Evaluation of Vision Disorders in Concussion Reviewed

Concussion is a common childhood injury, affecting an estimated 1.4 million children and adolescents annually in the United States1 and occurring most frequently in sports and recreational settings.2 Pediatricians will encounter concussions in their clinical practice, and their offices represent an important and frequent entry point into the health system for children and adolescents with concussion.3 In this way, pediatricians play an important role in the initial diagnosis and management of concussion.

The American Academy of Pediatrics (AAP) Clinical Report on Sports-Related Concussion in Children and Adolescents and the Centers for Disease Control and Prevention’s Guidelines on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children comprehensively summarizes the general approach to pediatric concussion.4,5

Neurological pathways associated with the visual system, including oculomotor and vestibular function, are widely distributed throughout the brain and appear to be sensitive even to subconcussive impacts to the head. Therefore, it is not surprising that diffuse shear injury associated with concussion often produces extensive dysfunction in all afferent and efferent visual systems.5–10 Although concussion symptoms typically resolve spontaneously over the course of 4 weeks after injuries in children and adolescents, up to one-third may have prolonged symptoms.11,12

Vision disorders are common in children and adolescents with prolonged symptoms after a concussion, with one study from a tertiary referral center reporting that 69% of children and adolescents with concussion had at least one vision disorder. associated vision7 and another study found that 62.5% of those with persistent symptoms had vestibulo-ocular dysfunction.13 These disorders include accommodative insufficiency (AI), convergence insufficiency (CI), saccadic and eye movement tracking dysfunction, or a combination of these diagnoses.7,10,13,14

Symptoms associated with these vision disorders include difficulty reading, blurred vision, difficulty focusing, and eye fatigue.

It is unclear whether these observed deficits are a result of direct injury to the efferent visual system or are more broadly related to the global dysfunction experienced by concussed patients. However, the presence of visual symptoms predicts delayed recovery from concussion in children and adolescents10 and may also be associated with a delay in the child’s return to school and recreational activities, as well as return to driving in the adolescents.15–18

Clinicians can learn how to recognize associated vision disorders in patients with concussion and understand how to monitor, recommend appropriate school facilities immediately after injury and throughout recovery, and refer for additional management when necessary.

This statement is intended to assist clinicians in their approach to the detection and diagnosis of vision conditions following concussion and to improve their understanding of the impact that vision disorders often have on a child’s functioning. and quality of life after a concussion.

> History of vision-related concussions

Visual discomfort is among the countless symptoms patients report after a concussion.8,19 Blurred vision, light sensitivity, and double vision occur in up to 40% of children and adolescents immediately after a concussion. 10,11 Additional symptoms may include complaints of losing one’s place or eye fatigue while reading. Another consideration is that children are often unable to recognize or articulate visual complaints; Therefore, doctors may need to have an adequate and high index of suspicion to identify specific vision problems.

> Vision-related physical exam

It is important to have a detailed visual history and thorough vision evaluation in the evaluation of concussion. Although patients with vision deficits may ultimately require referral to a specialist familiar with the diagnosis and management of concussion, it is important for the primary care provider to identify these visual deficits through a detailed evaluation of the visual history. and the examination in the office. Certain visual and vestibular deficits are associated with concussion and can be detected with objective investigations, with attention to saccadic movements, the vestibulo-ocular reflex (VOR), the near point of convergence and accommodation.

The AAP Clinical Report on Sports-Related Concussion provides a review of approaches to evaluating balance and the vestibular system.4 A complete evaluation of the visual system after concussion includes visual acuity, pupillary function, confrontation visual fields , and test of eye alignment, eye movements, accommodation and binocular vision.

The visual system can be evaluated using examination techniques that evaluate smooth movements, saccades, RVO, near point of convergence, and accommodation, ensuring that appropriate accommodation tests are used.7–10,13,14 The accompanying clinical report20 provides an overview. Detailed description of visual system evaluation after suspected concussion.

Specific components of this expanded vision assessment have demonstrated feasibility in general pediatric primary care and emergency department settings and can be used in a screening examination. 21,22 This screening can be performed by general pediatricians, representing an extended evaluation for concussion that can also be performed over multiple follow-up visits, therefore a proportional adjustment in payment is needed.

In the organized sports setting, an evaluation after a suspected concussion may include the King-Devick test, a rapid number naming test in which the total time required to read 3 test cards and the number of errors made when reading the cards.

Pre-injury testing is recommended to obtain an individual’s baseline test time and error rate for comparison with post-injury testing. 23

Another promising post-concussion tool, particularly in children, is the Mobile Universal Lexical Assessment System (MULES), a rapid picture-naming test comprising a series of 54 colored photographs.24 It is likely that These tests assess global dysfunction and may not necessarily be specific to the visual system alone.

Multiple vision disorders can occur after a concussion,7,10,13,14,25–29 including injury to the binocular vergence system.

Convergence is the inward turning of both eyes to maintain fusion on a close target. Convergence insufficiency (CI) is the reduced ability to converge and is one of the most common visual disorders seen acutely after a concussion, often persisting in patients with prolonged symptoms.7,14,25–27 CI can cause problems with reading, such as diplopia and asthenopia (eye strain), skipping words or losing your place, and becoming fatigued more easily while reading or having a disinterest in reading.

Accommodation is the ability of the eye to change focus from a distant target to a near target and contributes to binocular visual function. Accommodative insufficiency (AI) can also develop after a concussion, producing blurring of focus with nearby tasks, as well as headaches, fatigue, and loss of interest in reading. The rate of accommodative insufficiency after concussion is as high as 50% in a concussion subspecialty reference population.7

Accommodation, convergence, and pupillary miosis are intrinsically linked within brainstem reflexes, forming the close triad consisting of accommodation, convergence, and miosis. It is not surprising, therefore, that AI can be seen along with CI.30 These deficits in accommodation and convergence, which often resolve over time, are milder forms of similar abnormalities associated with other types of brain injuries. , suggesting a common mechanism in controlling the near triad.31,32

Eye movement dysfunction involving saccades and smooth pursuit may also be observed after a concussion.7,14,22,23 Saccades represent rapid refixation of eye movements from one target to another. Both vertical and horizontal saccades are important in most visual tasks, including reading and athletics. Generated from the frontal eye fields, saccades are found to be abnormal after a concussion in 25% to 33% of children and adolescents.7,14,28,29

Smooth pursuit eye movements are neurally complex and represent conjugate, fixed and symmetric eye movements when following a target, requiring attention, anticipation and working memory. In studies of children and adolescents with concussion, 33% to 66% had symptom provocation with gentle follow-up.10,14 The precise mechanism by which these disturbances occur is unknown, but is likely to be a complex interaction between the cerebral vestibulo-oculomotor pathways and cortical neurocognitive pathways that control both attention and the oculomotor system.

The reintegration of children and adolescents into the academic setting requires addressing their visual deficits and the potential impact on school activities.33–35

In general, treatment of visual complications of concussion can be divided into 2 categories: symptom management with task modification and referral to specialists for targeted treatment of observed oculomotor abnormalities.36,37 In concussion management concussion, school accommodations for visual disturbances can be provided during the recovery period and can be incorporated into return-to-learn plans as described in the AAP clinical report on return to learning after concussion.15

Decreasing external environmental stressors, such as bright lights or the use of electronic screens, and the duration of visual tasks play an important role in managing vision symptoms after a concussion.15–17,33– 35 For primary care providers, it is important to recommend these early accommodations during re-entry to school after a concussion.

Previous studies have documented that vision deficits such as CI and IA are common in children and adolescents with visual symptoms and may play a role in planning for returning to school.33–35 The AAP and the Centers for Disease Control and Prevention recommend returning to class with some symptom-based task modifications to decrease vision demands.4,5 These modifications can be achieved by reducing the time spent performing visual work as well as making changes to the student’s physical environment.

HF and AI may be associated with poor attention to tasks due to diffuse cortical dysfunction and often resolves over time, but can nevertheless be addressed and treated. Patients who have blurred vision when reading, especially when associated with accommodation and convergence insufficiency, may be treated with prescription lenses to correct strabismus and refractive correction to provide accommodation.

Visual tasks in the classroom include reading, adjusting visual focus up close and then at a distance to copy notes from a board or screen, and using electronic displays. Modifications include rearranging the material presented, such as double spacing or blocking sections, to decrease overall visual demands. If reading remains difficult despite these accommodations, audiobooks or text-to-speech software programs may be necessary short-term options.33–35 For students who have difficulty taking notes, possible solutions include obtaining notes preprinted notes from the teacher before class, photocopying a classmate’s notes after class, or recording lectures.33–35

Overall, emerging evidence indicates that early post-injury referral to sports medicine specialty improves outcomes, possibly through more active management, including exercise, rather than simply passive supportive care.

In a recent study, children and adolescents referred for sports medicine specialty within 7 days recovered faster than those seen more than 7 days after injury; The challenge remains to identify which pediatric patients with concussion warrant early referral.38

Another study found that girls had higher rates of vestibular and visual dysfunction after a concussion with longer recovery times, but if referred early for sports medicine specialty within 7 days of injury, they had recovery times. recovery similar to those of boys, indicating that early referral to specialized sports medicine care, a modifiable extrinsic factor, improves outcomes for girls.39

Up to one-third of children and adolescents with concussion12 may have persistent visual symptoms for several weeks or months,7–10,13,14 and these may contribute to prolonged academic difficulties and should be considered in the clinical management of concussion. pediatric.11–17,33–35 For these patients with persistent problems, timely referral to multispecialty concussion care may be helpful but may be limited depending on geographic location and the availability of relevant subspecialists.

In the future, further development of telemedicine may allow support for pediatricians in regions without specialized expertise in pediatric concussion. There is emerging evidence from 2 randomized controlled trials that active rehabilitation for balance and vestibulo-oculomotor problems, as well as exercise intolerance associated with concussion, is beneficial for symptomatic patients, but additional studies are needed to determine the optimal opportunity and best practices.36,37,40

Likewise, although vision therapy has been widely promoted for the treatment of concussion, a comprehensive evaluation of this practice does not provide sufficient evidence of the effectiveness of such therapy.41 Additional research is needed in all of these areas of concussion treatment. concussion.

Children and youth with special health care needs may have pre-existing conditions that must be taken into account when diagnosing and managing a concussion. Doing so can mitigate potential negative consequences of the interaction between concussion and special health care needs.

Consideration should be given to whether the underlying condition may make the diagnosis of concussion more challenging or require accommodations to evaluate the visual system. Additionally, school and activity accommodations should also take into account any additional diagnoses that interact with the concussion.

Academic adjustments must be incorporated into any existing plan or individualized education program (IEP) already in place for the student with special health care needs. Recovery goals should be similar, however, in children with special health needs as they should be able to return to their full pre-injury level of function despite having coexisting medical diagnoses that require consideration.

As there have been well-documented disparities in both visual care and concussion awareness and care, it is essential that clinicians caring for children with concussion be aware of the many factors that can lead to disparities.42–45

Recognition, diagnosis, and access to care have been identified as factors that improve outcomes for children with concussion.38,39

Efforts to raise awareness and recognize the signs and symptoms of concussion, particularly the specific visual signs and symptoms associated with concussion, may improve the recognition of concussion-related vision problems and the timing of specialized care.

It should be a priority to manage any barriers to accessing specialized care if there are vision-related complaints in concussion to optimize outcomes.

Visual symptoms following a pediatric concussion are important to recognize and can be managed to minimize their negative impact on children and adolescents’ school, sports, and activities of daily living function. For most patients who have only mild, temporary lesions, these symptoms are likely indicative of diffuse brain dysfunction associated with decreased attention and visual symptoms.

Patients with prolonged visual symptoms may have difficulty with convergence and accommodation attributable to brainstem dysfunction near the triad. For the minority of patients who continue to have visual problems, referral to appropriate specialist care centers (i.e. sports medicine, physiatry, neurology, neuropsychology, ophthalmology, otolaryngology) may be beneficial, and further studies are needed to establish best practices.

There remains a lack of high-quality evidence to support the isolated treatment of visual symptoms, such as double vision or blurred vision, after a concussion with vision therapy; additional studies are needed. It may help the clinician to obtain a specific vision history and perform a systematic visual examination aimed at identifying these problems; An assessment of visual acuity alone is insufficient in the setting of concussion.

If deficits are identified, clinicians can promptly provide supportive care and suggest academic accommodations during the school reentry process. Therefore, children and adolescents who have persistent visual symptoms may benefit from referral to specialists, as described above, with experience in comprehensive multidisciplinary concussion management for further evaluation and treatment to optimize visual function and quality. of life.

The present work highlights that visual symptoms are common after a concussion and that they generally recover within a month without interventions, but in some cases this does not occur.

Pediatricians should be prepared to perform a visual history and systematic visual examination on these children to identify those who will require referral to specialists with experience in concussion. In this way, appropriate curricular adaptations can be made both in school and in different activities of daily living to improve the quality of life of affected patients.