Round table: Diagnosis and treatment of concussion from the pediatric ophthalmologist’s point of view

OSN Board Members agree that there is a significant lack of scientific information available.

Concussions are a topic of conversation inside and outside of medical communities.

Emphasis is being made on the long-term consequences of concussions, not only in professional sports but also in collegiate, high school and even under 11-year-old athletes. On the sidelines, non-physicians are tasked with “diagnosing” concussions; after the game, management falls to physicians.

At the American Association for Pediatric Ophthalmology and Strabismus meeting in Nashville, Tennessee, OSN Pediatrics/Strabismus Editorial Board Members expressed their frustrations with lack of information in this field of interest.

In this second installment of the round table discussion, OSN Pediatrics/Strabismus Section Editor Robert S. Gold, MD, asked the board: “Many of us are seeing children post-concussion with visual issues. When you see these patients, what are your evaluations and treatments, and what are your recommendations?”

Roundtable Participants

  • Moderator

  • Robert S. Gold
  • Location
  • R.V. Paul Chan
  • Kenneth P. Cheng
  • Anthony P. Johnson
  • Scott E. Olitsky
  • Rudolph S. Wagner
  • Roberto Warman

Scott E. Olitsky, MD: There is a significant lack of information about this. When you look at the information that is available, it tends to be anecdotal, much of which is provided by people who are providing care. That is not to say that there are not treatments that we should be looking at. I am looking for advice from the scientific community about what we should be doing with these children. I discuss that with parents, but quite frankly, I do not know what the best information is for them. I know what I hear, but I am not sure I can tell parents that what I hear is scientifically valid.

Anthony P. Johnson, MD: I completely agree. There is so little information, but at the same time, there is a huge focus on this now. Most of these patients have some visual complaints, and then the question is, how do you put that together? I think you can be talked into unnecessary testing if you are not careful because we do not really know the specific associations. I am a good listener. I will follow them carefully. But I am reluctant to recommend any high-powered ancillary studies unless there is really an indication for it.

Rudolph S. Wagner, MD: I agree. There are certain things you can look for, and many of these patients do have photophobia — almost like what you see in kids with migraine, where they do not necessarily have uveitis or any other reason for having photophobia but they still behave that way. They are hypersensitive to light and to things in the environment. I have had a few patients who have come in because of head injuries and they were experiencing double vision, but it could be from something as extreme as a sixth nerve palsy from a subdural because they have more than a concussion or it could be convergence insufficiency, which is an issue that seems to be coming into more prominence now as far as diagnosing concussions or subconcussive injuries.

Briefly, there is a study that was done at Temple University on its football team that was published in JAMA Ophthalmology. The researchers looked at the football players and the number of hits they took, using mouthpieces with accelerometers, and they correlated this data with the players’ convergence measured with an accommodative ruler. Basically, they found that many of these subconcussive injuries do produce convergence insufficiency, which was temporary in most cases, but it was cumulative by the number of hits they took. So, I think that it is reasonable to check for convergence and watch for it to resolve. At least it gives you an indication that something is going on and that this player might not be a candidate to be playing football or whatever sport, at least temporarily.

I am not familiar with all the sideline tests used to screen for concussion, but there is one called the King-Devick. It started as a test for dyslexia in which the player reads a series of numbers and then rapidly repeats the numbers. I think that is a test commonly used by coaches and sideline staff to screen kids when they are injured. But by the time the patient gets to us, there is usually some specific complaint: double vision or headache or maybe light sensitivity.

R.V. Paul Chan, MD: Jonathan Trobe published a paper many years ago about post-traumatic accommodative spasm secondary to various types of trauma. I wonder whether or not that is what is happening to some of these people who have concussions.

Olitsky: There is some good data coming out about diagnostics. Maybe my bigger concern is the therapeutics.

Roberto Warman, MD: That is my problem. There is a concussion clinic in my hospital already, so the diagnosis is already made for one or another reason, and then patients are sent to me for eye symptoms or they are sent for “vision therapy.” We can look, like Rudy says, for convergence insufficiency and a few things, but when we do not find anything, what do we do? The patient insists he or she has had three concussions and has symptoms. That is the problem. I certainly will not support the vision therapy section of this, so we are stuck with doing nothing.

Kenneth P. Cheng, MD: Rudy is on to something here. Because the awareness of concussion has gotten so great, now the pendulum has swung the opposite way. For far too long, people ignored concussions and kids got back in the game and still played their sport while having symptoms of headaches and whatnot, and a lot of damage was done. But now the pendulum has swung the opposite way. Where I am from in Pittsburgh, there is an ImPACT test, developed at UPMC, and many kids playing competitive sports or contact sports take a pre or baseline ImPACT test, a psychological series of questions of memory and comprehension, and then when they have a head injury they take this test again to determine if there is a problem.

But coming up with treatments, as Scott said, is not well-proven, and as Rudy alluded to, we get into the realm of vision therapy, which is also not well-proven. We do know, though, from years of experience that the main healer of concussion is time. From my perspective as an ophthalmologist and the number of patients I have seen with concussion, which is a lot now, the visual symptoms tend to get better before the other symptoms, such as headache, lethargy and inability to concentrate. I tell patients that rather than going through complicated vision therapy, their time is better spent staying home and taking a nap. Do half an hour of homework and then take another nap. In terms of the testing I do in my office, I do very simple testing of convergence and I do very simple testing of accommodation. I do not measure accommodative amplitudes. I just ask, “Is that little birdy or are the letters still clear or are they blurry or double?” on my fixation stick. If they are in normal range, then they are OK.

Chan: As a retina specialist, I do not generally get these patients unless they are referred to me to rule out retinal pathology, but I am curious what type of testing you order for these patients. Do you get visual fields? Do you get other testing or imaging as a baseline? When do you recommend that they come back to see you for follow-up?

Gold: I think the consensus is “no” unless symptoms or signs during the examination warrant it.

Disclosures: The round table participants report no relevant financial disclosures.

Concussions are a topic of conversation inside and outside of medical communities.

Emphasis is being made on the long-term consequences of concussions, not only in professional sports but also in collegiate, high school and even under 11-year-old athletes. On the sidelines, non-physicians are tasked with “diagnosing” concussions; after the game, management falls to physicians.

At the American Association for Pediatric Ophthalmology and Strabismus meeting in Nashville, Tennessee, OSN Pediatrics/Strabismus Editorial Board Members expressed their frustrations with lack of information in this field of interest.

In this second installment of the round table discussion, OSN Pediatrics/Strabismus Section Editor Robert S. Gold, MD, asked the board: “Many of us are seeing children post-concussion with visual issues. When you see these patients, what are your evaluations and treatments, and what are your recommendations?”

Roundtable Participants

  • Moderator

  • Robert S. Gold
  • Location
  • R.V. Paul Chan
  • Kenneth P. Cheng
  • Anthony P. Johnson
  • Scott E. Olitsky
  • Rudolph S. Wagner
  • Roberto Warman

Scott E. Olitsky, MD: There is a significant lack of information about this. When you look at the information that is available, it tends to be anecdotal, much of which is provided by people who are providing care. That is not to say that there are not treatments that we should be looking at. I am looking for advice from the scientific community about what we should be doing with these children. I discuss that with parents, but quite frankly, I do not know what the best information is for them. I know what I hear, but I am not sure I can tell parents that what I hear is scientifically valid.

Anthony P. Johnson, MD: I completely agree. There is so little information, but at the same time, there is a huge focus on this now. Most of these patients have some visual complaints, and then the question is, how do you put that together? I think you can be talked into unnecessary testing if you are not careful because we do not really know the specific associations. I am a good listener. I will follow them carefully. But I am reluctant to recommend any high-powered ancillary studies unless there is really an indication for it.

Rudolph S. Wagner, MD: I agree. There are certain things you can look for, and many of these patients do have photophobia — almost like what you see in kids with migraine, where they do not necessarily have uveitis or any other reason for having photophobia but they still behave that way. They are hypersensitive to light and to things in the environment. I have had a few patients who have come in because of head injuries and they were experiencing double vision, but it could be from something as extreme as a sixth nerve palsy from a subdural because they have more than a concussion or it could be convergence insufficiency, which is an issue that seems to be coming into more prominence now as far as diagnosing concussions or subconcussive injuries.

PAGE BREAK

Briefly, there is a study that was done at Temple University on its football team that was published in JAMA Ophthalmology. The researchers looked at the football players and the number of hits they took, using mouthpieces with accelerometers, and they correlated this data with the players’ convergence measured with an accommodative ruler. Basically, they found that many of these subconcussive injuries do produce convergence insufficiency, which was temporary in most cases, but it was cumulative by the number of hits they took. So, I think that it is reasonable to check for convergence and watch for it to resolve. At least it gives you an indication that something is going on and that this player might not be a candidate to be playing football or whatever sport, at least temporarily.

I am not familiar with all the sideline tests used to screen for concussion, but there is one called the King-Devick. It started as a test for dyslexia in which the player reads a series of numbers and then rapidly repeats the numbers. I think that is a test commonly used by coaches and sideline staff to screen kids when they are injured. But by the time the patient gets to us, there is usually some specific complaint: double vision or headache or maybe light sensitivity.

R.V. Paul Chan, MD: Jonathan Trobe published a paper many years ago about post-traumatic accommodative spasm secondary to various types of trauma. I wonder whether or not that is what is happening to some of these people who have concussions.

Olitsky: There is some good data coming out about diagnostics. Maybe my bigger concern is the therapeutics.

Roberto Warman, MD: That is my problem. There is a concussion clinic in my hospital already, so the diagnosis is already made for one or another reason, and then patients are sent to me for eye symptoms or they are sent for “vision therapy.” We can look, like Rudy says, for convergence insufficiency and a few things, but when we do not find anything, what do we do? The patient insists he or she has had three concussions and has symptoms. That is the problem. I certainly will not support the vision therapy section of this, so we are stuck with doing nothing.

Kenneth P. Cheng, MD: Rudy is on to something here. Because the awareness of concussion has gotten so great, now the pendulum has swung the opposite way. For far too long, people ignored concussions and kids got back in the game and still played their sport while having symptoms of headaches and whatnot, and a lot of damage was done. But now the pendulum has swung the opposite way. Where I am from in Pittsburgh, there is an ImPACT test, developed at UPMC, and many kids playing competitive sports or contact sports take a pre or baseline ImPACT test, a psychological series of questions of memory and comprehension, and then when they have a head injury they take this test again to determine if there is a problem.

PAGE BREAK

But coming up with treatments, as Scott said, is not well-proven, and as Rudy alluded to, we get into the realm of vision therapy, which is also not well-proven. We do know, though, from years of experience that the main healer of concussion is time. From my perspective as an ophthalmologist and the number of patients I have seen with concussion, which is a lot now, the visual symptoms tend to get better before the other symptoms, such as headache, lethargy and inability to concentrate. I tell patients that rather than going through complicated vision therapy, their time is better spent staying home and taking a nap. Do half an hour of homework and then take another nap. In terms of the testing I do in my office, I do very simple testing of convergence and I do very simple testing of accommodation. I do not measure accommodative amplitudes. I just ask, “Is that little birdy or are the letters still clear or are they blurry or double?” on my fixation stick. If they are in normal range, then they are OK.

Chan: As a retina specialist, I do not generally get these patients unless they are referred to me to rule out retinal pathology, but I am curious what type of testing you order for these patients. Do you get visual fields? Do you get other testing or imaging as a baseline? When do you recommend that they come back to see you for follow-up?

Gold: I think the consensus is “no” unless symptoms or signs during the examination warrant it.

Disclosures: The round table participants report no relevant financial disclosures.