GREGORY L. GOODRICH, PH.D.
SUPERVISORY RESEARCH PSYCHOLOGIST AND
COORDINATOR, OPTOMETRY RESEARCH FELLOWSHIP PROGRAM
VETERANS AFFAIRS PALO ALTO HEALTH CARE SYSTEM
HOUSE COMMITTEE ON VETERANS AFFAIRS
SUBCOMMITTEE ON OVERSIGHT & INVESTIGATION
April 2, 2008
Chairman Mitchell, Ranking Member Brown-Waite, and members of the Committee, thank you for the opportunity to testify. I am joined today by Dr. Glenn Cockerham, Chief of Ophthalmology at the VA Palo Alto Health Care System. We are here today to discuss our research on vision issues and traumatic brain injury (TBI). This research was conducted at the Palo Alto Polytrauma Rehabilitation Center (PRC) and Polytrauma Network Site (PNS) on a samples of just over 100 patients, including both veterans and active duty service members. This is preliminary research and much more work needs to be done to determine conclusively the risks for this population and best clinical steps forward. My research has focused on two groups: first, veterans and service members receiving inpatient care at the Palo Alto PRC who have sustained visual impairments associated with life-threatening polytrauma injuries; and second, outpatients receiving care at the Palo Alto PNS who have sustained visual dysfunctions associated with mild TBI.
While the inpatient and outpatient groups seem far apart in terms of the severity of their injuries, they have two common factors: the most common cause of injury to both groups is a blast event, and both groups have sustained a traumatic brain injury ( TBI), although to varying levels of severity. Our preliminary research suggests both groups have rates of blindness, visual impairment, or visual dysfunction that appear to occur at rates higher than in prior conflicts.
During the Vietnam War eye injuries accounted for between 5% and 10% of all injuries. In the Persian Gulf War, eye injuries accounted for approximately 13% of all casualties. The precise incidence of eye injuries occurring in Operation Enduring Freedom ( OEF) and Operation Iraqi Freedom ( OIF) are currently unknown. Preliminary data suggests these rates are at least comparable to the Persian Gulf War. Our research suggests that, in addition to injuries to the eye, damage to the visual system within the brain can create significant functional impairments for many troops and veterans.
In analyzing data from our early studies, exposure to a blast seems to be most closely associated with vision dysfunctions in the populations we have studied in Palo Alto. Among the 108 patients studied, those who have injuries stemming from a blast event are about twice as likely to have a severe visual impairment, including blindness, as are those whose injuries are caused by all other events. Overall 26% of this population is blind or has a best-corrected visual acuity of 20/100 or less or a very severe visual field loss. In other work done by Dr. Cockerham, looking specifically at veterans in the PRC with TBI caused by combat blast, significant abnormalities in visual function were found, despite normal or near-normal visual acuity by conventional testing. Rigorous eye examinations by ophthalmologists, including neuro-ophthalmology, detected significant damage to eye structures including cornea, retina, and optic nerve. In many instances patients were asymptomatic and unaware of underlying eye damage. In other patients in this population, problems such as double vision, inability to effectively track moving objects, and other visual dysfunctions are present. The consequence of these visual impairments and dysfunctions potentially impede independent functioning and may contribute to a reduced quality of life. Patients with traumatic eye injuries risk development of sight-threatening complications later in life and will require ongoing eye care. In addition, these visual impairments and dysfunctions can complicate other rehabilitation efforts and impair the individual's ability to pursue education, obtain employment, and social functioning. Most, if not all, of these conditions usually respond to therapy and rehabilitation, and the resulting disability can be minimized. VA's Blind Rehabilitation Service provides ample evidence of the effectiveness of vision rehabilitation treatment.
Our clinical observations suggest addressing these visual issues during the rehabilitation process can facilitate the rehabilitative efforts of other members of the rehabilitation team and can provide valuable information that may help families better understand the problems facing their loved ones. VA's Polytrauma Rehabilitation Centers recognized the importance of early intervention for visual impairment and structured interdisciplinary teams to include blind rehabilitation specialists as team members. In addition, the need for neuro-ophthalmology services was identified as a key consultative service.
Our preliminary research also suggests blast events may have significant negative effects on visual function, even when overall physical injury appears to be minor. Since early 2007, we have studied outpatients at the Palo Alto PNS clinic. These patients have been diagnosed with mild TBI and often have PTSD, persistent pain, and hearing impairment. We have gathered self-reported data and conducted visual screenings on 125 OEF/ OIF patients served by the PNS clinic. Examination data suggests severe visual impairment is present in less than 2% of this population. However, data from optometric screenings suggest that as many as 40% of these patients have one or more binocular vision dysfunction symptoms. These binocular dysfunctions often manifest as an inability of the two eyes to effectively function together and may result in double vision eye fatigue, and other visual conditions which impair everyday visual function. When analyzing the self-reported conditions, more than 60% of these patients indicated an inability to perform sustained reading, and three out of four patients reported a vision complaint ranging from light sensitivity to eye strain and double vision. It is important to stress this is self-reported data and we cannot conclude the cause of these complaints.
In conclusion, I wish to emphasize our testimony is based upon findings from early studies with relatively small and selected population samples - this data is not definitive and conclusions should not be drawn from it. Instead, additional studies are needed and are ongoing. Uncovering these visual injuries and developing effective treatments has involved a collaborative effort utilizing the expertise and resources of many disciplines. VA's experience with vision related injury and impairment supports the claim that these patients can be effectively treated. Thank you again, Mr. Chairman, for inviting me today. At this time my colleague and I will answer any questions that you or other members may have.