Do You See What I See? The Role of Vision Evaluation in Concussions

Although most pediatric concussions resolve spontaneously within several weeks, about one-third of concussed patients will struggle with prolonged symptoms.¹  Managing these patients can be challenging, especially when they present with visual and/or oculomotor impairment, such as blurred vision, eye fatigue, and difficulties with focus and reading. These symptoms have been reported in 46-69% of patients,^2,3 and are associated with longer recovery times and often create academic challenges when these children and adolescents return to school.²  Fortunately, guidance for clinicians treating these patients can be found in the AAP Policy Statement, “Vision and Concussions:  Symptoms, Signs, Evaluation, and Treatment” (10.1542/peds.2021-056047), and its companion AAP Clinical Report, “Evaluation of the Visual System by the Primary Care Provider Following Concussion” (10.1542/peds.2021-056048) published in the August issue of Pediatrics.

For many of us, routine assessment of the visual and oculomotor systems typically includes visual acuity, pupil reaction, fundoscopic evaluation, and testing visual fields. But in these reports, Dr. Christina Master, pediatrician and sports medicine physician at the University of Pennsylvania,  and her co-authors emphasize the importance of a more comprehensive assessment in concussed patients to evaluate for possible issues with convergence, accommodation, version, strabismus, saccades, and the vestibulo-ocular reflex. The policy statement even links to an excellent video demonstrating these examination techniques (very handy for those of those of us who don’t quite remember these details from our training). Additional information on the significance and management of vision-related issues, and recommendations regarding potential academic accommodations to assist with “return to learn” in these patients are included in the policy statement as well. The clinical report goes into greater detail on the office-based assessment for primary care providers.

These articles nicely complement the 2018 AAP Clinical Report, “Sport-related Concussion in Children and Adolescents”, which provides a comprehensive overview of concussion management, and the role of brief periods of relative cognitive and physical rest in the initial treatment of these injuries.⁴ Managing patient symptoms (and parental anxiety) in those with more prolonged post-concussion difficulties can be challenging, particularly in those with symptoms in the visual and oculomotor domains. Clinicians interested in a practical, efficient, and comprehensive approach for these patients will find the policy statement and clinical report in this month’s Pediatrics to be a valuable resource. 

References:

1. Zemek R, Barrowman N, Freedman SB, et al. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED. JAMA. 2016 Mar 8;315(10):1014-25.
2. Swanson MW, Weise KK, Dreer LE, et al. Academic Difficulty and Vision Symptoms in Children with Concussion. Optom Vis Sci. 2017 Jan;94(1):60-67.
3. Master CL, Scheiman M, Gallaway M, et al. Vision Diagnoses Are Common After Concussion in Adolescents. Clinical Pediatrics. 2016;55(3):260-267.
4. Halstead ME, Walter KD, Moffatt K. Sport-Related Concussion in Children and Adolescents. Pediatrics. December 2018; 142 (6): e20183074.