Doctors of optometry should play role in clearing children for return to class and play

At the table—that's where doctors of optometry and other vision experts should be when decisions are made on whether and how children with prolonged concussions are reintegrated into classroom settings, a new study says.

Not only does the study link vision and academic problems in children with prolonged concussions, but the researchers also point out that too often eye doctors are not invited into "return-to-learn" conversations, though post-concussion vision symptoms—such as convergence, accommodation, saccadic abnormalities and smooth-pursuit tracking—often persist.  

The study, performed by researchers from the University of Alabama at Birmingham (UAB), appeared in the January 2017 issue of Optometry and Vision Science. According to the Centers for Disease Control and Prevention, the rate of children being brought to emergency rooms for traumatic brain injuries (TBIs) jumped by 57% (from 190 to 298 per 100,000 cases) between 2001 and 2009.  

"Return to learn after concussion is a delicate balance between cognitive rest and rehabilitation, and the academic success of students, which requires an individualized approach," the study says. "The American Academy of Pediatrics (AAP) consensus report on returning to learn after concussion prominently lists vision as a common problem, which may interfere with return to learn."  

The researchers add, "No vision specialists, neither optometrists nor ophthalmologists, are listed among the medical specialists who may be involved in return-to-learn decisions. This data and other research support vision care providers taking a greater role in the assessment of return-to-readiness and potential rehabilitative needs of children with concussions."  

Researchers cited a 2013 study published by the AAP that recommended creation of a multidisciplinary team to support concussed students. Among the medical professionals mentioned, "primary care providers" are listed but eye doctors are not called out specifically. Another AAP study published in December 2016 reported that, though all 50 states have adopted "return-to-play" laws that lay out the protocols for students returning to play athletics, only eight of them had "return-to-learn" laws as of May 2016.  

Vision and learning

Mark Swanson, O.D., M.S.P.H., is the lead author of the study. Dr. Swanson also is director of ocular disease and low vision service at UAB Eye Care and professor of optometry in the UAB Department of Optometry and Vision Science.  

Most concussion symptoms "resolve" themselves within 10 days after a period of cognitive rest, Dr. Swanson says. That rest includes limiting the use of cell phones, video games and computers, for instance.  

For some children, though, it takes longer for the symptoms to pass. Symptoms can linger for a month or longer before they go away and in the meantime, children may see their grades slip due to post-concussion symptoms such as headaches, dizziness, fatigue, vision problems and difficulty concentrating.  

"One of my colleagues at UAB, Dr. Kathy Weise, who is one of the leaders of our UAB concussion group and a study co-author, saw a child with a concussion who took a charge on the basketball court," Dr. Swanson says. "He had some of the typical vague visual complaints. It took almost a year before he was able to return to school full time. We became curious if vision was related to school difficulty."  

For the study, researchers looked at data for 276 patients—ages 5 through 18 years of age—with prolonged concussions seen at Children's of Alabama, the state's sole pediatric hospital. The patients were seen between January 2007 and October 2013.  

"In our larger cohort of kids with concussions, vision was the third most common symptom reported behind headaches and dizziness," Dr. Swanson says. "In the group of children whose symptoms last longer (10 days or more than 30 days), our work suggests that those with vision problems are more likely to report having academic difficulty."  

Symptom-free schooling

Doctors of optometry are integral to return-to-learn protocols so students can return to the classroom symptom free, Dr. Swanson says. That may mean no school, a limited study load for a period of time or even no return to play before being cleared to return to class, he says.  

He adds, "Vision problems are common after concussion and optometrists have a role to play. Children and high school athletes should be able to return to school and be symptom free before they begin 'return-to-play' protocols."  

Access the AOA's Brain Injury Electronic Resource Manual's Volume 1 A, Traumatic Brain Injury Visual Dysfunction Diagnosis, or Volume 1B, Traumatic Brain Injury Dysfuntion: Optometric Management and Advanced Topics.

Mary Gregory, O.D., who practices in Monticello, Minnesota, praised the findings of the study. Dr. Gregory, who received the 2014 Dr. W. David Sullins Jr., InfantSEE ^® Award for outstanding public service, operates a clinic where she provides vision rehabilitation for adults and children.  

Dr. Gregory says the study reinforces the value doctors of optometry bring to diagnosing and treating children with TBIs.

She highly recommends a symptom checklist, which will help patients, their parents and doctors track changes. The checklist also helps her know when to look at accommodations in school and at home, when to add rehabilitative glasses, and how to advise further care—occupational, physical or vision rehabilitation—if needed, she says.  

"In my personal experience, a reduced NPC (near point of convergence) is usually the most common predictor of further academic concerns," Dr. Gregory says. "When evaluating vision in other settings, such as the offices of an athletic trainer or a physician, they typically measure distance acuity. I find that many of these children can see fine at a distance but have reduced visual skills leading to increased fatigue, reduced stamina, and poor attention and comprehension once back in a classroom setting.

"All of these symptoms affect how a child will intake information visually in a classroom setting," she adds. "For these reasons, it is important that optometrists are involved in the return-to-learn process."