Gregory L. Goodrich

Program development and defining characteristics of returning military in a VA Polytrauma Network Site

The conflicts in Iraq and Afghanistan have resulted in a new generation of combat survivors with complex physical injuries and emotional trauma. This article reports the initial implementation of the Polytrauma Network Site (PNS) clinic, which is a key component of the Department of Veterans Affairs (VA) Polytrauma System of Care and serves military personnel returning from combat. The PNS clinic in Palo Alto, California, is described to demonstrate the VA healthcare systems evolving effort to meet the clinical needs of this population. We summarize the following features of this interdisciplinary program: (1) sequential assessment, from initial traumatic brain injury screening throughout our catchment area to evaluation by the PNS clinic team, and (2) clinical evaluation results for the first 62 clinic patients. In summary, this population shows a high prevalence of postconcussion symptoms, posttraumatic stress, poor cognitive performance, head and back pain, auditory and visual symptoms, and problems with dizziness or balance. An anonymous patient feedback survey, which we used to fine-tune the clinic process, reflected high satisfaction with this new program. We hope that the lessons learned at one site will enhance the identification and treatment of veterans with polytrauma across the country.

Visual impairment and dysfunction in combat-injured servicemembers with traumatic brain injury.

Purpose. The purpose of this study was to determine the frequencies of visual impairment and dysfunction among combat-injured Polytrauma Rehabilitation Center (PRC) inpatient and Polytrauma Network Site (PNS) outpatient military personnel with traumatic brain injury (TBI). Methods. A retrospective analysis of data from vision screenings of 68 PRC-inpatients with moderate to severe levels of TBI and 124 PNS-outpatients with mild TBI at the VA Palo Alto Health Care System was conducted. Results. Eighty-four percent of PRC-inpatients and 90% of PNS-outpatients had TBIs associated with a blast event. The majority of patients in both the PRC and PNS populations had visual acuities of 20/60 or better (77.8% PRC, 98.4% PNS). Visual dysfunctions (e.g., convergence, accommodative, and oculomotor dysfunction) were common in both PRC and PNS populations. In the PRC-inpatient population, acuity loss of 20/100 to no light perception (13%) and visual field defects (32.3%) were found. In the PNS-outpatient population, acuity loss of 20/100 to no light perception (1.6%) and visual field defects (3.2%) were infrequently found. In both the PRC and PNS populations, visual field defects were more often associated with blast than non-blast events. Conclusions. Blast events were the most frequent mechanism of injury associated with TBI in combat-injured servicemembers. The vision findings suggest that combat troops exposed to blast with a resulting mild TBI are at risk for visual dysfunction, and combat troops with polytrauma injuries are at risk for visual dysfunction and/or visual impairment. The visual consequences of such injuries necessitate further study and support the need for appropriate evaluation and treatment in all severities of TBI.

Visual function in patients of a polytrauma rehabilitation center: A descriptive study.

Little is known about the visual function deficits associated with polytrauma injury. In this retrospective descriptive study, we examined the records of a clinic established to assess visual function in patients experiencing deployment-related polytrauma. We describe the clinical findings and present a vision examination protocol that may be useful for screening polytrauma patients in other settings. Data from our sample suggested that self-reported vision complaints were common (74%) and confirmed that visual impairment occurred in 38% of all cases. When examining the mechanism of injury, we found that polytrauma due to blast injuries appeared to more than double the risk of visual impairment compared with all other polytrauma causes (i.e., motor vehicle accidents, gunshot and/or shrapnel, assault, falls, or anoxia). The rate of visual impairment in blast-related injury was 52% compared with 20% for all other sources of injury. Visual complaints and impairments were common in the polytrauma patients studied. This finding suggests that comprehensive eye examinations should be routinely administered, particularly when the mechanism of injury involves a blast.

Mechanisms of TBI and Visual Consequences in Military and Veteran Populations

Purpose Blast-related (BR) traumatic brain injuries (TBIs) occur secondary to explosive blasts. Blast-related TBIs can be caused by the blast wave itself or by direct head trauma caused by events surrounding the blast. Non–blast-related (NBR) TBIs are caused by direct head trauma. Recent evidence shows that TBIs are associated with vision problems, particularly binocular system problems. The purpose of this study was to determine if similar types and amounts of vision problems are present in patients with BR TBIs and NBR TBIs. Methods A retrospective analysis of eye examination records of 50 NBR TBI and 50 BR TBI patients was conducted. Frequencies of visual symptoms and abnormal vision function measurements were computed and compared for the two patient groups. Results More than 65% of NRB TBI and BR TBI patients reported vision problems. Reading complaints were found in approximately 50% of the patients. Light sensitivity was reported significantly more often in BR TBI patients (67%) than in NBR TBI patients (33%) (p < 0.01). Saccadic dysfunction was measured more often in NBR TBI patients (85%) than in BR TBI patients (58%) (p < 0.01). High rates of accommodative dysfunction and convergence insufficiency were also found, but the group differences were not significant. Strabismus, pursuit abnormalities, fixation defects, and visual field defects were also common in both groups. Conclusions For most findings, the mechanism of injury (NBR vs. BR) did not result in different frequencies or types of visual dysfunction. The reasons for finding higher frequencies of light sensitivity in the BR TBI group and saccadic dysfunction in the NBR TBI group are unknown, and further research is needed. Overall, the rates of vision complaints and oculomotor defects were high in both groups, indicating a need for a thorough eye examination for any patient with a history of TBI.

Visual function, traumatic brain injury, and posttraumatic stress disorder

Traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) are signature injuries of the Iraq and Afghanistan conflicts. The conditions can be comorbid and have overlapping signs and symptoms, making it difficult to diagnose and treat each. TBI is associated with numerous changes in vision function, but vision problems secondary to PTSD have not been documented. To address this shortcoming, we reviewed the medical records of 100 patients with a history of TBI, noting PTSD diagnoses, visual symptoms, vision function abnormalities, and medications with visual side effects. Forty-one patients had PTSD and 59 did not. High rates of binocular vision and oculomotor function deficits were measured in patients with a history of TBI, but no significant differences between patients with or without PTSD were evident. However, compared to patients without PTSD, patients with PTSD had more self-reported visual symptoms in all four assessments and the complaint rates were significantly higher for light sensitivity and reading problems. Together, these findings may be beneficial in understanding vision problems in patients with TBI and PTSD as comorbid conditions compared with those with TBI alone.

Development of a mild traumatic brain injury-specific vision screening protocol: A Delphi study

Although traumatic brain injury (TBI) can happen to anyone at any time, the wars in Iraq and Afghanistan have brought it renewed attention. Fortunately, most cases of TBI from the recent conflicts are mild TBI (mTBI). Still, many physical, psychological, and social problems are associated with mTBI. Among the difficulties encountered are oculomotor and vision problems, many of which can impede daily activities such as reading. Therefore, correct diagnosis and treatment of these mTBI-related vision problems is an important part of patient recovery. Numerous eye care providers in the Department of Veterans Affairs, in military settings, and in civilian practices specialize and are proficient in examining patients who have a history of TBI. However, many do not have this level of experience working with and treating patients with mTBI. Recognizing this, we used a modified Delphi method to derive expert opinions from a panel of 16 optometrists concerning visual examination of the patient with mTBI. This process resulted in a clinical tool containing 17 history questions and 7 examination procedures. This tool provides a set of clinical guidelines that can be used as desired by any eye care provider either as a screening tool or adjunct to a full eye examination when seeing a patient with a history of mTBI. The goal of this process was to provide optimal and uniform vision care for the patient with mTBI.

Goldilocks and the three training models: A comparison of three models of low vision reading training on reading efficiency

The purpose of the study was to determine if there were performance differences for subjects with age-related maculopathy (ARM) reading with optical devices or closed circuit televisions (CCTVs) based upon amount of training. Performance was measured as reading speed and duration. METHODS In the first experiment ninety subjects participated in an experiment comparing two models of training: a traditional model (TM) consisting of 10 optical device training sessions and 15 CCTV training sessions was compared to a shorter training model termed the empirical model (EM) derived from a post hoc review of training records. The EM consisted of five optical device training sessions with five practice sessions and seven CCTV trainings sessions with eight practice sessions. In the second experiment the EM was compared to a training model used by many private agencies/clinics termed the private sector model (PS) that consisted of one optical device training session or two CCTV training sessions. RESULTS Reading speed...

The low vision timeline: An interactive history

Gordon E. Legge, PhD University of Minnesota This paper presents an edited, timeline chronology of the important developments in the field of low vision. The history of any discipline is inherently worth recording, although we recognize that what is history to one person may be trivia to another. To help preserve the history of low vision we have developed a timeline of events we consider to be significant in the development of the field. Since our viewpoint may well be limited in scope, or at odds with the views of others, we have chosen to present the timeline as an interactive document. The timeline is brought to each International Conference on Low Vision where an opportunity is provided for attendees to edit the timeline. The current timeline was edited following the Vision 2002 conference in Sweden and again following the Vision 2005 Conference in London. It has been further edited following the Vision 2008 conference held in Montreal, Canada. We will continue this process at the 2011 conference in Kuala Lumpur, Malaysia. In the interim we offer the timeline as an open access document in the hopes that it will provide historical information and an expanded opportunity for input. Those seeking to add information or contest the inclusion of items may do so by emailing detailed comments to the corresponding authors (addresses are supplied at the end of this document). Please include source documentation or URL addresses where appropriate. Thank you. We hope you find this document informative and thought provoking.

Visual Dysfunctions at Different Stages After Blast and Non-blast Mild Traumatic Brain Injury.

PURPOSE To assess the prevalence of visual dysfunctions and associated symptoms in war fighters at different stages after non-blast- or blast-induced mild traumatic brain injury (mTBI). METHODS A comprehensive retrospective review of the electronic health records of 500 U.S. military personnel with a diagnosis of deployment-related mTBI who received eye care at the Landstuhl Regional Medical Center. For analysis, the data were grouped by mechanism of injury, and each group was further divided in three subgroups based on the number of days between injury and initial eye examination. RESULTS The data showed a high frequency of visual symptoms and visual dysfunctions. However, the prevalence of visual symptoms and visual dysfunctions did not differ significantly between mechanism of injury and postinjury stage, except for eye pain and diplopia. Among visual symptoms, binocular dysfunctions were more common, including higher near vertical phoria, reduced negative fusional vergence break at near, receded near point of convergence, decreased stereoacuity, and reduced positive relative accommodation. CONCLUSIONS The lack of difference in terms of visual sequelae between subgroups (blast vs. nonblast) suggests that research addressing the assessment and management of mTBI visual sequelae resulting from civilian nonblast events is relevant to military personnel where combat injury results primarily from a blast event.

A trend analysis of the low-vision literature

An account is given of the design and compilation of a freely-available database, updated on a monthly schedule, listing journals, books, conference proceedings and online publications concerned with any and every aspect of low vision. Specific topic areas can be located by means of keywords and through other bibliographical details such as the author’s name, year of publication, etc. The authors present a summary historical analysis revealing that there has been an unprecedented rise over the last few decades in the number and diversity of journals and other literature sources addressing issues to do with low vision. Among the opportunities provided by the database are searches to ascertain not only what is currently being practiced and researched but also to identify the changes in the priorities being given to the multitude of topics of interest to optometrists, ophthalmologists, paediatricians, psychologists, educators, rehabilitation practitioners, epidemiologists, gerontologists and other professional workers.