O1011: A Glaring Omission in the Pediatric Emergency Department (ED): Is Visual Acuity Assessed in the Concussed Patient?

Background: Over 50% of the human brain is dedicated to visual processing and left vulnerable to traumatic brain injury (TBI). More than 1/3 of high school athletes with concussion report vision changes after their injury. Nearly 70% will receive a vision diagnosis. As the ED is often the point of entry within the healthcare system for patients with concussions, all pediatric patients who present to the ED with TBI in whom the diagnosis of concussion is considered, would benefit from a thorough vision assessment including traditional visual acuity and more novel vestibular-oculomotor testing. Our research focused on the visual acuity portion of this assessment and we hypothesized that it is rarely performed in these patients.

Methods: This cross-sectional, retrospective chart review study aimed to establish how frequently visual acuity is assessed in pediatric patients with TBI who present to a single pediatric tertiary-care academic medical center ED and are diagnosed with concussion. The University of Southern California Institutional Review Board granted this study an exemption from seeking subject specific authorization for use of data because there was minimal risk to individual privacy. All pediatric patients aged five to eighteen who were diagnosed with concussion in 2019 at Children’s Hospital Los Angeles (CHLA) ED were eligible for inclusion. Participant biological sex, age, ethnicity, and whether visual acuity testing was received were collected.

Results: 202 pediatric patients were diagnosed with concussion in 2019 at the CHLA ED, all of whom were included in the final analysis. Of these individuals, 10, or roughly 5%, had visual acuity performed. The average age was 11.7 years. 69% of patients identified as Hispanic. 40% were female. 47% were involved in a sports-related concussion. 37% were referred to concussion clinic on discharge. 15% had head imaging performed. Patients presented to the ED, on average, 3 days after their TBI.

Conclusion: Visual acuity can be affected in traumatic brain injuries of all levels of severity. Often patients present with subjective complaints of visual changes, including blurry vision, but these are not formally quantified. Changes in vision can persist to various lengths in concussed patients and dramatically impact their quality of life both in school and sport. Emergency medicine physicians are often the first to diagnose a patient’s concussion and therefore, well-positioned to identify vision abnormalities, counsel patients on safe return to academics or sport, and recommend accommodations. Early documentation would allow the patient’s primary physician to check for resolution or progression of vision changes and determine the need for ophthalmology referral and vision correction. However, visual acuity assessment may rarely be performed in patients with concussion, as this study suggests. Whether these results are consistent among other EDs warrants further investigation.