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.
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
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
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
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
“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
Abstract#1504.39. Presented at PAS 2014; May 2-6, 2014; Vancouver, Canada.
reports no relevant financial disclosures.