Research In Action

I recently published a research study in Clinical Pediatrics that is of relevance to healthcare providers (including pediatricians, optometrists and ophthalmologists), school administrators and parents. The take home message is that, for adolescent concussion patients, it’s important to identify vision disorders that are not picked up as part of the routine vision screen and to consider these diagnoses in that patient’s post-injury management in school.

We conducted a cross-sectional study of patients with concussion who presented to the Minds Matter program at CHOP. Of the 100 adolescents (ages 11-17 years) who enrolled in the study, 69% had one or more of concussion-related vision diagnoses: accommodative disorders (51%), convergence insufficiency (49%), and saccadic dysfunction (29%). Nearly half had more than one of these vision diagnoses.

Let me define these for you:

Accommodative disorders – Accommodation refers to the automatic adjustment in the focal length of the lens of the eye to permit retinal focus of images of objects at varying distances.

Convergence insufficiency – Convergence refers to the coordinated (binocular) turning of the eyes inward to focus on an object at close range.

Saccadic dysfunction – Saccade refers to rapid intermittent eye movement, as that which occurs when the eyes fix on one point after another in the visual field.

The visual system has a widespread neural architecture in the brain that connects all this integrative visual processing. When a concussion event occurs, it can cause a diffuse stretch injury of the neurons that are critical to the visual oculomotor system. This system’s accommodative, vergence, and saccadic responses are necessary to gather visual information in tasks as basic as reading.

Identifying these types of vision deficits from concussion in adolescents is important because of the extensive visual demands placed on kids in full-time school, especially with the electronic interfaces of the modern classroom.

Tools to Diagnose Concussion Related

There are objective clinical tools healthcare providers can use to diagnose visual deficits. In this study, the Convergence Insufficiency Symptom Survey (CISS)--originally designed to assess change in symptoms in clinical trials--proved to be a more useful screening tool in identifying visual diagnoses than the Post-Concussion Symptom Scale (PCSS). For general practitioners, the CISS may be a highly cost-effective way to identify patients with concussion-related vision deficits who then might benefit from referral to a concussion specialist or eye care professional who has experience with binocular vision problems and rehabilitation for those deficits.

Classroom Accommodation Strategies

In our practice, we work with our patients’ schools to provide strategies that allow students to keep up with their studies as they recover from their concussion and their visual deficits. We recommend strategies such as frequent visual breaks, oral teaching, audio-books, large-font printed material, or pre-printed notes. Find more here.

Read the Clinical Pediatrics abstract

See a video of Dr. Master discussing this research with Healio