Focus On Vision Problems For Troops With Brain Injuries

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Hartford Courant
April 20, 2008
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Doctor Tries To Bring Troops' Vision Damage Into Traumatic Brain Injury Treatment Fold
By Lisa Chedekel, Courant Staff Writer
Army Staff Sgt. Brian Pearce came home from Iraq with 20/20 vision — and a diagnosis of legal blindness.
It has taken Pearce much of the last 18 months, since he arrived home on a stretcher with severe injuries from the blast of an improvised explosive device, to make sense of that paradox.
He didn't fully understand the visual consequences of his traumatic brain injury until he landed at the West Haven veterans hospital last fall, and Dr. Kara Gagnon, director of low vision optometry, laid out the problem:
"Your eyes are healthy. It's your brain that won't allow your eyes to work the right way."
Gagnon has spent the last four years trying to draw attention to the visual impairments associated with traumatic brain injury, or TBI, and Pearce is one of her success stories.
During six weeks of intensive therapy in Gagnon's clinic, Pearce, who lives in Virginia with his wife and their two young children, learned how to navigate a disjointed visual field and to compensate for his loss of peripheral vision.
"They didn't make me medically better," said Pearce, whose optic nerves were damaged when shrapnel penetrated his skull and the force of the blast jarred his brain, "but they made me functionally better."
Pearce's experience, however, is not the norm. Troops diagnosed with TBI or exposed to explosions are not routinely referred by the military or the VA for evaluations by vision specialists — something Gagnon is working to change.
Last winter, Gagnon helped to pull together military and Department of Veterans Affairs clinicians for a national summit on the visual consequences of TBI, and she is now planning a second conference in June. At the West Haven hospital, she has started a special vision clinic for veterans who have suffered brain trauma.
Eventually, she hopes, every service member who was in close proximity to an IED blast will receive a full evaluation for visual function.
"I really had to shake the bushes to get people to pay attention to the vision thing," Gagnon said. "Everyone was talking about PTSD, memory loss, hearing loss, other impairments. The visual symptoms can be very subtle — they can be easily passed over."
"The danger is, these young men and women will go back to work or school and they'll have trouble reading and concentrating," she said. "They're going to assume they have a disability that can't be addressed. I don't want to see that happen."
Gagnon's hurry-up efforts to bring vision specialists into the TBI-treatment fold come as the VA and military are still figuring out the best way to screen and treat brain injuries.
A recent congressional report by the Government Accountability Office found that while the VA put in place a screening protocol last year to identify veterans who might have mild TBI, it has not yet evaluated how effective that screening is.
The report also noted that there currently are no "objective diagnostic tests," such as an MRI, that can definitively identify mild TBI — let alone tests that would detect subtle visual impairments.
Last week, a new study by the RAND Corporation estimated that about 320,000 service members may have experienced a traumatic brain injury during deployment. Just 43 percent reported ever being evaluated by a physician for that injury, the study found.
Meanwhile, the Defense Department just recently took the first steps to establish a "center of excellence" for traumatic brain injury, and veterans' advocates have been frustrated to learn that plans for an affiliated eye center, authorized by Congress earlier this year, are in limbo because of a lack of funding.
"This has turned into an epic battle, for no reason," said Thomas Zampieri, director of government relations for the Blinded Veterans Association, a national group. "There are not enough centers doing specialized [eye] exams, diagnosis, treatment. … For people with TBI, undiagnosed vision problems can have a profound negative impact on their rehabilitation."
Gagnon, 44, said she began worrying about the visual consequences of TBI as soon as the war started, and IED blasts emerged as a frequent cause of injury. When the brain is jogged by a blast, the force can disrupt the circuitry that allows the eyes to work in unison or to process the entire visual field. Double vision, trouble focusing and poor spatial orientation are among the deficits that can result from TBI. Some can be fixed easily, with corrective lenses or other adaptive devices; others require extensive therapy to re-train the brain and eye muscles.
Gagnon began sounding the alarm about "the vision thing" for both personal and professional reasons. In 12 years at the VA, she had seen too many aging veterans show up at her clinic and confide they'd been unable to read or focus for decades because their visual impairments went unattended, she said. She didn't want a new generation of veterans showing up with the same story in 20 years.
At the same time, she said, her own 8-year-old son was having learning problems that she was able to trace back to a head injury from three years earlier when he fell off a bike.
"The light bulb went off for me," she said. "With all the reports of these IED blasts, I went, 'Oh my God, this is going to be a much bigger problem than anyone realizes.' I knew eventually I would be seeing these soldiers."
When Gagnon began organizing a national conference on the visual consequences of TBI, some of the officials she contacted urged her to slow down, arguing that more research was needed into the visual deficits caused by blast-related TBI.
"Some people said, 'Wait, we need medical evidence-based research and outcomes before we can have a conference,'" Gagnon recalled. "I said, 'We can't wait for that. These guys are already coming home.'"
Gagnon said the conference accomplished what she had hoped: bringing together vision specialists with poly-trauma professionals to collaborate on the screening and treatment of TBI. Putting that partnership into everyday practice remains a challenge. In their recent report, congressional investigators found that only one of the nine VA facilities they reviewed was referring all veterans with TBI symptoms to a vision specialist.
In the general population, about a third of people with acquired brain injuries have associated neurological vision impairment, studies have shown. Last November, doctors at the VA in Palo Alto, Calif., released a study of veterans at their clinic that found 74 percent of those with TBI and other traumatic injuries reported vision problems.
"The extent and severity of vision-related injury and deficit suggest that all poly-trauma patients should have routine, comprehensive vision examinations," the study recommended.
Neither the Defense Department nor the VA, which is working to expand its vision rehabilitation programs, has released national figures on veterans with TBI who have been diagnosed with visual problems. At a congressional hearing earlier this month, Col. Loree Sutton, director of the military's new Center of Excellence for Psychological Health and TBI, testified that the Defense Department was planning to start a TBI registry to track visual impairments.
Zampieri, of the Blinded Veterans Association, said the military and the VA have done a better job addressing hearing loss than visual impairment. He cited VA statistics showing that more than 58,000 returning troops have been diagnosed with hearing impairments.
Zampieri calls vision loss the "silent epidemic," saying troops who were close enough to a blast to sustain hearing loss also are likely to also have visual problems.
Gagnon, who acknowledges that she is impatient by nature — ("I'm an Irish Italian hothead," she half-apologizes) — is not waiting for registries and numbers. Besides opening a clinic for veterans with head trauma, she is now involved in a research project with a private company that is testing a device that could be used to measure visual impairments associated with TBI, she said.
This month, Gagnon presented research on visual impairments at a Washington, D.C., conference that had international experts exploring the neurological effects of blast injuries — still a largely uncharted field of study.
"These blasts are causing such extreme injury, compared to other head traumas," she said. "There's still a lot we have to learn."
Maj. Gen. Gale Pollock, the Army's deputy surgeon general for force management, acknowledged that addressing the visual consequences of blast-related trauma is a frustration for the military because of a dearth of research and expertise.
"We have not had soldiers survive in large numbers after these types of blasts before," she said. "We don't have the systems that can diagnose these [complex] injuries."
Pollock called Gagnon "one of our pioneers. … It requires people who have passion to move ideas and systems forward. She has both talent and passion."
Gagnon said she wants to encourage primary-care physicians and other practitioners who treat returning troops to ask questions about headaches, double-vision or trouble reading.
"Those aren't the symptoms that usually get the most attention, but we need to look for them, ask about them," she said.
Pearce, the Iraq veteran, said he feels lucky he found his way to Gagnon's clinic, after meeting her at a Blind Veterans Association meeting. He said he had received "minimal help" for his vision in the year after he was injured, with Army doctors telling his wife that his vision had to take a "back seat" to his other TBI-related injuries.
Because of a binocular dysfunction that kept his eyes from working in unison, Pearce was straining his upper body to compensate and was bothered by headaches and neck pain, he and Gagnon said. Pearce said those problems have been eased by the special prism glasses and ongoing visual therapy that Gagnon prescribed.
"I'm grateful I got the care I did," said Pearce, 37. "I will never gain back my peripheral vision — I know that. But it's easier for me to live with now."