabilities (that is how far a cervical vertebrae has wandered out of place) measure more than 3 mm.
- Nerve impulse start being blocked when the nerves are stretched 5 – 6 %. It does not take much to set off a cascade of neurologic-like disorders.
- Nerves are very sensitive to compression. The reason for many cervical spine surgeries is to get the compression off the nerve.
- Nerves are resilient if the compression is intermittent and infrequent. You can live with it and get good long-term non-surgical treatments because medication.
- If the compression is too intense and/or too frequent, damage to the nerve can occur.
Overall the SCG innervation is much more important to overall eye health and diseases as it controls eye circulation and thus intraocular pressure. Stimulation of the SCG causes the pupil to dilate and thus allows more light to strike the retina. Changes in pupil size modulate not only retinal illumination, but also depth of focus, optical aberrrations and diffraction. As pupil diameter decreases, depth of focus increases and the image degrading effects of optical aberrations decrease butt the image degrading effects of diffraction increase.
As noted then, the SCG is not a lone wolf. It relies on the glossopharyngeal and vagus nerves to send blood pressure in the carotid sinus and aorta arch, respectively to control blood pressure and pulse, not just so the eye structures can have appropriate circulation but the brain. So what happens to the SCG affects the vagus nerve (and other nerves) and vice versa. The nerves are the regulators of vascular tone. For eye structures including he retina, and optic nerve this is the SCG is the nerve relay station.
This article deals in part with the wandering vertebra and the pull of these vertebras on the nerve, ganglia and blood vessels that attach to them. This pull or stretching can cause many of the symptoms we see in our patients including the vision problems. In August of 2021, neurosurgeons in Turkey reported in the journal Surgical and radiologic anatomy (12) of the variations (or wandering) of the cervical sympathetic ganglia according to vertebral levels on preoperative neck magnetic resonance imaging (MRI) by designating carotid artery (CA) as the standard landmark at the center. The did this as a means to assist surgeons injury the cervical sympathetic ganglia in the anterior-anterolateral approaches performed in the cervical spinal region.
Here is what the surgeons noted after examination of cervical spine MRIs:
- At C1 level, a superior ganglion was located on the right side in 32 (64%) and on the left side in 30 (60%) patients.
- Middle ganglion was observed most frequently at C3 level, which was detected on the right side in 17 (34%) and on the left side in 17 (34%) patients.
The study concludes: “This study sheds light on high-risk zones in the surgical site and could guide surgeons to better understand the location of cervical sympathetic ganglia before surgical planning.”
What is displayed in this image?
The pupillary dilator acts to increase the size of the pupil to allow more light to enter the eye, as when driving at dusk or at night. Thus, any lesion affecting the superior cervical gangli may make it harder to focus one’s eyes in a dark room.
Superior cervical sympathetic ganglion and pupillary dilation. The Superior cervical sympathetic ganglion innervates the pupillary dilator muscle which dilates the pupil. When Superior cervical sympathetic ganglion activity is too great or disturbed this constant pupillary dilation can cause photophobia (sensitivity to light not actually a phobia or fear of it) and ultimately increased intraocular pressure since the Superior cervical sympathetic ganglion sits right in front of the C2 – C3 joint. When C2 – C3 instability is present, it is a likely structural cause of vision problems.
- Between the C2 and C3 vertebrae in the Superior cervical sympathetic ganglion in the area are the parasympathetic fibers of the oculomotor nerve
Another way upper cervical instability affects vision is through the optic nerve. When upper cervical instability causes interruptions/blockages of any flow into or out of the brain, as can occur with craniomedullar compression syndrome (vertebral artery compression), swelling can occur in the optic nerve causing a condition called papilledema. Vision changes such as blurred vision, double vision, constriction of the visual field (enlarging of the blind spot), decreased color perception or flickering of vision (lasting seconds) are common visual complaints with papilledema. Resolution of the upper cervical instability affects thus would restore normal hemodynamics in the cranium and thus the vision returns to normal. Having said this, when patients come with significant visual complaints and have not yet seen an ophthalmologist, we refer them to one. You always want to make sure that some internal eye condition does not exist, as some of these (like retina injuries) can be emergencies.
In this video:
Vision problems from vagus nerve injury and cervical instability
Ross Hauser, MD discusses vision problems from vagus nerve injury and how these can be caused by cervical instability and resolved with Prolotherapy and curve correction. Below the video is a summary of the video with explanatory notes to help further and explain some of the concepts that Dr. Hauser is putting forth in explaining vision problems as they relate to neck pain.
Summary learning points
- Dr. Hauser emphasizes that to understand the impact on symptoms of cervical neck instability causes, including ultimately vision problems, you have to understand that the nerves that travel the spine are so intertwined with each other and through the cervical vertebrae that any compression to the nerves will cause far-reaching problems.
- At 1:30 of the video: Dr. Hauser talks about C1-C2 instability and its impact on the Vagus Nerve (Cranial Nerve X)
- When the Vagus nerve is injured by compression caused by instability at C1-C2, this can cause vasospasms (narrowing of the arteries and reduction of blood flow). If these vasospasms impact the ophthalmic artery, the artery that supplies blood to the eye and eye area including the orbit – this can lead to some of the symptoms are patients describe to us such as darkening, black spots, or grayness in the vision of one eye.
At 2:00 Minutes of the video, Dr. Hauser refers to this slide: The details of what this slide says is below:
What is being described in the above image?
In this image, vision problems caused by cervical spine instability are connected to Diminished ocular blood flow, Exaggerated pupillary hippus dilating, Hampered accommodation or human ocular accommodation mechanism or accommodation reflex, Increased intraocular pressure, or elevated intraocular pressure, Limited pupillary constriction, Optic nerve damage. Here are brief explanatory notes:
- Diminished ocular blood flow can cause symptoms, usually in one eye, blurred vision, or partial or complete loss of vision
- Exaggerated pupillary hippus dilating and constricting which can cause problems with light sensitivity and the pupil fails to respond correctly to light sources.
- Hampered accommodation or human ocular accommodation mechanism or accommodation reflex. This is the function of the eye that maintains a clear focus on objects whether close by or far away.
- Increased intraocular pressure or elevated intraocular pressure. This is high pressure inside the eye is caused by an imbalance of production and drainage of the inner eye fluids. The symptoms here include various vision disturbances. Researchers speculate a connection to the development of glaucoma.
- For a more detailed discussion on intracranial hypertension and pressure, please refer to our articles: Cervical Spine Instability, Vein blockage, fluid build up, and intracranial hypertension, Transient monocular blindness – Amaurosis fugax – Transient visual loss, and Cervical spine compression causes internal jugular vein stenosis.
- Limited pupillary constriction. This is also a problem with the dilation of the pupil. Your eye may not respond properly or at all to light stimulus.
- Optic nerve damage caused by blood flow restriction.
A swollen optic nerve – “Patients with abnormal visual function most likely have demyelinating optic neuritis”
We see in some patients, with vision problems that relate to a problem of cervical spine instability, a swollen optic nerve. A paper in the journal Practical Neurology (1) describes problems of a swollen optical nerve in this way:
“Patients with abnormal visual function most likely have demyelinating optic neuritis (swelling of the nerve sheath and optic nerve) or non-arteritic anterior ischaemic optic neuropathy (loss of blood flow to the optic nerve). . . “
These are characteristic symptoms of compression or entrapment of the nerves and arteries in the cervical spine.
What does this image suggest?
In this ultrasound image, the swelling of the optic nerve is clear compared to a normal optic nerve. A common but not as commonly diagnosed cause of swollen optic nerve and problems of vision is increased intracranial pressure from cervical spine instability.
Non-arteritic anterior ischaemic optic neuropathy
A December 2020 study (2) in the International Journal of Ophthalmology evaluated whether narrowing of internal carotid artery siphon (a branch of the carotid artery) may increase the risk of developing non-arteritic anterior ischaemic optic neuropathy (NAION). This is as mentioned above a problem of loss of blood flow to the optic nerve.
- Non-arteritic (there is no inflammation in the artery so an outside cause of artery compression is suspected, such as cervical spine compression on the arteries).
- Anterior (near the front),
- Ischaemic (reduced blood flow from, at this moment of diagnosis, an unknown origin),
- Optic Neuropathy (some type of optic nerve abnormalities or damage).
What this study concluded was that a narrowing of the internal carotid artery siphon may increase the risk of developing non-arteritic anterior ischaemic optic neuropathy NAION. In essence, something is causing loss of blood flow to the optic nerve, it is a non-descript cause, but it is not vascular inflammation and it is causing vision problems. At our center, this cause is often identified as cervical spine instability. One tool that we use to assess problems, especially swelling, of the optic nerve is to take the nerve’s measurements to check for swelling via ultrasound. The test is illustrated below:
What are we seeing in this image?
In this photograph, an optic nerve measurement is taken via ultrasound. We are looking for swelling of the optic nerve that may explain vision problems by way of demyelinating optic neuritis (swelling of the nerve sheath and optic nerve) or non-arteritic anterior ischaemic optic neuropathy (loss of blood flow to the optic nerve). Characteristic symptoms of compression or entrapment of the nerves and arteries in the cervical spine.
The superior cervical ganglion influence on the eye circulation and optic nerve is enormous. Sympathetic nerves innervating the orbital structures come from the superior cervical ganglion and are conducted cranially in the internal carotid nerve. The autonomic nerves from the internal carotid plexus are transmitted to the orbit with the opthalmic artery.
- The ophthalmic artery is the first branch off of the internal carotid artery. It spits off into many branches and brings blood to the The ophthalmic artery gives off many branches, which supply the orbit, meninges, (the three layers of protective membrane covering the brain and spinal cord) face, and upper nose. When the ophthalmic artery is blocked or compressed, symtoms of vision problems can occur.
An increase in optic nerve sheath diameter can be due to increased intracranial pressure. Increased intracranial pressure causes the optic nerve to swell.
What does this image suggest? In this ultrasound image, the swelling of the optic nerve is clear compared to a normal optic nerve. A common but not as commonly diagnosed cause of swollen optic nerve and problems of vision is increased intracranial pressure from cervical spine instability.
The traditional treatments of spinal fluid shunts and optic nerve sheath fenestration (operation to reduce swelling on optic nerve) never explain why the cerebrospinal pressure is high.
The optic nerves, as well as the other cranial nerves and spinal nerve roots, are surrounded by cerebrospinal fluid in the subarachnoid space. As intracranial pressure rises from increased cerebrospinal fluid in the brain, the cerebrospinal fluid looks for a path of least resistance, one of which surrounds the optic nerve and can be evaluated by optic nerve sheath diameter measurements. It is the pressure on the optic nerve that accounts for some of the vision changes that are seen with cervical spine instability.
Historically, the optic nerve and its sheath diameter were noninvasively assessed by MRI and ophthalmoscopy but transorbital ultrasound has recently emerged as a promising assessment tool.
In the image below, the caption reads: A comparison of an enlarged optic nerve sheath diameter measurement from orbital ultrasound compared to one that is normal.
- The left side: Image A is enlarged
- The right side is Image B or normal size.
Optic nerve sheath diameter measurement is one non-invasive way to diagnose intracranial pressure hypertension (increased brain pressure).
What are we seeing in this image?
Here we are looking at a transverse view of the neck at the level of C2, showing the effect of malrotation of C2 on the C2 nerve root, compression of the carotid sheath as well as the superior cervical ganglion on the right side. Malrotation can affect the signaling of important nerves which impair the function of numerous systems. Many people with blurred vision also suffer from dizziness, headaches, swallowing difficulties, brain fog, and ringing in the ears, among other symptoms.
Can a herniated disc in the neck or whiplash cause blurred vision?
Many people contact us via email with their medical concerns. Here are some generalized examples of a person diagnosed with a herniated disc and a vision problem.
I have been having problems getting my eyes to focus. I went to the eye doctor, I got an exam and I am told my eyes are okay.
I have had neck problems for a long time. I have degenerative arthritis and it is not getting better. I have been having problems getting my eyes to focus. I went to the eye doctor, I got an exam and I am told my eyes are okay. The eye doctor suggested I should go to a cardiologist and make sure I do not have a blockage in my neck arteries. I have noticed that as my neck pain is progressing I get more frequent headaches and pain radiates into my jaw. When I told my eye doctor about the jaw pain that is when he suggested the cardiologist.
After I went to the cardiologist
After the cardiologist, I seem to be okay heart and circulation-wise. I have been treated by a chiropractor for a herniated disc at C5-C6. He is also treating me for cervical lordosis. He has been telling me that my vision problems are related to my neck issues and that I should consider some type of injections or eventually a fusion surgery. I need to consider something because the blurry vision, especially in my one eye, is worse.
“Characteristics of visual disturbances reported by subjects with neck pain”
People, perhaps like yourself with visual disturbance will usually report on many problems that this condition is causing them. It is usually not limited to one aspect of vision.
In their 2014 paper: “Characteristics of visual disturbances reported by subjects with neck pain,” Researchers at The University of Queensland wrote in the journal Manual Therapy (3) of the most difficult to treat and manage visual disturbances in their patients with neck pain.
- The most prevalent symptoms that they found in the patients of the study were:
- ‘patient found that they had to concentrate to read‘ (70%) and
- ‘patients found that they had sensitivity to light’ (58.6%).
- Lesser prevalent but still impacting many patients were:
- double vision (28.6%) and
- ‘dizzy reading‘ (38.6%).
- The most troublesome symptoms were
- ‘need to concentrate to read’
- ‘visual fatigue’
- ‘difficulty judging distances
- and ‘sensitivity to light’
Let’s do some simple definitions before we proceed.
- The vestibular system is the body’s sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment).
- It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism.
- In human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is the constant and our vestibular system makes constant involuntary adjustments to “keep things steady.”
- The vestibulo-ocular reflex is part of the vestibular system. It is a reflex eye movement that stabilizes images during head rotation.
- The cervico-ocular reflex is a vision stabilization reflex that is called on by the rotation of the neck when your trunk turns sideways but your head does not turn. Such as rotating either shoulder so it sits under your chin or the trunk rotation during power walking or nordic type exercises.
- The vestibulo-ocular reflex and the cervico-ocular reflex work in conjunction with the optokinetic reflex (your ability to follow moving objects).
While these are very simple definitions, they get the point across that the vestibular system is a complex, delicate balancing system that stabilizes vision. More simply, it “keeps your eye steady.”
One more definition:
- Cervical afferent dysfunction. This is a medical term to describe blockage or dysfunction of nerve messages or blood flow in the neck.
The SCG innervates the eye and lacrimal gland and causes vasoconstriction of the iris and sclera, pupillary dilation, widening of the palpebral fissure and the reduced production of tear. When the SCG is damaged Horner’s syndrome results which causes drooping of the eyelids (ptosis), constriction of he pupil (miosis) and apparent sinking of the eyeball.
“Altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility (eye muscle movement) and coordination should become an essential part of the routine assessment of those with traumatic neck pain”
Dr. Julia Treleaven, Ph.D., is a member of the Neck Pain and Whiplash Research Group, Division of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia. She has also written numerous papers on the problems of impaired function in the cervical neck. The paper cited at the top of this article is one that she co-authored.
In the July 2017 edition of The Journal of Orthopaedic and Sports Physical Therapy (4), she wrote:
There is considerable evidence to support the importance of cervical afferent dysfunction in the development of dizziness, unsteadiness, visual disturbances, altered balance, and altered eye and head movement control following neck trauma, especially in those with persistent symptoms.
However, there are other possible causes for these symptoms, and secondary adaptive changes should also be considered in the differential diagnosis.
Understanding the nature of these symptoms and differential diagnoses of their potential origin is important for rehabilitation. In addition to symptoms, the evaluation of potential impairments (altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility (eye muscle movement) and coordination) should become an essential part of the routine assessment of those with traumatic neck pain, including those with concomitant injuries such as concussion and vestibular or visual pathology or deficits.
Smooth pursuit eye-movement abnormalities
Smooth pursuit eye-movement abnormalities are as they are described. Your eyes follow the movements of objects, and they should do so smoothly. An August 2020 paper presented by Stanford University researchers (5) described the case of a 22-year-old woman who suffered a whiplash injury. Here are the learning points of this case:
Whiplash injuries may disrupt normal cervical afferent and efferent projections. (As we discussed above, the blockage or dysfunction of nerve messages or blood flow in the neck.) Oculomotor abnormalities have been reported in chronic whiplash cases, but there is limited knowledge of their presence in acute whiplash and how acute assessment may target early intervention.
(The doctors of the study) presented a literature review and case study of a 22-year-old female with an acute concussion and whiplash caused by a high-speed motor vehicle collision.
The more the patient moved her had, the more eye-movement abnormalities were observed
- Smooth pursuit eye-movement abnormalities were observed in relative cervical rotation in the setting of clinical examination of cervicogenic dysfunction.
- The more the patient moved her head, the more eye-movement abnormalities were observed.
The patient was sent to physical therapy
- Treatment was focused on cervical manual therapy.
- While concussive symptoms resolved after seven days, eye-tracking showed a mild improvement and continued to exist in relationship with cervicogenic dysfunction.
After completing physical therapy
- After completing physical therapy twice weekly for two weeks and in-home exercises, clinical signs and symptoms of whiplash-associated cervicogenic dysfunction and abnormal smooth pursuit eye movement resolved across all cervical positions.
Manual therapy can help in acute situations
The doctors of this case history acknowledged that visual disturbance is a problem in acute whiplash situations and chronic whiplash situations, as we have seen in chronic cervical spine instability.
The conclusion of this case offered the doctors a chance to suggest: “This case highlights the need for ocular-motor impairment assessment following acute whiplash, specifically during cervical rotation. Early intervention should focus on cervical manual therapy and may be important in supporting altered cervical afferents causing oculomotor dysfunctions following acute whiplash.”
In other words, look for a problem when the patient is turning his or her head. This is a sign that something in the cervical spine is causing vision problems. Fix the neck, fix the vision problems.
Altered cervical joint position. Can a herniated disc in the neck cause blurred vision?
In our offices, we see patients following acute head or neck trauma, such as concussion, whiplash, and sports injury who suffer from these various problems including double vision and other vision problems. But as pointed out in this article, we also see patients with the same symptoms who suffer from cervical degenerative disc disease. What both challenges have in common is that the cervical vertebrae are hypermobile and are moving in and out of their natural position.
In this video, Danielle R. Steilen-Matias, MMS, PA-C describes various challenges patients have with whiplash injury. There are many symptoms associated with whiplash, vision problems may only be one. In regard to vision problems, Danielle describes treatment options, here are the summary points:
- When someone comes into our office with post-whiplash injury or trauma and neurological complaints such as dizziness, ringing in their ears, blurry vision, we often begin our evaluation with a Digital Motion X-Ray DMX. The description of the digital motion X-ray begins at 4:00 into the video.
- The DMX displays how the vertebrae may be shifting during the patient’s head movement and how the vertebrae may be compressing on the nerves and arteries of the neck. If we see the hypermobility of the vertebrae causing pressure and compression with certain movements, we can have a realistic expectation that Prolotherapy injections (which are explained and demonstrated below) can help stabilize the neck and reduce or eliminate many symptoms.
Whiplash and cervical ligament damage – can this be the cause of your double, blurry vision?
In a 2019 study, researchers at The University of Queensland published their findings in PM & R: the Journal of Injury, Function, and Rehabilitation,(6) that suggests that people with whiplash-associated disorders who have difficulty with quick head movements and cervico-ocular dysfunctions, should be evaluated for changes in coordination between eye movement and neck muscle activity.
- In other words, something is off between the patient’s eye movements and the patient’s neck muscle movements. (Watch the video above) There is a break in the connection between how your head turns and how your eyes focus. In many patients, we see the break as cervical instability.
It is interesting to note that the research above also suggests that this problem with the neck muscles should be explored because not only is there a connection to vision problems, but, “Contrasting (new) changes are present in deep and superficial neck muscles with implications for neck function that may explain some common WAD symptoms.” If the muscle problem is affecting vision, it is affecting other symptoms as well.
In the journal Physical Therapy, researchers led by the Erasmus University Medical Center in the Netherlands showed the cervico-ocular reflex could be altered in non-traumatic neck pain patients. (7)
Here again, the problems of vision connected to cervical degenerative disc disease. To show the similarities between the non-traumatic neck pain patients and the traumatic neck pain patients, the researchers noted the same symptoms in patients with Whiplash Associated Disorder (WAD).
- What the researchers found in both groups was an increased cervico-ocular reflex. Increased cervico-ocular reflex is not a good thing, it is vision impairment.
The researchers offer an explanation for the increased cervico-ocular reflex in people with neck pain as altered afferent information from the cervical spine. (The blockage or dysfunction of nerve messages or blood flow in the neck that we mentioned above).
Quoting the study: “In the cervical spine, the information from muscles is a dominant source of information. Deficits in afferent information are suggested by magnetic resonance imaging studies showing a widespread presence of fatty infiltrates in the neck muscles of patients with chronic whiplash and to a lesser extent in patients with idiopathic neck pain (neck pain that is coming from an undiagnosed source).”
Problems of neck stability and movement are caused by muscle atrophy. Can muscle atrophy cause double, blurry vision?
So the researchers are looking at problems of neck stability and movement caused by muscle atrophy. They also suggest that a reduced range of motion in the neck alters the afferent information from the cervical spine. In our practice, we look also at the problems of cervical ligament instability.
One more problem. The vestibulo-ocular reflex and the cervico-ocular reflex work in conjunction, as the researchers noted:
“the vestibular and cervical system cooperate in order to maintain a clear visual image during head and eye movements. (These) findings suggest that the vestibulo-ocular reflex does not compensate for the increased cervico-ocular reflex in the neck pain group.
This mismatch between cervico-ocular reflex and vestibulo-ocular reflex could lead to visual disturbances, dizziness, and postural control disturbances.”
The researchers then speculated a question that they said they would look at in a future study:
Is it possible to use the cervico-ocular reflex as an outcome measure to evaluate the effectiveness of interventions in people with neck pain? In other words, does vision improvement mean the treatment is working? A patient who has vision impairment improved my neck pain treatments would certainly think so. That is something we have seen here in our practice.
For more information on problems related to vision problems and the cervico-ocular reflex, please see our article: Oscillopsia caused by cervical spine instability
Our treatments for cervical instability and related challenges of vision
Regenerative Medicine Injections | Caring Cervical Realignment Therapy
Part of our treatment program is a focus on cervical spine ligaments. The ligaments are the strong connective tissue that holds the vertebrae in place. When you have a slipped disc, a pinched nerve, a herniated disc, or a nerve, the underlying problem is that the vertebrae are compressing these structures and causing pain and possible neurologic-type symptoms. When the cervical spine instability is great enough or even focused enough on a certain neck segment, it can also cause compression on the arteries and veins that travel through and around the cervical vertebrae.
Prolotherapy is an injection technique that stimulates the repair of unstable, torn, or damaged ligaments. In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal. (8) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles. In this research, we suggested that:
- In the upper cervical spine (C0-C2), this can cause symptoms such as nerve and tendon irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, migraine headaches, and vision problems.
Treating and stabilizing the cervical ligaments can alleviate vision problems by preventing excessive abnormal vertebrae movement, the development or advancing of cervical osteoarthritis, and the myriad of problematic symptoms they cause.
An introduction to the treatment is best observed in the video below. A patient with cervical neck instability is treated with Prolotherapy using a Digital Motion X-ray machine.
Actual Prolotherapy treatment
This video jumps to 1:05 where the actual treatment begins.
This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.
In 2015, our research team published our findings in our paper “The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study.” This peer-review research was published in the European Journal of Preventive Medicine. (9)
Here we wrote: “In an effort to facilitate the diagnosis and treatment of clinical cervical spine instability and chronic neck pain, we investigated the role of proliferative injection Prolotherapy in the reduction of pain and recovery of constitutional and neurological symptoms associated with increased intervertebral motion, structural deformity and irritation of nerve roots. . . 95 percent of patients reported that Prolotherapy met their expectations in regards to pain relief and functionality.”
An individualized cervical spine instability and vision problem treatment protocol may include the following:
- A certain number of Prolotherapy visits to resolve the instability.
- Chiropractic consultation and treatment
- An initial period of cervical immobilization with a cervical collar in order to limit neck forces while the ligaments regenerate.
- A program is initiated to help restore the correct and proper cervical spine curve.
- Our goal is to provide long-term solutions. Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization was achieved with Prolotherapy and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable. As with any medical technique, the treatment will not work for everyone. We provide a detailed prescreening process to help assess the ideal candidates for treatment.
A case history using PRP injections with Prolotherapy to alleviate symptoms related to cervical spine instability and vision problems
A case history is a description of one person’s medical journey, treatment, and alleviation of symptoms. The results achieved may not be typical.
- PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint and spine deterioration.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
A patient came to Caring Medical after visiting multiple specialists without any explanation why his vision was blurry and he could not focus on objects. He originally saw various eye specialists who ran a vast series of tests, which were all negative. He then saw Neurologist and ENT doctor and was prescribed various medications including antibiotics, B12 shots, and steroids. These treatments did not help his vision problems.
MRI with and without contrast of the head, neck, and MR angiogram of the neck with and without contrast all were negative. He eventually saw a chiropractor and was told he had neck instability. The major cause? The patient was a chronic self-manipulator of his neck. He had cracked his neck over a thousand times.
On initial history at our neck center he specifically complained of blurred vision (worse at night), double vision, feeling off-balance, constant crepitus with neck movement, tinnitus mostly in the left ear, feeling of fullness in both ears, left posterior shoulder pain, and trouble sleeping.
His symptoms seemed to be worse when rotating his head left or right. He was unable to drive at night and was unable to play golf. He had a constant 4/10 throbbing headache posterior or towards the rear of his upper neck.
A digital motion x-ray at our facility revealed multiple areas of cervical instability including significant anterolisthesis of C2-C3, C4-C5, and C5-C6, as well as gapping of facet joints bilaterally at C4-C5 and C5-C6, encroachment of the facet joint at C3-C4 and C4-C5 on the left with flexion and extension, as well evidence of overhang on lateral flexion of C1-C2.
The patient received Comprehensive Dextrose Prolotherapy to his whole neck, but PRP was used as the solution injected into the upper neck. At his second visit, 5 weeks later he stated overall his symptoms were 40% better and he was now able to drive at night. After his second visit, his symptoms were 70% improved and his balance was so much better than he was back to playing golf.
The third treatment was decided to be the last treatment the patient would receive. He was 85% improved overall. He said his vision was back to normal and his ear fullness was gone. He had slight tinnitus and neck stiffness. Overall, his neck motion was much improved. He did not have the floaty or imbalance feelings anymore. His headaches were now minimal. Six months since his last visit on follow up he states he continues to improve.
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and it helped answer many of the questions you may have surrounding vision problems, craniocervical instability, upper cervical spine instability, cervical spine instability, or simply problems related to neck pain. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
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This article was updated July 10, 2022