Is there a link between nonorganic visual loss (NOVL) and a history of childhood brain injury or repeated concussions?

Connection Between Nonorganic Visual Loss (NOVL) and Childhood Brain Injury or Repeated Concussions

There is no established direct connection between nonorganic visual loss (NOVL) and a history of childhood brain injury or repeated concussions based on current medical evidence. NOVL is diagnosed through exclusion after thorough investigation shows no organic cause for visual impairment.

Understanding Nonorganic Visual Loss (NOVL)

• NOVL is not uncommon in school-age children and is diagnosed by exclusion based on clinical history, inconsistent clinical examination findings, and negative imaging studies 1
• NOVL represents the presence of visual impairment without an organic cause despite comprehensive investigation 2
• Diagnosis requires both the absence of findings on examination and proof of the integrity and functioning of the visual system 2

Diagnostic Approach for NOVL

• MRI of the head and orbits with contrast is the most useful imaging modality for evaluating acute nontraumatic vision loss to rule out organic causes 1
• Various bedside techniques and specialized testing can help determine if visual loss is organic or nonorganic 2
• Electrophysiologic testing may occasionally be helpful when clinical examination is insufficient to establish NOVL diagnosis 3

NOVL in Pediatric Populations

• NOVL is relatively common in children, with one study identifying 30 children with NOVL out of 973 examined 4
• The mean age of children with NOVL was approximately 9 years, with 70% being girls 4
• In 20% of cases, psychosocial anomalies were detected, and 40% of children were seeking to wear glasses 4

Concussion and Visual Symptoms

• Visual symptoms are common after concussion in children and adolescents, but these represent organic visual disturbances rather than NOVL 5
• Post-concussion visual issues may include problems with visual acuity, ocular alignment, smooth pursuit, saccades, vestibulo-ocular reflex, convergence, and accommodation 5
• Most children with visual symptoms after concussion recover spontaneously by 4 weeks 5

Brain Injury Considerations

• Traumatic brain injuries are more commonly associated with orbital fractures in younger children 1
• MRI is more sensitive in detecting TBI lesions and may be particularly helpful in cases of non-accidental trauma 1
• Long-term effects of concussions in young athletes are cause for concern, with persistent deficits in processing complex visual stimuli observed in children 8-16 years of age three months after concussion 1

Clinical Implications

• When evaluating a child with visual loss, it's important to distinguish between organic causes (including those related to brain injury) and nonorganic causes 1
• If visual symptoms persist or worsen independently of other symptoms, further evaluation for true optic pathway disease is warranted 6
• Treatment for NOVL centers around reassurance, close follow-up, and psychiatric referral when necessary, as these patients may have underlying psychiatric disorders 2

Key Considerations in Differential Diagnosis

• Persistent, progressive, or severe visual loss warrants evaluation for organic conditions affecting the visual pathway 6
• Nonorganic overlay should be considered in children with NOVL, as the combination of organic and nonorganic visual loss is relatively common 3
• Simple diagnostic tests can often establish NOVL without need for extensive imaging and electrophysiologic testing 4