Vision problems caused by concussion often overlooked

VANCOUVER, Canada — A vision examination to specifically evaluate oculomotor function should be considered in the evaluation for concussion, according to findings presented here at the 2014 Pediatric Academic Societies Annual Meeting.

Christina L. Master, MD, FAAP, CAQSM, pediatric sports medicine specialist and associate professor of clinical pediatrics, Perelman School of Medicine at the University of Pennsylvania, said a high prevalence of certain vision problems, including binocular vision disorders, accommodative disorders, such as convergence insufficiency, and eye movement/saccadic disorders, have been observed after concussion in the adult population, both civilian and military. The symptoms are most often associated with prolonged visual near work, including eye strain, headaches, and blurred/double vision. Therefore, school-age children, especially adolescents, may be particularly vulnerable to the consequences of such deficits after concussion because of their schoolwork, much of which is done on a computer.

Christina L. Master

“Schoolwork is highly visual, especially with the increase in electronic interfaces these days, smart boards, tablets, computers, and if you have visual deficits, they’re going to give you visual symptoms,” Master told Infectious Diseases in Children. “And these symptoms can be a cause of prolonged headache seen with concussions.”

Master and colleagues conducted a prospective, cross-sectional study of adolescents aged 11 to 17 years who were recruited from the Minds Matter Concussion Program at The Children's Hospital of Philadelphia.

Patients with the diagnosis of concussion underwent vision testing, including an assessment of visual symptoms, visual acuity, eye alignment, near point of convergence, vergence amplitude and facility, accommodative amplitude and facility, and saccadic eye movement speed and accuracy,

A total of 72 children (mean age 14.6 years) were examined, and 49 (68%) of those were found to have one or more vision problems. The most common problems were convergence insufficiency (47.2%); accommodative insufficiency (33.3%); saccadic dysfunction (30.5%); and accommodative infacility (11.1%). The investigators also found that 64% of the children with convergence insufficiency also had an accommodative disorder.

The Convergence Insufficiency Symptom Survey (CISS) was used to assess visual symptoms. The mean CISS score for children without a vision problem was 13.2 vs. 21.4 in children diagnosed with significant vision problems (P=.001).

No significant difference in the prevalence of vision problems was found when recent (less than 3 months) vs. longstanding (more than 3 months) concussion injuries were compared. Patients with a vision problem also had deficits in verbal memory and visual motor scores on ImPACT neurocognitive testing (P=0.016 and P=0.0074).

Master also noted that children in the study had to have 20/20 vision, with or without corrective lenses, in order to be included in the study, indicating that the visual symptoms are not simply about visual acuity.

“All these children can see 20/20, but the problem is that their eyes don’t work well together. It’s the idea of eye teaming, focusing and tracking. If you go to a regular eye doctor for a vision assessment of visual acuity, the typical tests will not detect these problems that we found associated with concussion,” she said.

Based on these findings, Master said there are two important points to highlight. First is that pediatricians should look for these visual oculomotor symptoms because it has a big impact on a child’s schoolwork. Second, a simple visual acuity test will not reveal these symptoms.

“It’s not as simple as just having a headache after concussion. We need to have objective measures or findings that can distinguish a migraine headache vs. an injury headache vs. headache associated with eye issues, etc.,” Master said. “Having pediatricians be aware of this and determining ways —aside from doing a formal visual examination to see if they have these oculomotor visual deficits — are going to be really important in helping children get optimal care after a concussion.” — by Cassandra A. Richards

For more information:

Master CL. Abstract#1504.39. Presented at PAS 2014; May 2-6, 2014; Vancouver, Canada.

Disclosure: Master reports no relevant financial disclosures.