The eyes, the brain and learning

Excerpted from page 48 of the July/Aug 2022 edition of AOA Focus.

Once a concussion has occurred, a child may report sensitivity to lights, blurred vision, dizziness, fatigue when reading, headaches and difficulty concentrating. A primary care doctor of optometry may have such a child visit their office with any of these symptoms.

After evaluating the concussed child, the doctor is then faced with the question of whether to monitor, provide minimal intervention or refer for vision therapy. A significant percentage of first-time concussion patients will do well with little or no intervention, but for those who need more, the next step would be to consult with a doctor of optometry who does concussion management for possible additional assessment and/or treatment.

Here is an example of a child who did well with minimal intervention.

Case study: pediatric concussion

This case begins with a 13-year-old white female (C.F.) who was hit in the head with a soccer ball during a game at school. She did not lose consciousness but was disoriented and dizzy. The coach had her mother take her to the pediatrician, who diagnosed C.F. with a concussion; she was told to stay home and rest. While at home, she complained that the lights hurt her eyes and she felt her vision was blurry. They visited their family doctor of optometry, who referred her to our practice, which services a large population of patients with traumatic brain injury, concussions and strokes.

The comprehensive eye exam of a concussion patient includes: 

• Visual acuities, visual fields, pupils, stereo vision, color vision
• Retinoscopy/refraction
• Eye movements (saccades, pursuits, NPC, vergences and developmental eye movement test)
• Accommodative measurements
• Slit lamp, intraocular pressures, dilated retinal evaluation

When evaluating C.F., her entering V.A. was 20/20, she had minimal uncorrected hyperopia, photophobia, ocular motor dysfunction and convergence insufficiency. The slight hyperopic prescription subjectively made a big improvement in clearing up her blurry vision complaints and following a filter evaluation, a wavelength specific lens was added to her compensating glasses. We recommended that the glasses were to be worn for comfort and clarity to reduce her photophobia and blur complaints.

We educated C.F. and her mother about the findings and treatment plan. We comanaged her case with the pediatrician, who also was monitoring her concussion. We agreed on following a “Return to Learn” guide catered to her specific situation. Stage 1 was limited television viewing but no near point activities (no phone use, no video games). Stage 2 was limited reading and limited near point activities. Stage 3 was more time reading and near point activities, and Stage 4 was return to school with accommodations (including breaks every 20 minutes). After two weeks, C.F. returned to school and was able to rejoin her class. She did not report any more headaches, blurry vision, photophobia or lack of concentration.

At her one-month follow-up visit to our office, C.F. reported that the glasses were only needed when she was tired or overwhelmed. When we repeated the developmental eye movement test, her scores had returned to normal. Additional testing showed that her overall vergence system also had recovered. We released C.F. from our care and had her return to her family doctor of optometry for her annual comprehensive eye health and vision exams. Brief letters were written to both her pediatrician and doctor of optometry about her recovery.

C.F. was lucky that she recovered so quickly and fully from this concussion with minimal intervention. Quick medical assessment and management helped the process, as she was given the tools and guidance needed to expedite her recovery. As she was not an avid soccer player, after the concussion she and her family decided she would try track as a school sport instead. Some concussion patients are not so fortunate in their recovery and require longer management times and/or more extensive vision rehabilitation.

Interested in providing more concussion care in your office?

Join the AOA Vision Rehabilitation Advocacy Network (AOA VRAN) and consider working with concussion prevention programs, offering pre-season baseline testing, post-concussion testing and vision therapy/vision rehabilitation to remediate some of the symptoms. You can simply become an AOA VRAN member and connect with a vision rehabilitation doctor of optometry in your area to refer these cases.

Written by Maria Richman, O.D., a member of the AOA’s Vision Rehabilitation Committee 

Disclaimer: The information contained in this article represents the opinion of the author and not the AOA. These are not clinical practice guidelines, nor has the evidence been peer-reviewed. There are additional aspects to this topic that may not be presented, or considered, based on the specifics of the case.