2009/03/25 00:00:00
A need for adaptation
Figuring out the connection
Help is on the way
By Don Vaughan
On April 18, 2005, Petty Officer 1st Class Glenn Minney, USN-Ret., was standing atop Haditha Dam, a 10-story hydroelectric power plant in Haditha, Iraq, when his squad came under mortar attack. One round exploded just 30 feet from Minney, slamming him backward against a metal guardrail. Minney was knocked unconscious momentarily but appeared otherwise unharmed.
The next day, Minney experienced a headache and red, watery eyes. He was diagnosed with conjunctivitis, given medication, and sent back to work. But the condition didn’t clear up. In fact, it steadily grew worse, to the point where Minney lost sight in his right eye and had blurry vision in his left eye.
Minney was flown to an Army hospital in Balad, Iraq, where an ophthalmologist determined the retina in his right eye had become detached, and the retina in his left eye was starting to tear away. These injuries, Minney learned, were a direct result of the blast wave that had knocked him backward atop Haditha Dam.
Minney, who now lives in Frankfort, Ohio, is one of more than 1,100 American servicemembers to return from Afghanistan and Iraq with eye wounds requiring surgery. Vision, hearing, and vestibular disorders rapidly are becoming “signature injuries” of these conflicts, says Dr. James Orcutt, executive director of Surgical and Perioperative Care at the VA Puget Sound Health Care System in Seattle and national director for Ophthalmology for the VA.
A need for adaptation
The growing number of eye injuries is due, in part, to how operation Enduring Freedom and Iraqi Freedom (OEF and OIF, respectively) have been fought, notes Col. Robert A. Mazzoli, M.D., the Army surgeon general’s ophthalmology consultant and chief of Ophthalmology at Madigan Army Medical Center in Tacoma, Wash. In the early stages of these conflicts, most wounds were caused by small-arms fire, and eye injuries were relatively few. But as insurgents turned more and more to IEDs, the number of eye injuries increased. Today, IEDs are the leading cause of eye injuries in theater, Mazzoli confirms.
It didn’t help that early in both conflicts, servicemembers generally were reluctant to wear military combat eye protection (MCEP) because they claimed the shatterproof plastic goggles obstructed their vision. “Then all of a sudden the culture shifted,” says Mazzoli. “The senior leaders started making the troops wear eye protection, and we saw some decrease in that kind of eye injury.”
As the wars continue, the value of MCEP has become evident. Lt. Col. David Hilber, USA, program manager for the Tri-Service Vision Conservation and Readiness Program at the U.S. Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Grounds, Md., recently completed an Army-wide survey regarding the use, awareness, and effectiveness of eye protection. When asked whether their MCEP had protected their eyes from injury, 36 percent of those deployed in OEF and OIF said yes. “That’s a pretty significant finding,” says Hilber. “It dramatically demonstrates the value of MCEP in theater.”
But even the strongest MCEP offers little protection from the up-close, high-intensity mortar and IED blasts that are very common in Afghanistan and Iraq. When eyes are involved, medics do what they can. The wounded then are sent to a combat-support hospital where an ophthalmologist takes a look at them. If more extensive care is required, patients are evacuated to a Level-4 military hospital such as Landstuhl Regional Medical Center, Germany; Walter Reed Army Medical Center, Washington, D.C.; or the National Naval Medical Center in Bethesda, Md.
Figuring out the connection
Military doctors are well-trained in treating traditional eye wounds, but far less is known about vision problems related to traumatic brain injury (TBI), a common side effect of explosive blasts.
“TBI can result in damage to specific areas of the brain that manage visual and cognitive processes,” explains Gale Watson, acting national director, Blind Rehabilitation Services at the VA. “This damage can take many forms: disrupting the movements of the eyes and the ability of the eyes to focus smoothly at different distances; disrupting the interpretation of visual signals from the eyes to the brain [or] disrupting the ability to perceive and process the visual signals and causing visual field loss. In some cases the eyes may be perfectly healthy, but the person may be unable to process visual input, resulting in an inability to read print, for example.”
In a study of polytrauma patients published in the Journal of Rehabilitation Research and Development, Dr. Gregory L. Goodrich, et al, presented data from a patient sample suggesting self-reported vision complaints were common (74 percent) and confirming that visual impairment occurred in 38 percent of all TBI cases.
DoD and VA officials are quick to note, however, that the sampling in Goodrich’s study was relatively small, and its findings shouldn’t suggest all patients with TBI will experience visual impairment. “But it’s high enough that I think it’s coming to the [attention] of eye providers that we need to look into it more,” notes Orcutt. “The VA has funded research, and the DoD is doing research at Walter Reed [Army] Medical Center as well.”
The issue of TBI is so important that the VA and DoD cosponsored a symposium in San Antonio in December 2007 titled “Visual Consequences of Traumatic Brain Injury” that drew more than 500 attendees.
According to Mazzoli, DoD has increased screening for TBI-related visual impairment among servicemembers returning from Afghanistan and Iraq. “Everyone who comes back is screened for TBI,” he states. “The questions we are using [specifically] address visual symptoms, and that will kick off the referral and evaluation.”
At the 11,000-member Blinded Veterans Association (BVA), the issue of TBI-related vision impairment is of great concern. “Guys who were injured two years ago are starting to show up with [various] complications. It’s a delayed effect,” observes Thomas Zampieri, director of Government Relations. “The frustrating thing for the doctors I’ve spoken with is that they’ve never dealt with this before.”
Staff Sgt. Brian Pearce, USA-Ret., of Mechanicsville, Va., lost his vision and much of his hearing to a TBI. On Oct. 20, 2006, his squad was escorting a water tanker when the convoy was hit by an IED in Mushada, Iraq. Pearce was struck in the back of his skull by a piece of shrapnel, and during a craniotomy to remove the fragments, nerves related to his sight and hearing were severed.
“I have severe tunnel vision in both of my eyes and no peripheral vision at all,” says Pearce, who has become a patient advocate with the BVA. “My doctors tell me it won’t get any worse, but it won’t get any better either.”
Help is on the way
Pearce believes the military and the VA need to do more when it comes to researching the issue of TBI and assisting those who have related vision impairment. “They don’t want to admit that many eye injuries are related to traumatic brain injury,” Pearce says. “In my opinion, neither the military nor the VA are dedicating enough money or manpower to research how these eye problems are affecting people.”
Pearce isn’t the only veteran to express such a sentiment, and DoD and the VA are listening.
“Our blind-rehabilitation specialists have learned and continue to develop new techniques for delivering blind and vision rehabilitation that are unique to TBI,” says Watson. “Further, they are building interdisciplinary teams with the [Veterans’ Health Administration] polytrauma system of care to address the unique needs of this special population of patients and their families.”
Indeed, the VA’s blind-rehabilitation service is in the process of rolling out a “massively enhanced” continuum of care for the nation’s estimated 1 million visually impaired veterans, Watson adds. “This reorganization expands from a program centered on 10 existing blind rehabilitation centers [BRCs] to a continuum of care spread throughout the entire VA health care system,” she notes.
This expansion includes a commitment of $50 million in the next three years to establish a comprehensive nationwide rehabilitation system for veterans and active duty personnel with visual impairments. Under the plan, each of the VA’s 21 veterans integrated service networks will redesign its blind-rehabilitation care delivery system to provide services for veterans regardless of where they land on the visual-impairment spectrum.
The blind-rehabilitation service also has plans to add three more inpatient BRCs in the next five years. “BRCs are residential inpatient programs that provide comprehensive adjustment to blindness training, offering a variety of skill courses designed to help blinded veterans achieve their full potential in independence,” Watson explains. “These skill areas include orientation and mobility, communication skills, activities of daily living, manual skills, visual skills, and computer access training. Adjustment counseling for individuals and groups is provided by staff social workers and/or psychologists. Social and recreational activities that assist in adjustment are provided and encouraged.”
A short-term lodger program, known as VISOR (Visual Impairment Services Outpatient Rehabilitation) also is available for veterans whose need for rehabilitation can be met with a shorter program and who do not need medical support. Currently, VISOR programs are available in VA medical centers in Lebanon, Pa., and West Haven, Conn.
Additionally, says Watson, the blind-rehabilitation service is adding 35 more blind rehabilitation outpatient specialists (BROS) to the 35 currently assigned to medical centers across the U.S. BROS instructors have advanced technical knowledge and competencies in at least two disciplines that include orientation and mobility and living, manual, and visual skills.
Looking to the future, the blind-rehabilitation service is establishing a nationwide vision rehabilitation system that will ensure veterans with vision impairment get appropriate rehabilitative care and technology when that care is first needed and in a setting that is convenient for the patient, Watson says.
“In our new programs we want to provide services at the earliest point of vision loss to maximize independence and increase quality of living,” she explains. “This need for early intervention, combined with the expansion of services to serve the newest veterans from OEF [and] OIF, were the motivation for VA’s fast-tracked reorganization of its blind-rehabilitation services.”
Copyright Don Vaughan and Military Officers Association of America. All rights reserved.
