Vision Problems Not Always Diagnosed in Vets with TBI

by U.S. Medicine

December 13, 2012

By Brenda L. Mooney

CHICAGO — More than 160,000 veterans treated by VA are considered legally blind, and another million have low vision that challenges daily activities.

While VA has an extensive network of services for those beneficiaries, new studies suggest that attention also needs to focus on a new group of vision-impaired veterans: those returning from recent conflicts with eyesight affected by mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD).

Capt. John Stehulak, deputy commander, 124th Medical Detachment, 18th Medical Deployment Support Command, examines Staff Sgt. Alexander Champigny, automation specialist, 18th MDSC, during the unit’s field training exercise to evaluate the unit’s equipment and training for deployment last year.

At the same time as more Korea and Vietnam war veterans are incurring vision loss due to age-related diseases such as macular degeneration, diabetic retinopathy and glaucoma, younger veterans who suffered brain injuries from blasts are reporting symptoms such as blurred vision, double vision, sensitivity to light and difficulty reading.

VA estimates that as many as 64% of servicemembers with traumatic brain injury also have a vision problem.

That’s in line with recent studies presented at the 116th Annual Meeting of the American Academy of Ophthalmology in Chicago, which noted that vision problems are common side effects of TBI and PTSD but often go undiagnosed and untreated among veterans.

Researchers at the Washington, VAMC found that 67% of 31 patients with mild TBI reported chronic vision disorders more than a year after their initial injuries. Most commonly reported were problems with convergence, the ability to focus both eyes simultaneously in order to read or see other nearby objects, and sensitivity to light.

Reduction in accommodation, the ability to readjust focus between far and near objects, also was reported, as were double vision and “floaters.”

Five Years to Recovery

Study authors noted that full recovery of visual function took five years or more in many of the veterans—longer than usually seen in sports concussions and other non-blast-related TBI. Nearly 200,000 deployed servicemembers suffered a TBI from 2000 to the present, according to DoD.

“Physicians who care for veterans with TBI need to know that many of them have vision problems,” said lead author M. Teresa Magone, MD, staff ophthalmologist with the Washington VAMC “It is critical that these patients receive vision assessment and, when appropriate, be referred to ophthalmologists to make sure they get the eye care they need for as long as they need it.”

Aware of those issues, the Army last year began a new traumatic brain injury vision rehabilitation initiative to ensure that soldiers with TBI-associated eye problems are diagnosed and referred for comprehensive, functional eye examinations and rehabilitative care.

“In addition to headaches or general problems with comprehension, attention, concentration or memory, TBI patients commonly suffer functional vision difficulties including focusing problems, double vision, difficulty reading, sensitivity to light, aching eyes, or loss of visual field,” said Maj. Jinjong Chung, who led leading the project for the Rehabilitation and Reintegration Division of the Office of the Army Surgeon General.

The key component to this initiative, he said, is educating eye health providers, patients and rehabilitation providers about different techniques.

Before the initiative, soldiers diagnosed with TBI were not routinely examined for functional visual problems at MTFs.

“Even facilities that have a robust TBI program may not have systems in place to appropriately follow up with eye examinations or vision rehabilitative care,” Chung said when the initiative was announced.

The goal is to have a standardized TBI vision exam for all Army personnel with traumatic brain injury and to coordinate the care with other providers.

Dry eye syndrome

In another study presented at the ophthalmology meeting, researchers from the Miami VAMC and the University of Miami reviewed more than two million veterans’ medical records and found that about 20% of those with PTSD or depression also have dry eye syndrome, which disrupts the tear glands’ normal ability to keep the eyes moist.

Treatment options for the disorder, which can cause the eyes to feel scratchy or irritated, become overly-watery or secrete stringy mucus, include warm compresses, artificial tears and surgical insertion of plugs to retain tears.

While the risk of dry eye syndrome increases with age in the general U.S. population, affecting about 3.2 million women age 50 and older and 1.68 million men age 50 and older, it occurred much earlier in the veterans’ studies.

Study authors said they could not determine whether dry eye problems in veterans was directly caused by PTSD or depression, the medications given for these conditions or both.

“Many vets won’t mention that their eyes always feel gritty or seem to water for no reason, unless they’re asked,” said author Anat Galor, MD, assistant professor of clinical ophthalmology at the University of Miami. “Since dry eye can escalate and permanently damage vision if untreated, it’s crucial that health professionals who care for veterans with psychiatric diagnoses ask them about specific dry eye symptoms and refer them to an ophthalmologist if needed.”

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