Last updated July 19, 2022

Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment

Summary of Recommendations

Clinicians should consider screening for vision problems after concussion in children and adolescents to determine potential academic and activity modifications after injury.
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Beyond visual acuity, a screening examination that assesses the patient’s smooth pursuit, saccades, VOR, convergence, and accommodation may be helpful to the clinician in identifying these problems after concussion.
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Academic accommodations for school that account for possible vision problems after concussion may be helpful to children during recovery from concussion.
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Some children with persistent visual issues after concussion may benefit from appropriate specialist referral for treatment.
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Tables

Visio-vestibular Examination After a Suspected Concussion

Test Description
Pursuit eye movements Pursuit is examined by holding a near visual stimulus at 1–2 feet from the patient. Move the stimulus back and forth in a slow and steady fashion, horizontally about 160 degrees (from patient’s ear to ear) and vertically about 120 degrees (from patient’s forehead to chin).Both eyes should follow the stimulus symmetrically and smoothly.
Saccadic eye movements Saccades are tested with 2 near stimuli as above, 1 in each hand.Hold them about 2 feet apart, 1–2 feet in front of the patient, horizontally then vertically.Ask the patient to refixate between the 2 stimuli on your command several times horizontally then vertically.The eyes should move quickly and symmetrically and end accurately on the stimulus.
VOR VOR is examined while holding the stimulus at 1–2 feet directly in front of the nose. The patient rotates his or her head horizontally for about 160 degrees (shaking head from side to side) and then vertically for about 120 degrees (nodding head up and down).The eyes should remain on the near stimulus throughout the head movement.
Near point of convergence Convergence testing is accomplished by holding a visual stimulus about 2 feet in front of the patient and bringing the stimulus toward the face until the eyes stop converging.The eyes should continue to converge on the stimulus until about 6 cm (∼2 in.) from the forehead.
Accommodative amplitude Accommodation testing is performed monocularly using a standard reading card.After patching one eye, ask the patient to fixate on the smallest readable letter at about 2 feet away, move the card toward the eye until the patient reports blurring of that same letter, then measure that distance in centimeters.Most children will be able to see the letter clearly until 10 cm (∼4 in.) from the eye.
Strabismus While the patient fixates on a distant target, the monocular cover-uncover test is performed by covering and uncovering each eye (right eye, then left eye), with the examiner watching carefully for any movement in the opposite, noncovered eye; such movement indicates the possible presence of strabismus.

Strategies to Address Concussion-Related Vision Disorders

Item Strategies
Initial symptom management with task modification after concussion Reduce time spent on visual work and reading, use of reprinted notes, audiobooks, temporary use of reading glasses, guided reading strips, limiting time on electronic screens, visual pacing (taking breaks as needed from visual work to manage symptoms), enlarged font or double spacing or blocking out sections, adjusting brightness on electronic devices, gradual return to full visual workload over course of recovery
Comprehensive multidisciplinary management of concussion Referral to appropriate specialist (eg, sports medicine, physiatry, neurology, neuropsychology, ophthalmology, otorhinolaryngology) with expertise in comprehensive management of concussion, including active management

Recommendation Grading

Overview

Title

Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment

Authoring Organization

Publication Month/Year

July 18, 2022

Document Type

Consensus

Country of Publication

US

Document Objectives

Visual symptoms are common after concussion in children and adolescents, making it essential for clinicians to understand how to screen, identify, and initiate clinical management of visual symptoms in pediatric patients after this common childhood injury. Although most children and adolescents with visual symptoms after concussion will recover on their own by 4 weeks, for a subset who do not have spontaneous recovery, referral to a specialist with experience in comprehensive concussion management (eg, sports medicine, neurology, neuropsychology, physiatry, ophthalmology, otorhinolaryngology) for additional assessment and treatment may be necessary. A vision-specific history and a thorough visual system examination are warranted, including an assessment of visual acuity, ocular alignment in all positions of gaze, smooth pursuit (visual tracking of a moving object), saccades (visual fixation shifting between stationary targets), vestibulo-ocular reflex (maintaining image focus during movement), near point of convergence (focusing with both eyes at near and accommodation (focusing with one eye at near because any of these functions may be disturbed after concussion. These deficits may contribute to difficulty with returning to both play and the learning setting at school, making the identification of these problems early after injury important for the clinician to provide relevant learning accommodations, such as larger font, preprinted notes, and temporary use of audio books. Early identification and appropriate management of visual symptoms, such as convergence insufficiency or accommodative insufficiency, may mitigate the negative effects of concussion on children and adolescents and their quality of life.

Inclusion Criteria

Male, Female, Adolescent, Child

Health Care Settings

Ambulatory, Childcare center, Emergency care, School

Intended Users

Athletics coaching, nurse, nurse practitioner, optometrist, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D013177 - Sports, D001924 - Brain Concussion

Keywords

sports, vision loss, concussion, sports injury, vision, pediatric vision

Source Citation

Christina L. Master, Darron Bacal, Matthew F. Grady, Richard Hertle, Ankoor S. Shah, Mitchell Strominger, Sarah Whitecross, Geoffrey E. Bradford, Flora Lum, Sean P. Donahue; AAP SECTION ON OPHTHALMOLOGY; AMERICAN ACADEMY OF OPHTHALMOLOGY; AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS; and AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS, Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment. Pediatrics 2022; e2021056047. 10.1542/peds.2021-056047