February 08, 2018
Ophthalmology: Journal of the AAO
TAKE-HOME MESSAGE
- In a cohort of patients with whiplash-associated disorder (WAD) secondary to motor vehicle accidents, the authors found that the incidence of convergence insufficiency–related visual symptoms was greater than in the control group (45.6% vs 15.4%). However, objective findings of convergence insufficiency were similar between patients with WAD and controls.
- The authors conclude that careful objective assessment by a qualified clinician is needed to determine if patients with WAD after motor vehicle accidents have visual disability related to convergence insufficiency.– Kathleen Freeman, OD, FAAO
Written by Joseph W Sassani MD
Another very interesting paper that nicely illustrates the dichotomy between symptoms and signs in whiplash-associated disorder. The authors noted that approximately three times as many patients with a history of whiplash had a positive survey score for convergence insufficiency compared with control individuals; however, the objective clinical findings were virtually identical between the two groups. What are we missing here?
Abstract
PURPOSE
Motor vehicle accidents (MVAs) are a pandemic associated with human suffering and a burden to national economies. Whiplash-associated disorders (WADs) after MVAs are associated commonly with disability claims, many of which are related to vision. Convergence insufficiency (CI) leads to visual disability associated with symptoms of ocular discomfort. We examined the incidence of symptoms and findings consistent with CI in a cohort of patients after MVA-related WAD compared with age-matched control participants.
DESIGN
Prospective cohort study.
PARTICIPANTS
Patients with WAD after MVA were recruited from the Orthopedic Emergency Department between July 2014 and March 2017. Control participants were recruited among hospital personnel and relatives of WAD patients.
METHODS
The Convergence Insufficiency Symptom Survey (CISS) questionnaire was completed by each participant, followed by a detailed visual examination including measurements of distance and near best-corrected Snellen visual acuity, distance and near cover test, Randot stereopsis, Maddox distance and Maddox-Thorington near heterophoria, near point of convergence, base-out step fusional reserves, and amplitude of accommodation using the push-away method.
MAIN OUTCOME MEASURES
The CISS score and binocular measure findings of CI were recorded and analyzed using Student’s t test, the chi-square test, and multiple logistic regression adjusted for age and gender.
RESULTS
A pathologic CISS score of 16 or more occurred in 26 of 57 WAD patients (45.6%) compared with 6 of 39 control participants (15.4%; P = 0.002). Absolute CISS score was higher in the WAD group compared with the control group (15.3±10.0 vs. 7.7±7.7; P < 0.001). Findings consistent with CI occurred in 7.0% of WAD patients and 7.7% of control participants (P = 0.90).
CONCLUSIONS
Visual symptoms suggestive of CI were reported more frequently among WAD patients compared with control participants, yet the incidence of examination findings indicating weakness of convergence was not increased. The discrepancy between subjective and objective measures of CI in WAD patients versus control participants stresses the importance of training healthcare personnel to assess disability using objective, validated standards of examination.