Occasional Jumpy Vision

4/7/20224/7/2022

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Ross A. Hauser, MD. Caring Medical Florida, Fort Myers
Brian R Hutcheson, DC. Hauser Neck Center, Caring Medical Florida

Chronic Neck Pain and Blurred or Double Vision Problems – Is the answer in the neck ligaments?

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 greater problem of the soft tissue damage in your neck causing the blurred, double vision.

An ocular migraine is a rare condition characterized by temporary vision loss or even temporary blindness in one eye. Ocular migraines are caused by reduced blood flow or spasms of blood vessels in the. Shaky vision is medically termed as nystagmus or the uncontrolled eyeball movement. This involuntary movement can happen on a horizontal or lateral direction, or on a circular way. Vertical nystagmus or the up and down motion of the eyeballs can also occur at times.

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 is not treated. We will provide treatment options below.

We are going to start with an introductory video by Ross Hauser, MD. 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:

In this image, vision problems caused by cervical spine instability is 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, of 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.
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

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. 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:

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.

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.

Further below in this article – treatments are discussed.

Here we are looking at the back of the neck and some of the arteries, nerves, and ligaments that cross between and through the C1-C2 ligaments. Many people with blurred vision also suffer from dizziness, headaches, swallowing difficulties, numbness in the tongue and ringing in the ears. While possible suffering from these issues, it is the vision problems that are most concerning.

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 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 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.

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 (2) 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
- ‘patient 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
1. 1. ‘need to concentrate to read’
  2. ‘visual fatigue’
1. ‘difficulty judging distances’
2. 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.

Now to the research

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(3) 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.

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 new 2019 study, researchers at The University of Queensland published their findings in PM & R: the Journal of Injury, Function, and Rehabilitation,(4) 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.(5)

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. Increasedcervico-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 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 by 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

Prolotherapy is an injection technique that stimulates repair of unstable, torn, or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can stress tendons, atrophy muscles, pinch on nerves and cause other symptoms associated with cervical instability including problems of vision.

Treating cervical ligaments – published research from Caring Medical

In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal.(6) 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 the 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

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. We are going to refer our 2014 study where we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments.

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative/reparative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

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.(7)

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.”

If this article has helped you understand the problems of double, blurred vision and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

1 Margolin E. The swollen optic nerve: an approach to diagnosis and management. Pract Neurol. 2019;19(4):302-309. doi:10.1136/practneurol-2018-002057 [Google Scholar]
2Treleaven J, Takasaki H. Characteristics of visual disturbances reported by subjects with neck pain. Manual Therapy. 2014 Jun 1;19(3):203-7. [Google Scholar]
3 Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun 16(0):1-25. [Google Scholar]
4 de Vries J, Ischebeck BK, Voogt LP, Janssen M, Frens MA, Kleinrensink GJ, van der Geest JN. Cervico-ocular reflex is increased in people with nonspecific neck pain. Physical Therapy. 2016 Aug 1;96(8):1190-5. [Google Scholar]
5 Bexander CS, Hodges PW. Cervical rotator muscle activity with eye movement at different speeds is distorted in whiplash. PM&R. 2019 Jan. [Google Scholar]
6 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The Open Orthopaedics Journal. 2014;8:326. [Google Scholar]
7 Hauser RA, Steilen D, Gordin K. The Biology of Prolotherapy and Its Application in Clinical Cervical Spine Instability and Chronic Neck Pain: A Retrospective Study. European Journal of Preventive Medicine. 2015 Jun 16;3(4):85. [Google Scholar]

These movements often result in reduced vision and depth perception and can affect balance and coordination. These involuntary eye movements can occur from side to side, up and down, or in a circular pattern. As a result, both eyes are unable to steadily view objects. People with nystagmus might nod and hold their heads in unusual positions to compensate for the condition. Generally, nystagmus is a symptom of another eye or medical problem. Fatigue and stress can make nystagmus worse. However, the exact cause is often unknown.

The forms of nystagmus include:

Infantile. Most often develops by 2 to 3 months of age. The eyes tend to move in a horizontal swinging fashion. It is often associated with other conditions, such as albinism, congenital absence of the iris (the colored part of the eye), underdeveloped optic nerves and congenital cataract.
Spasmus nutans. It usually occurs between 6 months and 3 years of age and improves on its own between 2 and 8 years of age. Children with this form of nystagmus often nod and tilt their heads. Their eyes may move in any direction. This type of nystagmus usually does not require treatment.
Acquired. Develops later in childhood or adulthood. The cause is often unknown, but it may be due to the central nervous system and metabolic disorders or alcohol and drug toxicity.

Causes & risk factors

Nystagmus is most commonly caused by a neurological problem that is present at birth or develops in early childhood. Acquired nystagmus, which occurs later in life, can be the symptom of another condition or disease, such as stroke, multiple sclerosis or trauma.

Other causes of nystagmus include:

Lack of development of normal eye movement control early in life.
Albinism.
Very high refractive error, for example, nearsightedness (myopia) or astigmatism.
Congenital cataracts.
Inflammation of the inner ear.
Medications such as anti-epilepsy drugs.
Central nervous system diseases.

Symptoms

Involuntary eye movement.
Movement can be in one eye or both.
Objects may appear blurry and shaky.
Nighttime vision problems or sensitivity to light.
Balance and dizziness.

Diagnosis

Nystagmus can be diagnosed through a comprehensive eye exam. Testing for nystagmus, with special emphasis on how the eyes move, may include:

Occasional Blurred Vision Followed By Headache

Patient history to determine any symptoms the patient is experiencing and the presence of any general health problems, medications taken, or environmental factors that may be contributing to the symptoms.
Visual acuity measurements to assess the extent to which vision may be affected.
A refraction to determine the appropriate lens power needed to compensate for any refractive error ( nearsightedness, farsightedness, or astigmatism).
Testing how the eyes focus, move and work together. In order to obtain a clear, single image of what is being viewed, the eyes must effectively change focus, move and work in unison. This testing will look for problems that affect the control of eye movements or make it difficult to use both eyes together.

Since nystagmus is often the result of other underlying health problems, a doctor of optometry may refer the patient to their primary care physician or another medical specialist for further testing. Using the information obtained from testing, a doctor of optometry can determine if the patient has nystagmus and advise on treatment options. Other testing may include an ear exam, neurological exam, and/or a brain MRI.

Treatment

While eyeglasses and contact lenses do not correct the nystagmus itself, they can sometimes improve vision. Using large-print books, magnifying devices and increased lighting can also be helpful. Some types of nystagmus improve throughout childhood. Rarely, surgery is performed to change the position of the muscles that move the eyes. While this surgery does not cure nystagmus, it may reduce how much a person needs to turn his or her head for better vision. If another health problem is causing the nystagmus, a doctor of optometry will often work with a primary care physician or other medical specialists to treat that underlying cause.

Prevention