Optometry students + residents–earn $500 to attend the 2018 Annual Meeting by writing something just like this!

Last year, Amanda Beaudry, OD, MS  and Emily Cheng, OD received Travel Grants for the 2017 Annual Meeting with their summaries of an article on academic performance and concussion. We’ve shared it with you here, combined with new practice-relevant insights, as inspiration for this year’s applicants!

Childhood traumatic brain injury and concussions have been on the rise. While most children who suffer a concussion are recovered in 7-10 days, there is a substantial minority whose symptoms persist for longer, and this can impact their academic performance. The current standard treatment after a concussion is “cognitive rest.” The Zurich Consensus Report outlines guidelines for when it is safe to Return-to-Play in athletes who suffer from concussions, however, there are less universally-accepted guidelines for Return-to-Learn. In order to develop a Return-to-Learn protocol, it is necessary to know what symptoms are associated with academic difficulty. Studies have shown that the visual system is affected after concussion, yet vision is rarely included in Return-to-Learn protocols. The official 2014 National Athletic Trainers Position Statement recommends testing smooth pursuits, nystagmus, and pupil reflex, which may be important with sports, but does not mention any convergence, accommodation, or saccade testing, which are important for academics and learning.

The purpose of the study “Academic Difficulty and Vision Symptoms in Children with Concussion” was to evaluate a group of children with prolonged post-concussive symptoms to determine if vision symptoms are associated with increased academic difficulty. This study retrospectively reviewed data of 1021 children who were evaluated at Children’s Hospital of Alabama between the years 2007 to 2013. The data collected on each child was reported by parents and child at the point of care and included demographic information, concussion event history, previous medical history, symptom history, and Sport Concussion Assessment Tool 2 scores (SCAT2). The date of concussive event was recorded as the “index date”. The symptom history included questions about 13 symptoms typically associated with a concussion and included a yes/no question about having academic difficulty after the concussive event. Using time since index date and symptom history, a subset of children showing 3 or more symptoms present for 10 days or more were identified as having prolonged post concussive symptoms. The primary symptom of interest was reported vision problems. The SCAT2 captures symptom severity on a 1 to 6 scale about 22 concussion-related symptoms. It also includes the severity results, Maddock’s side-line assessment, brief physical assessment, and balance assessment, The dependent variable was academic difficulty after concussive event. A higher overall SCAT2 score indicates better performance. For the symptom score, cognitive and balance subset, a higher score indicates less symptoms. For symptom severity subset, a higher score indicates worse symptoms. The subset of children identified with prolonged post concussive symptoms included 276 subjects ages 5 to 18 years old.

The most common symptoms were headaches (98%) and dizziness (70%).  Fatigue, vision abnormalities, nausea and concentration difficulty were present in 40 to 50% of the subjects. Balance problems, confusion, hearing disturbances and vomiting were less common, present in 20 to 30% of subjects.

All of the symptom variables were associated with academic difficulty except headaches. Lower symptom score and higher symptom severity scores were associated with academic difficulty. Concentration difficulty, confusion, and balance difficulty were all associated with academic difficulty. Vision and hearing were associated with doubling the odds of academic difficulty. Concentration difficulty accounts for a 21 fold increase in odds.   What was most interesting was that for those with symptoms longer than 30 days, only vision and concentration difficulty remained significant for academic problems.  This finding does make sense, since learning is highly vision-dependent and that the brain is known to have 30 areas that are dedicated to vision.   This study and previous studies suggest that visual acuity is NOT enough to identify problems related to visual dysfunction.

This study does have a few limitations. Firstly, the responses used for analysis are all based on self-report, and may or may not relate to objective findings. Also, it cannot be concluded what the direction of causation is between vision problems and academic difficulty from this study. It is possible that children with academic difficulty may have had pre-existing academic difficulty that could skew this finding. Although the American Academy of Pediatrics consensus report lists vision as a common problem after concussion that it may interfere with Return-to-Learn, no vision specialists were included in the Return-to-Learn readiness decision-making process. This study supports the view that vision specialists should be given a greater role in assessment for Return-to-Learn, as well as in addressing any visual needs of children with concussion.

This study makes a strong statement for the need of detailed functional vision testing in students who have sustained a mild traumatic brain injury or concussion, especially if symptoms persist longer than a few weeks.  If we can identify the cause of students’ academic struggles, then we can treat them, and we can prevent such students from experiencing unnecessary hardship and frustration in returning to the classroom. 

If your child has suffered a concussion, find a member of COVD near you for a comprehensive vision exam and get the full picture on their readiness to Return to Learn!


Swanson MW, Weise KK, Dreer LE, Johnston J, et al. Academic Difficulties and Vision Symptoms in Children with Concussion. Optometry and Vision Science 2017 94:60-67