Visual Conditions in Veterans Followed at a VA Polytrauma Network Site

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Visual Conditions in Veterans Followed at a VA
Polytrauma Network Site

• Thomas R Stelmack, O.D.1,3,4, Theresa Firth,
  O.D.2
• Dennise VanKoevering, M.A.2, Steve Rinne2, MA,
  Barbara Hunt2, Ph.D., Joan A Stelmack, O.D.,
  MPH2,3,4

1 Jesse Brown VAMC, 2 Hines VAH, 3 Illinois
College of Optometry 4 University of Illinois
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War

• Brain and eye injuries are well recognized
  consequences of war. The etiology of these
  injuries reflects the wounding patterns of the
  war.
• Over 1.5 million U.S. military personnel have
  been deployed to Iraq or Afghanistan since
  military operations were initiated in 2001.
• Service members from Operation Enduring Freedom
  (OEF) and Operation Iraqi Freedom (OIF) have
  survived injuries that would have been fatal in
  previous wars because of speedy evacuation,
  timely acute trauma care and improvements in
  protective body armor.

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Blast injuries

• are the most common wound in the current
  conflicts.
• soldiers may be exposed to multiple blast waves
  during deployment.
• account for two thirds of army war zone
  evacuations.

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Blast wave injuries occur from

• changes in atmospheric pressure (overpressures)
• collision with objects carried by the blast wave
• personnel set in motion hitting a stationary
  object.

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Traumatic Brain Injury

• primary neuropathology of TBI diffuse axonal
  injury caused by shearing forces that disrupt
  axons and small vessels during sudden
  deceleration
• focal brain edema
• anoxia
• hematoma

Sandia Corp brain-model shear 1 msec red 30 blue
1 atmospheres
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TBI

• The news media has also reported a high incidence
  of traumatic brain injury (TBI) caused by blasts
  noting rates as high as 18 based on interviews
  with military officials
• The provision of medical care and rehabilitation
  for those soldiers injured in the current
  conflict is a major priority for the Department
  of Veterans Affairs, Veterans Health
  Administration (VHA).
• VHA created an infrastructure referred to as the
  Polytrauma System of Care to guide medical care
  and rehabilitation of injured veterans and active
  duty service members.

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VA System

• Polytrauma Rehabilitation Centers (PRCs)
• Regional Polytrauma Network Sites (PNS)
• Polytrauma Support Clinic Teams
  (PSCTs)Polytrauma Points of Contact (PPOCs)
• Mandates screening all OEF / OIF participants for
  TBI.

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Polytrauma Rehabilitation Centers (PRCs)
provide acute inpatient medical and
rehabilitation care

• Minneapolis, MN
• Palo Alto, CA

• Richmond, VA
• Tampa, FL
• San Antonio, TX

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Regional Polytrauma Network Sites (PNS)

• post-acute sequelae of polytrauma
• interdisciplinary evaluation
• care coordination for inpatient and outpatient
  rehabilitation
• day programs
• transitional rehabilitation

21 Centers distributed nationwide
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Polytrauma Support Clinic Teams
(PSCTs)Polytrauma Points of Contact (PPOCs)
130 Nationwide

• support by managing those who are medically
  stable
• provide regular follow-up visits
• respond to new programs
• coordinate with the Polytrauma Network Sites

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TBI mandated screening

• Exposure
• Blasts
• Wounds
• Falls
• MVA
• Amnesia
• LOC
• Symptoms
• Neurobehavioral inventory

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TBI mandated screening

• Exposure
• Symptoms
• Poor memory
• Balance / dizziness
• Photophobia
• Irritability
• HA
• In (hypo) somnia
• Neurobehavioral inventory

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TBI mandated screening

• Exposure
• Symptoms
• Neurobehavioral inventory
• 5 point scale
• Extent to which symptoms have disturbed them
  since trauma

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TBI mandated screening

• Neurobehavioral inventory
• Feeling dizzy
• Loss of balance
• Poor coordination, clumsy
• Headaches
• Nausea
• Vision problems, blurring, trouble seeing
• Sensitivity to light
• Hearing difficulty
• Sensitivity to noise
• Numbness or tingling on parts of my body
• Changes in taste or smell
• Loss of appetite or increased appetite
• Poor concentration, cant pay attention, easily
  distracted
• Forgetfulness, cant remember things
• Difficulty making decisions
• Slowed thinking, difficulty getting organized,
  cant finish things
• Fatigue, loss of energy, getting tired easily

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Visual Function Polytrauma

• Goodrich et al from Palo Alto Polytrauma
  Rehabilitation Center (Optometry Dec 04 Nov 06)
• 50 records TBI
• 50 explosive devices (IED, RPG, mortars etc)
• 44 penetrating injuries
• 74 self reported visual complaints
• 14 legal blindness
• 10 visual impairment (20/63-20/100)
• gt2x prevalence visual sxs with blast injury

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Visual Function Polytrauma

• Lew et al from Palo Alto PRC (interdisciplinary
  team consisting of psychology, physical and
  rehabilitation medicine physicians,
  neuropsychology, social worker, occupational and
  physical therapy, speech-language therapy and
  optometry screening Jul 06 - Feb 07) 62 records
• Most had (near) normal VF / VA
• 75 visual sxs
• 59 photosensitivity
• 84 reading difficulty
• 70 reading difficulty post injury

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Visual Function Polytrauma

• Lew et al from Palo Alto PRC
• 70 oculomotor
• Binocular vision problems
• 46 convergence
• 25 pursuits / saccades (different neuro control)
• 21 accommodation
• 11 strabismus
• 5 fixational / strabismus
• Other
• 66 Visual disturbance
• 42 balance
• 40 dizziness (? Vertigo vs light headed)

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Methods

• A retrospective review of VA electronic medical
  records was conducted to identify patients
  flagged as POLYTRAUMA and those with a confirmed
  diagnosis of TBI who were seen at the Hines PNS.
• 103 patients with POLYTRAUMA seen in clinics from
  October, 2005 March, 2008
• 88 patients with TBI seen in the TBI Clinic from
  December, 2007 March, 2008. The level of TBI
  was not routinely available in the electronic
  medical record.

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Demographics

• Polytrauma
• 96 male
• 30 years mean age
• 85 OEF / OIF
• 77 injury in theatre
• 23 US or other countries
• 46 TBI

• TBI
• 92 male
• 31 years mean age
• 88 OEF / OIF injury in theatre
• 95 non penetrating

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Basic Visual assessment

• Polytrauma
• Mean visual acuity was .04 log MAR (Snellen
  Equivalent 20/20)
• bilateral no light perception (3)
• legally blind (4)
• visually impaired 1 (VA less than 20/63 to
  20/100)
• self-reported visual symptoms (76 )
• TBI
• mean .04 log MAR (20/20 Snellen Equivalent)
• legally blind (1)
• visually impaired (visual acuity less than 20/63
  to 20/100) (0)
• self-reported visual symptoms (67)

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Symptoms TBI
Symptoms of moderate or greater intensity on the
Neurobehavioral Symptom Inventory Symptoms
reported on Polytrauma BROS screening Problems
reported in the electronic medical record
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TBI / Polytrauma receiving eye examinations
52 polytrauma 42 TBI eye exams by Optometry /
Ophthalmology
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Visual treatments Polytrauma or TBI
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Other conditions Hines patients

• TBI with
• diagnoses of
• PTSD (58)
• depression (26)
• depression PTSD (40)

• Polytrauma with diagnoses of
• TBI (46)
• PTSD (50)
• depression (32)
• depression PTSD (18)

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Center differences in severity

• Patients seen at the Palo Alto Polytrauma
  Rehabilitation Center were more likely to have
  vision loss from moderate to total blindness as a
  result of visual acuity, visual field loss, and
  or bilateral enucleation (38) compared to
  patients at the Hines PNS (8 of patients with
  TBI and 18 of patients with polytrauma).
• Patients admitted to the PRCs are severely
  injured and require acute care and rehabilitation
  in a hospital setting.

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What weve learned What is needed

• Hines VA Hospital and the Palo Alto Health Care
  System are both Polytrauma Network Sites.
• A high percentage of patients self-reported
  visual symptoms at both sites
• 70 Hines TBI patients, 78 Hines polytrauma
  patients
• 75 Palo Alto patients
• Binocular vision screening
• Palo Alto indicated that oculomotor problems were
  found in 70 of patients screened by optometry
• Hines found these problems in 83 of patients
  with TBI and 70 of patients with polytrauma who
  received an eye examination.
• These statistics emphasize the importance of
  including vision screening and examinations
  within the Polytrauma System of Care.

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What weve learned What is needed

• VHA does not have a national directive that
  establishes a protocol for OIE/OEF eye
  examinations
• a VA directive establishing a protocol for eye
  examinations, screenings and reporting is needed
  to facilitate research on the incidence, natural
  course of recovery and outcomes of brain injury
  treatment in soldiers returning from the war
• disciplines comprising the Polytrauma team,
  vision screening procedures and eye examination
  protocols vary making it difficult to combine or
  compare data from different sites

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What weve learned What is needed

• A VA TBI workgroup was formed for optometrists to
  share information and experiences working with
  OEF/OIF veterans during regularly scheduled
  conference calls.

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Reported Binocular Vision ProblemsVA vs non
military TBI

• Ciuffreda et al. reported in his retrospective
  analysis of 160 patient records that 90 of
  patients with TBI had oculomotor dysfunction
• accommodative (56.3)
• vergence deficits (56.3)
• Kowal reported from a series of 161 closed head
  injury patients
• 16 had poor accommodation
• 14 convergence insufficiency
• 19 pseudomyopia

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Reading difficulty co-morbidities concentration
memory

• Palo Alto
• 84 self reported reading difficulty

• Hines
• 50 self reported reading difficulty (TBI) 25
  (polytrauma)
• exam 50 TBI 40 polytrauma had reading problems

Reading ability has concentration and memory
components. Despite unknown pre morbid
conditions, Hines TBI self reported 80 memory
76 concentration difficulty which is
consistent with known TBI data.
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Natural course success of treatment

• Civilian population
• 85 90 attention memory problems associated
  with neural damage from mild TBI resolve within
  weeks to months.
• Remainder persist for year and are associated
  with compensation / medical disability.
• Military population
• Statistics may not apply given frequent
  association with PTSD.
• 43.9 OEF / OIF reporting LOC had TBI had sxs
  sufficient for PTSD dx

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Natural course success of treatment

• AMA study (PTSD, depression etc) mental illness
• 19.1 OEF / OIF
• 11.3 Afghanistan
• Depression etc known to exacerbate attention
  memory.
• Natural vs. treated course will be difficult to
  follow as many opt out of treatment for
  convergence / accommodative disorders.

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VA benefits

• All OIF/ OEF veterans serving in the armed
  forces, Reserves or National Guard are entitled
  to 5 years of free care for most conditions
  through the VA.
• Veterans with service-related conditions must
  file a claim to have their diagnoses
  service-connected in order to obtain lifelong
  medical care from the VA.

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• Thank you
• To
• Those who have served to defend our freedom !!!!