July 19, 2022

For young concussion patients, managing visual symptoms crucial

A policy statement from Vanderbilt and other institutions says it’s essential that pediatricians and other clinicians know how to screen, identify and initiate clinical management of visual symptoms after this common childhood injury.

Visual symptoms are common in children and adolescents who suffer a concussion, and it’s essential that pediatricians and other clinicians know how to screen, identify and initiate clinical management of visual symptoms after this common childhood injury.

This direction is part of a first-of-its-kind policy statement in the current issue of the journal Pediatrics, the official peer-reviewed journal of the American Academy of Pediatrics. Sean Donahue, MD, PhD, Sam and Darthea Coleman Professor of Pediatric Ophthalmology at Vanderbilt University Medical Center and chief of the Pediatric Ophthalmology Service, is a co-author of the statement, issued in conjunction with the American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus and the American Association of Certified Orthoptists.

The statement notes that one study from a tertiary referral center reported that 69% of children and adolescents with a concussion had at least one associated vision disorder.

Sean Donahue, MD, PhD

“Early identification and appropriate management of visual symptoms, such as convergence insufficiency (when your eyes don’t work together) or accommodative insufficiency (when you can’t focus on nearby objects) may mitigate the negative effects of concussion on children and adolescents and their quality of life,” the statement reads.

Concussion affects about 1.4 million children and adolescents annually in the United States, occurring most often in sports and recreational settings. Chronic and repeated concussions can lead to severe and permanent brain injury, which has been reported in professional football players.

“Parents are very concerned about their kids in contact sports having repeated concussions in football or soccer, or because they bang heads with someone on the trampoline,” Donahue said. “There’s been a real controversy in the field about vision rehabilitation and the best way to manage these patients. It’s nice to have an official statement that the various academies recognize that gives direction to pediatricians, and pediatric ophthalmologists, about what to look for, how to give guidance to parents and how to treat those who suffer from the effects of a concussion.”

Pediatricians play an important role in the initial diagnosis and management of children who have suffered a concussion, Donahue said. They are usually the first point of entry into the health care setting with patients suffering a concussion.

Visual complaints are among the myriad symptoms that patients report after a concussion, the statement says, including blurred vision, light sensitivity and double vision that occur in up to 40% of children and adolescents after concussion. Other symptoms may include losing one’s place or eye fatigue when reading.

Concussion symptoms in most patients spontaneously resolve in about four weeks, Donahue said. Up to one-third of patients may have prolonged symptoms.

Donahue said that children are also often unable to recognize or articulate specific visual complaints, so clinicians should be particularly aware and have an “appropriately elevated index of suspicion” to identify specific vision issues.

The statement says there is a lack of high-quality evidence supporting isolated treatment of concussion-associated visual symptoms, such as double vision or blurred vision, with vision therapy. Additional study is needed regarding that issue, Donahue said. Until that occurs, he added, vision therapy is not an appropriate treatment. In the interim, reading glasses with or without prisms to help with reading can be appropriate depending on the setting.

“This first formal policy statement by AAP on the topic of concussion really synthesizes the literature that’s happened over the past five to 10 years that shows that there are neurologic abnormalities that happen within the brain and the brain stem that can be observed and treated as necessary,” Donahue said.