New mild TBI guideline for children provides opportunity for doctors of optometry

A new clinical guideline on treating children with mild traumatic brain injury (mTBI) provides insights for doctors of optometry partnering or seeking to partner on post-concussion care teams. 

On Sept. 4, the clinical guideline, Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children, was published in JAMA Pediatrics. The guideline includes 19 sets of recommendations—covering diagnosis, prognosis and management/treatment—on pediatric TBI. More than 800,000 children seek care for TBI in U.S. emergency departments each year, said Deb Houry, M.D., director of the CDC's National Center for Injury Prevention and Control, upon the guideline's release.

Among the recommendations:

• Do not routinely image pediatric patients to diagnose mTBI.
• Use validated, age-appropriate symptom scales to diagnose mTBI.
• Assess for risk factors for prolonged recovery, including history of mTBI or other brain injury, severe symptom presentation immediately after the injury, and personal characteristics and family history (such as learning difficulties and family and social stressors).
• Provide patients and their parents/caregivers with instructions on returning to activity customized to their symptoms.
• Counsel patients and their parents/caregivers to return gradually to non-sports activities after no more than two to three days of rest.

Patients with TBIs typically experience visual symptoms including double vision, poor eye-tracking, difficulty shifting their gaze quickly between points, light sensitivity and eyestrain. A brain injury also can affect a person's spatial orientation, balance and depth perception.

Role of doctors of optometry

Doctors of optometry are in a unique and vital position to make sure patients are ready to return to work, to play or to learn after sustaining brain trauma injuries.

They serve 10,000 communities across the nation. In about a third of those communities, they are the only eye doctors and provide a critical path to reaching patients who may not recognize they suffered a brain injury, underscoring the essentialness of regular, in-person, comprehensive eye examinations.

The mTBI guideline for children supports the important inclusion of doctors of optometry on post-concussion care teams, says Mary Gregory, O.D. Dr. Gregory, who practices in Monticello, Minnesota, cares for patients (adults and children) with developmental delays (reading and learning needs), as well as visual effects of traumatic brain injury. She has a therapy clinic, Omni Vision & Learning Center, where she provides visual rehabilitation.

Dr. Gregory noted that the guideline does not specifically call out optometry and the role of eye health and vison care in caring for children with mTBI. In a letter last November to the CDC, the AOA expressed concern that the agency had missed the opportunity to underscore eye care and vision health's role in the diagnosis and management of mTBI among children.

"Because so much of the brain is involved with the visual system, it is critical that eye doctors are engaged in the mTBI care team to help diagnose, refer and manage mTBIs," the letter read. "It is imperative that any child with a diagnosed mTBI be referred to any eye doctor to evaluate and treat any vision impairments caused by the mTBI."

The AOA's Evidence-Based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination notes that concussions in adolescence can lead to "significant" vision disorders, including convergence insufficiency, accommodative insufficiency and saccadic dysfunction. It recommends that children with concussions see their general practitioner for emergent care and make an appointment with their eye doctor for a comprehensive eye exam to make sure their vision is protected.

Still, Dr. Gregory calls the new guideline a "wealth" of information and "a big step toward uniform care and education" for doctors caring for children with mTBI.

Aside from the recommendations previously cited here, she notes guidance validating symptom scales to assess recovery in children with mTBIs among other tools (reaction time and cognitive testing); suggesting families be provided resources that include the warning signs of more serious injury, descriptions of the expected course of symptoms and recovery; and offering instructions on how to monitor symptoms and prevent further injury.

"We now have the opportunity to communicate in a manner that is documented as the suggested method across all disciplines," Dr. Gregory says. "This is a benefit for optometry because we can each be talking to doctors in our own communities and speak a common verbiage. This communication increases the multi-disciplinary approach that is needed with the mild TBI population.  

"As optometrists, we will all encounter concussion patients in our practices, so it is imperative that we remain knowledgeable and at the forefront when it comes to vision care," she adds. "A large percentage of concussion patients report visual symptoms, and we should be the provider addressing this for them."