Transcript Visual Conditions in Veterans Followed at a VA Polytrauma

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
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.
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.
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.
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
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.
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.
Polytrauma Rehabilitation Centers
(PRCs)
provide acute inpatient medical and rehabilitation care
• Minneapolis, MN
• Palo Alto, CA
• Richmond, VA
• Tampa, FL
• San Antonio, TX
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
Polytrauma Support Clinic
Teams (PSCTs)
Polytrauma Points of Contact
(PPOCs)
130 Nationwide
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support by managing those who are medically stable
provide regular follow-up visits
respond to new programs
coordinate with the Polytrauma Network Sites
Vision Care of OEF / OIF Veterans at
the Hines VA Hospital Polytrauma
Network Site (PNS)
Vision Screening: any
positive findings
Symptoms & concerns
Visual Acuity
Visual Field
oScanning
Reading ability
Eye Exam
Ocular health
Visual Field
Binocular Vision / Ocular
motor function
Spatial orientation / neglect
Special Testing as indicated
BROS Case
Management
Visual Impairment Services Team
(VIST) Coordinator
Blind Rehabilitation Center
Low Vision Rehabilitation Clinic
TBI mandated screening
• Exposure
– Blasts
– Wounds
– Falls
– MVA
– Amnesia
– LOC
• Symptoms
• Neurobehavioral inventory
TBI mandated screening
• Exposure
• Symptoms
– Poor memory
– Balance / dizziness
– Photophobia
– Irritability
– HA
– In (hypo) somnia
• Neurobehavioral inventory
TBI mandated screening
• Exposure
• Symptoms
• Neurobehavioral inventory
– 5 point scale
– Extent to which symptoms have disturbed
them since trauma
TBI mandated screening
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Neurobehavioral inventory
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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, can’t pay attention, easily distracted
Forgetfulness, can’t remember things
Difficulty making decisions
Slowed thinking, difficulty getting organized, can’t finish things
Fatigue, loss of energy, getting tired easily
Difficulty falling or staying asleep
Feeling anxious or tense
Feeling depressed or sad
Irritability, easily annoyed
Poor frustration tolerance, feeling easily overwhelmed by things
Visual Function
Polytrauma
• Goodrich et al from Palo Alto Polytrauma
Rehabilitation Center (Optometry Dec 04 – Nov 06)
– 50 records TBI
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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)
>2x prevalence visual sxs with blast injury
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
Visual Function
Polytrauma
• Lew et al from Palo Alto PRC
• 70% oculomotor
• Binocular vision problems
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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)
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.
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
Basic Visual assessment
• Polytrauma
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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
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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%)
Symptoms TBI
Visual symptoms
No.
(%)
*Feeling dizzy
40/88
(45)
*Loss of Balance
35/88
(40)
*Poor coordination
36/88
(41)
*Headaches
75/88
(85)
*Nausea
30/88
(34)
*Blur/trouble seeing
64/88
(73)
*Light sensitivity
61/88
(69)
**Difficulty reading
12/78
(15)
**Difficulty reading since injury
6/78
( 8)
**Eye pain
6/78
( 8)
*Poor Concentration
67/88
(76)
*Forgetfulness
70/88
(80)
***Other body pain
17/88
(19)
Other symptoms
*Symptoms of moderate or greater intensity on the Neurobehavioral Symptom Inventory
** Symptoms reported on Polytrauma BROS screening
***Problems reported in the electronic medical record
TBI / Polytrauma receiving eye
examinations
Diagnoses
TBI
Polytrauma
Orbit/eye trauma
2/36
(6)
11/53
(21)
Optic neuropathy
2/36
(6)
3/53
(6)
Visual field loss
6/36 (17)
12/53
(23)
Cranial nerve disorder
0 (0)
0/53
(0)
Strabismus
2 /36
(6)
2/53
(4)
Accommodative disorder
17/36 (47)
16/53
(30)
Convergence disorder
10/36 (28)
7/53
(13)
Binocular Vision or Reading Problems
Pursuits/saccade disorders
2/36
(6)
5/53
(9)
Fixation disorders
0/36
(0)
3/53
(6)
Diplopia
3/36
(8)
8/53
(15)
Suppression
0/36
(0)
0/53
(0)
18/36 (50)
31/53
(58)
Reading
52% polytrauma & 42% TBI eye exams by Optometry / Ophthalmology
Visual treatments
Polytrauma or TBI
Treatment
TBI
Polytrauma
Ocular surgery
0/36 (0)
2/52
(4)
Contact Lenses
1/36 (3)
1/52
(2)
Spectacles
28/36 (78)
33/52 (63)
Vision Therapy
5/36 (14)
4/52
Blind Rehabilitation
0/36 (0)
5/52 (10)
Low Vision Rehabilitation
1/36 (3)
1/52
(8)
(2)
Other conditions Hines patients
TBI with
diagnoses of
– PTSD (58%)
– depression
(26%)
– depression &
PTSD (40%)
Polytrauma with
diagnoses of
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TBI (46%)
PTSD (50%)
depression (32%)
depression &
PTSD (18%)
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.
What we’ve 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.
What we’ve 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
What we’ve 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.
Reported Binocular Vision Problems:
VA 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
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.
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
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.
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.
References
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Thank you
To
Those who have served to defend our
freedom !!!!