A Review of the Current Practice in Diagnosis and Management of Visual Complaints Associated With Concussion and Postconcussion Syndrome

Laura Heinmiller; Kammi B. Gunton

Disclosures

Curr Opin Ophthalmol. 2016;27(5):407-412. 

In This Article

Abstract and Introduction

Abstract

Purpose of review Concussions and their related sequelae have received significant attention given the high-profile media coverage from professional sports and recreational leagues. A better understanding of the diagnosis and symptom management may limit the long-term impact these injuries have on the affected individual. The aim of this review is to provide updated information for both diagnosis and ongoing management for visual symptoms of concussions.

Recent findings New testing including a brief vestibular/ocular motor screening assessment and the importance of near point of convergence measurements may prove beneficial to the diagnosis and identification of patients at greater risk for developing postconcussion syndrome. Additionally, the development of postconcussion syndrome is more likely when symptom burden is greater upon presentation.

Summary Currently, there is not a single testing method that can universally identify all individuals with concussion. Current management of concussion focuses on targeted treatment based upon symptoms and signs present at onset to decrease disease burden and help restore baseline functioning as soon as possible.

Introduction

The media coverage of professional athletes with long-term disability including chronic traumatic encephalopathy and the subsequent physical and mental health struggles has highlighted the potential severity of the long-term effects of concussions. As evidence mounts about the potential long-term morbidity of repetitive traumatic brain injury (TBI), including altered cognition, depression, and neurodegenerative diseases (Alzheimer's disease and chronic traumatic encephalopathy),[1,2] there has been an increase in the focus and attention on improved identification and treatment of athletes who experience head injuries. The Centers for Disease Control (CDC) states that in 2009, an estimated 248 418 children (age 19 or younger) were treated in United States emergency departments for sports and recreation-related injuries that included a diagnosis of concussion or TBI.[3] Additionally, the rate of emergency department visits for sports and recreation-related injuries with a diagnosis of concussion or TBI, alone or in combination with other injuries, rose 57% among children (age 19 or younger) from 2001 to 2009. As a result, tremendous progress has been made in both the diagnosis and management of TBI and concussions.[3]

Concussions are a mild form of TBI resulting from a diffuse axonal injury with microstructural white matter changes that have been shown with diffusion tensor imaging (DTI) to have a high prevalence of injury in the frontal lobes, corpus callosum, corona radiata, and diffuse deep white matter.[4,5] With around half of the neural connections in the brain involved in vision and visual processing, visual complaints such as photophobia, double vision, blurred vision, and visual processing problems are seen throughout the spectrum of severity in TBI.[6]

Sixty-nine per cent of adolescents with a concussion had an associated visual diagnosis in a recent cross-section study performed by Master et al.[7] in their comprehensive concussion program. The most common visual abnormalities included accommodative disorders, convergence insufficiency, and saccadic dysfunction (29%).[7] Although this number may be inflated based upon their role as a subspecialty referral center, there is ample literature to support the frequency of vision problems in adults in the literature.[4,8–16] Given the significant number of concussions and frequency of associated visual complaints, it is essential that quick diagnosis and comprehensive postconcussion care be provided.

Along with visual dysfunction, significant morbidity from vestibular dysfunction following concussion can arise from central or peripheral structures within the vestibulospinal system resulting in disequilibrium and impaired balance. This can also be combined with dizziness, vertigo, nausea, and difficulty in active environments from disruption of the vestibulo-ocular system resulting in significant impact in function.[17] The most common vestibular issues following sports-related concussion are benign paroxysmal positional vertigo (BPPV), visual motion sensitivity (VMS), balance dysfunction, vestibule-ocular reflex (VOR) impairment, cervicogenic dizziness, and exercise-induced dizziness.[18] Corwin et al.[19] completed a retrospective cohort study at a tertiary pediatric hospital and found that 81% of their 247 patients had a vestibular abnormality (defined by abnormality in VOR testing or abnormal tandem gait) on initial clinical examination.

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