2012 Issues   /   Ophthalmology

New Eye Centers Goal is Vision Rehabilitation and Restoration for Injured Troops

USM By U.S. Medicine
February 20, 2012

By Sandra Basu

WASHINGTON — Eye wounds are devastating for deployed troops, and the past decade’s conflicts have created ample opportunities for that type of injury, with the prevalence of explosive devices, projectiles, chemicals, biohazards, lasers and extreme environmental conditions.

While treating vision damage is a priority for both the DoD and VA, and both are committed to providing excellent care, military and congressional leaders are seeking something more: leveraging integration across both agencies to develop new strategies for vision rehabilitation and restoration.

In 2006, 1st Lt. Anthony Aguilar wears the ballistic protective eyewear that prevented a bomb-fragment from possibly damaging his eyes when an IED detonated near his Stryker vehicle while on patrol in Mosul. (Photo by Company C, Task Force 2-1)

To help meet those goals, a new Vision Center of Excellence (VCE) is beginning operations this month at the Walter Reed National Military Medical Center. Established under the National Defense Authorization Act of 2008, the VCE’s mission is to “continuously improve the health and quality of life for members of the armed forces and veterans through advocacy and leadership in the development of initiatives focused on the prevention, diagnosis, mitigation, treatment and rehabilitation of disorders of the visual system.”

An official opening ceremony will occur this spring.

Establishing the VCE is the culmination of years of efforts to address the high rate of eye injuries for deployed troops in Afghanistan and Iraq. In addition to direct eye injuries, as many as 70% of severe and moderate TBI cases and 40% of mild TBI cases include some form of visual impairment, such as nerve damage from concussive events, according to the Military Health System.

Advocates: More Funding Needed for Military-Specific Vision Research

More innovations in the care of the eye cannot come from data alone, according to advocates for more research funding.

James Jorkasky, executive director at the National Alliance for Eye and Vision Research (NAEVR), said that funding for military-specific eye and vision research remains a critical need.

A DoD program called the Peer Reviewed Medical Research-Vision was established in FY 2009 by Congress to fund extramural research. This program provides a dedicated funding source for extramural vision research for combat-related eye injuries, which is not conducted by the VA, elsewhere within the DOD or at the National Eye Institute (NEI), according to NAEVER.

“We are very concerned that there be sufficient funding,” Jorkasky told U.S. Medicine. Advocacy organizations requested a funding level of $10 million for the past three years. They were disappointed when Congress finalized a bill in December that funded the Peer Reviewed Medical Research-Vision program at $3.2 million, a 20% cut from the FY2011 funding level of $4 million.

Michael Brennan, MD, a comprehensive ophthalmologist in Burlington, NC, who served as a past president of the American Academy of Ophthalmology and is retired from the military, said one reason research funding is so important to help troops who have suffered vision injuries is that those types of injuries create a distinct burden on patients and their families.

“I am not saying that life is pleasant if you are in a wheelchair,” he said. “But if you are in a wheelchair and you can see and read and write, you are pretty functional. If you have vision barely in one eye and no vision in the other, you can’t do much, and you are a distinct burden to probably two or three people, because someone has to see for you and walk for you. We tend to think that the multiplier effect on families and caregivers is great in dealing with blinding conditions.”

Tom Zampieri, who also is advocating for more research funds as director of government relations at the Blinded Veterans Association, pointed out that eye and vision-related injuries do not impact only the servicemember but also their families.

Zampieri knows this firsthand. He conducts peer-support visits to combat eye-injured troops at the Walter Reed National Military Medical Center in Bethesda, MD.

“I try to meet with them and explain to them what vision rehabilitation is all about and that they should not give up hope, regardless of the severity of the injury,” Zampieri, who is blind, told U.S. Medicine. “When you lose vision, it doesn’t just happen to the servicemember, it impacts everyone in the family.”

A 2006 study published in the journal Optometry noted that “The U.S. Army faces major challenges in balancing the need to protect a soldier from harm while not impeding his ability to fight. Unfortunately, the incidence of combat eye injuries has increased over time, despite the development of protective measures.”

That study found that, from March 2003 through December 2004, 15.8% (258 of 1,635 patients, 309 eyes) of all medical evacuations were a result of battle eye injuries.

While efforts are in place to better understand the current rates of these injuries, what is clear is the need for evidence-based care and data on outcomes.

“The loss of vision has been the most feared injury, even more than the loss of a limb, arm or leg or any other type of injury, because a little loss of vision has a devastating consequence on the ability to function,” Col. Donald Gagliano, MD, who serves as director of the VCE, told U.S. Medicine. “There are very few people who deploy back to the deployed environment who have lost vision, because vision is so critical on the battlefield. You can’t function as a warrior if you can’t see.”

A May 2011 report from the Armed Forces Health Surveillance Center said that, from 2000 to 2010, 186,555 eye injuries were diagnosed among deployed troops, not including those at sea, with 3% requiring hospitalization. The publication reported that, between 2005 and 2010, “8,323 incident eye injuries were reported from deployed medical-treatment facilities.”

The article in the Medical Surveillance Monthly Report noted that injuries with “high risk of blindness” increased sharply from 2002 to 2004 and then generally declined through 2008, likely as a result of increased use of eye protection. The sharp rise, it stated, “was concurrent with increasing numbers of deployed servicemembers and combat-specific activities (including IED attacks) — and poor compliance with the use of protective eyewear — in Afghanistan and Iraq.”

“The results suggest that the increased use of eye protection accounted at least in part for lower eye-injury rates among deployed servicemembers,” stated the report, which also suggested that the rate of injury could be undercounted.

Eye-injury surveillance, which resulted in that report, is being conducted by the Tri-Service Vision Conservation Readiness Program, according to Col. David J. Hilber, the occupational and environmental medicine portfolio executive officer and senior member of the Tri-Service Vision Conservation and Readiness at the U.S. Army Public Health Command.

The Tri-Service Vision Conservation Readiness Program is gathering data on rates and trends of eye injuries among active-component servicemembers by cause and by specific military, occupational and demographic characteristics for all services.

“The reality is that, up until now, we really have not had a systematic, repeatable way to assess the frequency, rate and demographic breakdown of eye injuries for really anybody, but in particular for the DoD active duty,” Hilber told U.S Medicine. “That made it difficult to substantiate or easily develop data to support decisions, inform policy and respond to inquiries from outside agencies when they were asking about eye injuries. That is one of the big things that the eye-injury surveillance will provide.”

More data will be available in the future. As part of the authorization for the VCE, Congress mandated that an eye injury and vision registry be developed to record the occurrence, treatment and outcomes of military eye-related injuries and vision impairment. The Defense and Veterans Eye Injury and Vision Registry will be the first to combine DoD and VA clinical information into a single data repository for tracking patients and assessing longitudinal outcomes, according to the VCE.

“It will be the largest and most robust registry on eye injuries probably that the world has ever seen,” Mary Lawrence, MD, deputy executive director of the DoD/VA Vision Center of Excellence told U.S. Medicine. “We will be collecting information on all patients who have had an eye injury while they have been on active duty since 2001.”

While eye and vision research will not be conducted by the VCE, the center’s role will be to lead “the process of identifying and prioritizing the research that is conducted” and then “find the places that can conduct that research” and “monitor the progress of that research and implement the translational component of it,” according to Gagliano.

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