WASHINGTON—Delays in the creation of joint Department of Veterans Affairs and Department of Defense Vision Centers of Excellence have legislators wondering what the cause is, whether it is a question of funding, direction or the will to act.

The National Defense Authorization Act of 2008 included directives to the two departments to establish a VCE in prevention, diagnosis, mitigation, treatment and rehabilitation of military eye injuries in order to coordinate care. The act also called for the creation of a VA and DoD eye injury registry. The NDAA was passed over a year ago; however, the VCE has yet to progress beyond the earliest planning stages, with very little money expended by either agency, though millions have been allocated.

Initial Excitement Tempered by Waiting

At a hearing of the House VA Subcommittee on Oversight and Investigations on March 17, legislators, veterans and veterans advocates told a tale of initial excitement followed by long months of waiting with minimal results.

“We started off with a lot of excitement. The ophthalmologists in the VA and the ophthalmologists in the military and the optometrists actually started planning and talking about what could be accomplished with these vision centers of excellence, right around the same time that the legislation was being brought forth in Congress,” explained Tom Zampieri, Ph.D., director of government relations for the Blind Veterans of America.

“In April a year ago we had a hearing in this very room. DoD witnesses came and talked about all the excitement of what they’re going to do and how they were going to do it, but nobody in writing said how much they were going to put into this,” Dr. Zampieri continued.

The directive in the NDAA calling for the vision center was one of several similar mandates in the law, which called for joint DoD and VA centers in traumatic brain injury and post-traumatic stress disorder. The reasoning was that events traumatic enough to cause TBI frequently led to PTSD. And vision problems are common in TBI patients, either due to brain injury or to penetrating eye trauma. The VCE was envisioned not as one single center, but a number of clinical sites—with the headquarters located at the National Naval Medical Center in Bethesda—that would act as hubs in a web of communication and cooperation between VA and DoD vision care programs.

“The VCE is not one big hospital; it’s a virtual center that will work across both the VA and DoD systems, finding thousands of these individuals who have come back with TBI vision dysfunction or penetrating eye trauma,” Dr. Zampieri said.

And while work has moved forward on joint TBI and PTSD centers, progress toward the realization of the VCE has been slow.

“We thought that the train would pull out together, that all of these centers would be established at the same time, that they would be equally funded, equally staffed, they would all deserve the same amount of resources and support,” Dr. Zampieri told legislators.

Little to Show

Currently, the only VCE staff that have been hired are its director and deputy director, Col. Donald Gagliano, MC, USA, and Claude Cowan, M.D. On the VA side, $2 million has been set aside for the eye trauma registry and $6.9 million for the VCE in FY 2009, with much of that money slated to hiring support staff. DoD has set aside $3 million in FY 2009 for creation of the VCE. However, according to DoD officials, only about $7,000 had been spent by the March 17 hearing.

Legislators wondered how so little could be spent considering the NDAA had been law for 14 months.

Jack Smith, M.D., DoD acting deputy secretary for clinical and program policy explained to committee members that, despite the lack of money spent, progress was being made, and that a lot of planning and groundwork had to be laid before the VCE could become a physical reality.

“Col. Gagliano and Dr. Cowan have already begun the challenging work of strategic planning, of establishing better linkages and communication between DoD and VA vision treatment and research assets, and started identifying their near-, intermediate- and long-term requirements for space and support for the center,” Dr. Smith said. “We do have computers for Dr. Galliano, and communication devices, and space available to get started. The director and deputy director have been spending time largely in strategic planning, working with directors for clinical research in eye injuries, and that hasn’t been very expensive so far. Certainly we expect those requirements to ramp up substantially as we get more staff on board.”

“The results of all your planning and your talk, and so on, really hasn’t been very fruitful,” declared Rep. Harry Mitchell, D-Ariz, whose sentiments were echoed by the rest of the subcommittee. Asked why efforts to partner on TBI and PTSD moved so much more quickly, Dr. Smith intimated that the amount of money thrown at the problem had a positive impact on the speed at which the programs were implemented. “Congress did appropriate over $900 million in funding for TBI and PTSD, which was very helpful in accelerating the process,” Dr. Smith said. Asked if he was saying that the VCE work is moving so slowly because of lack of funds, Dr. Smith said, “I didn’t mean to suggest

we had money problems. What I meant was that the requirements for establishing the Vision Centers of Excellence were different than the TBI and PTSD Centers of Excellence.”

“We already had centers of excellence in clinical care around the country,” he said. “The challenge here with the vision center of excellence was to link those together, and establish better communication and collaboration between those than has previously existed, along with the VA centers.”

Col. Gagliano admitted that the slow pace at which VA and DoD created avenues of communication was a systemic problem that needed to be solved.

“I totally concur with everything you are saying about what needs to happen. I will say that everybody who works in the system knows there is a problem. And it’s not a problem that’s just in vision care; it’s a deep problem. Vision care will actually be the leader, I believe, in solving this problem,” Col. Gagliano said. “I’ve been able to break many barriers in just the short time I’ve been working on that. I think we’re making progress and we’re continuing to make progress.”