EYE AND VISION CARE FOLLOWING BLAST EXPOSURE AND/OR TRAUMATIC BRAIN INJURY (TBI) A Clinical Recommendation Felix M Barker II OD, MS, FAAO, Associate Director of Research Rehabilitation and Reintegration Directorate AMSUS 2015 | San Antonio, TX vce. health. mil
Disclosures • The presenter has no financial relationships to disclose. • This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. • Neither PESG, AMSUS, nor any accrediting organization support or endorse any product or service mentioned in this activity. • PESG and AMSUS staff has no financial interest to disclose. • Commercial support was not received for this activity. AMSUS 2015 | December 3, 2015 vce. health. mil | 2
Learning Objectives: At the conclusion of this activity, the participant will be able to: 1. Recognize “invisible” nature of blast-related eye injury and visual dysfunction 2. Identify eye injuries and TBI related vision losses in combat and blast -related casualties 3. Manage combat eye injury and TBI-related vision loss and dysfunction AMSUS 2015 | December 3, 2015 vce. health. mil | 3
Presenter – Felix Barker, II, OD, MS, FAAO § Graduate of the Indiana University School of Optometry and the University of Houston Visual Sciences Program § Emeritus Professor of Salus University, having served there as Dean of Research § Veteran of the U. S. Army § VA Optometrist at the Salisbury VAMC § Associate Director of Research of the Do. D/VA Vision Center of Excellence AMSUS 2015 | December 3, 2015 4 vce. health. mil | 4
Vision Center of Excellence Mission To be a leader in the prevention, diagnosis, mitigation, treatment and rehabilitation of military vision and eye injuries AMSUS 2015 | December 3, 2015 vce. health. mil | 5
Vision Center of Excellence (VCE) • National Defense Authorization Act (NDAA) 2008 – Vision Center of Excellence Established by Congress - To continuously improve the health, readiness, and quality of life for members of the Armed Forces and Veterans through advocacy and leadership in the development of initiatives focused on the prevention, diagnosis, mitigation, treatment and rehabilitation of disorders of the visual system – Joint Department of Defense (Do. D) and Department of Veterans Affairs (VA) operations • • Care coordination Education Research Policy support – Develop a Defense and Veterans Eye Injury & Vision Registry U. S. Department of Defense AMSUS 2015 | December 3, 2015 U. S. Department of Veterans Affairs vce. health. mil | 6
Centers of Excellence Alignment Army DCo. E PH/TBI Air Force Navy VCE HCE EACE Army AMSUS 2015 | December 3, 2015 7 vce. health. mil | 7
VCE Governance AMSUS 2015 | December 3, 2015 vce. health. mil | 8
VCE Stakeholder Engagement Keeping Service members, Veterans, and their families at the center of our mission, VCE links together a network of Do. D and VA clinical and research centers around the world and encompasses a vast array of other strategic partners. AMSUS 2015 | December 3, 2015 vce. health. mil | 9
Defense and Veterans Eye Injury and Vision Registry (DVEIVR) • DVEIVR is populated using both electronic and manual data collection methods from Do. D and VA Sources • Over 20, 000 records of Service members with eye related problems. Do. D Medical Systems VA Eye Injury Data Store Other Do. D Data Sources (i. e. Do. D Registries and Data Warehouses) DVEIVR AMSUS 2015 | December 3, 2015 vce. health. mil | 11
Defense and Veterans Eye Injury and Vision Registry (DVEIVR) Creating Opportunities to Improve Vision Health Longitudinal analysis of conditions, treatments, and outcomes data Expand best practices and clinical guidelines for vision injuries and dysfunction Guide eye injury related research Inform Do. D and VA policy regarding vision care AMSUS 2015 | December 3, 2015 12 vce. health. mil | 12
VCE Research Advocacy & Gap Analysis 2015 VRP Priorities – Improved First Response to Eye Injuries – Improved Surgical Management – Improved Rehabilitation – Improved Restoration AMSUS 2015 | December 3, 2015 vce. health. mil | 13
Clinical Recommendations AMSUS 2015 | December 3, 2015 vce. health. mil | 14
VCE Educational Programs AMSUS 2015 | December 3, 2015 vce. health. mil | 15
Visual Dysfunction and Psychological Health Epidemiology/Scope of the Problem – TBI, Psychological Health, Visual Dysfunction and Impairment in Veterans AMSUS 2015 | December 3, 2015 vce. health. mil | 16
Shields Save Sight Campaign • “Shields Save Sight” launched on October 1, 2013… – To raise awareness leading to an increase in the use of Do. Dapproved eye protection listed on the Authorized Protective Eyewear List (APEL) among active duty Service members – To encourage proper procedures following an eye injury by promoting the proper use of rigid eye-shields and discouraging the common technique of applying pressure following an injury – “Shields Save Sight” communicated best practices to active duty Service members, front line leadership and medical first responders • Message sent out via: over 1000 TV & radio airings on Armed Forces Network; VCE Facebook® & Twitter® pages; VCE website; blogs AMSUS 2015 | December 3, 2015 vce. health. mil | 17
Rigid Eye Shields In close collaboration with Joint Trauma System, Committee on Tactical Combat Casualty Care (TCCC) and Defense Health Agency-Medical Logistics - spearheaded effort to include use of protective eye shield on DD Form 1380, TCCC card - approved June 2014 Led the way to initial inclusion of protective (Fox) eye shield in joint first aid kits (JFAKs); coordinating with Services to expand into individual first aid kits (IFAKs) Disposition / Instructions: Immediately discontinue use, remove, and destroy {First Aid Kit, Eye Dressing} “The Joint Trauma System (JTS) Clinical Practice Guidelines, Tactical Combat Casualty Care Guidelines, and the Vision Center of Excellence's recommendations advocate the use of a rigid eye shield and rapid evacuation to an eye care provider when treating traumatic eye injuries. This is the only authorized clinical practice guideline for treating traumatic eye injuries. ” AMSUS 2015 | December 3, 2015 DHA MEDLOGS notice, 22 Jul 14 vce. health. mil | 18
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Continuum of Care for Eye and Vision Injury Ocular Trauma • Globe • Orbit • Eyelids Brain (TBI-associated Vision Dysfunction) • Optic nerve injuries • Diffuse brain injury affecting visual processing • Cranial nerves (eye movement) • Visual field losses • Photosensitivity AMSUS 2015 | December 3, 2015 vce. health. mil 20 | 20
History of Eye Injuries in Modern Combat Ocular Injuries as Percentage of Total War Injuries GWOT 10 -16%, high >20% AMSUS 2015 | December 3, 2015 vce. health. mil | 21
Contemporary War Casualties • Current war casualties are driving changes in healthcare needs and changes in R&D • Specific types of casualties driving changes: • Blast Injuries • Eye and Vision Injuries • Ear and Hearing Injuries • Traumatic Brain Injury (TBI) • Post Traumatic Stress Disorder (PTSD) • Amputations % Body Area WWII Korea Vietnam OIF/OEF Head & Neck 12% 21% 16% 29% Chest 16% 14% 10% 13% 6% Abdomen 11% 8% 8% 9% 11% Extremities 61% 58% 60% 61% 54% Owens, J Trauma FEB 2008 AMSUS 2015 | December 3, 2015 vce. health. mil | 22
Vision Impairment vs Visual Dysfunction • Physical Injuries --> anatomical damage --> Acuity loss, blindness • "Invisible" injuries --> 20/20 eye with visual complaints often associated with TBI - Reading difficulties - Difficulty concentrating - Trouble with glare and brightness of lights AMSUS 2015 | December 3, 2015 vce. health. mil | 23
Blindness and Low Vision • Total blindness (no light perception) – Loss of the eye(s) – Nerve damage/cortical blindness • Legal blindness is defined as: – Worse than 20/200* acuity in the better eye – Less than 20 degrees of visual field (tunnel vision) • Low vision – No defined acuity range but a patient who has impaired visual function AMSUS 2015 | December 3, 2015 vce. health. mil | 24
Combat Ocular Trauma-Related Blindness • MAJ Marcus Colyer, MD, USA, Interim Chief Ophthalmology, WRNNMC • Studied a cohort of OEF/OIF Service members returning from deployment in the period 2002 -2007 • Age: 27. 44 years +/- 7. 67 (19 -53 range) • 265 eyes of 239 patients • Reports on the causes of legal blindness resulting from these injuries – Visual acuity = or < 20/200 J Trauma Acute Care Surg Vlasov et al 2015 AMSUS 2015 | December 3, 2015 vce. health. mil | 25
Combat Ocular Trauma-Related Blindness • 265 eyes of 239 patients – Laterality • Right eye blindness • Left eye blindness • Bilateral blindness – Enucleations • 108 (40. 6%) 129 (48. 5%) 133 (50. 0%) 26 (9. 77%) J Trauma Acute Care Surg Vlasov et al 2015 AMSUS 2015 | December 3, 2015 vce. health. mil | 26
Combat Ocular Trauma-Related Blindness Mechanism of Injury – – – IED RPG Gunshot Grenade Other 170 (64. 2%) 29 (10. 9%) 27 (10. 2%) 9 (3. 4%) 30 (11%) Anterior Equator Posterior J Trauma Acute Care Surg Vlasov et al 2015 AMSUS 2015 | December 3, 2015 vce. health. mil | 27
Blind/Low Vision Rehabilitation • Blind Rehabilitation – Text: Braille and text to speech systems – Mobility-cane walking and GPS – Smart phone/tablet technologies • Low Vision Rehabilitation- uses remaining vision – Magnification • • Spectacle telescopes/microscopes Hand/Stand magnifiers CCTVs New wave of “smart systems”: smart phones, tablets, computers – Field expanding prisms • Field awareness training • Low Energy Bluetooth Beacon – Occupational therapy/mobility training AMSUS 2015 | December 3, 2015 vce. health. mil | 28
Smart Phone Technologies • • • Voice control Voice-to-text Camera capture Clock/alarm GPS Bluetooth Beacon AMSUS 2015 | December 3, 2015 vce. health. mil | 29
Looking Forward. Seeing the Future. Do. D/VA Vision Center of Excellence Assistive Technologies for the Blind and Visually Impaired Presentation to the First VCE BVA “Industry Day” Forum on Assistive Technologies 26 March 2015 Felix M Barker II OD, MS, FAAO and William Boules Associate Directors Rehabilitation and Reintegration Directorate AMSUS 2015 | December 3, 2015 vce. health. mil | 30
The Horus Vision Restoration Project • US Army Medical Research & Materiel Command (USAMRMC) R&D program investigating use of artificial vision to restore sight to those w/traumatic ocular injuries – Can technology be used to circumvent traumatic visual loss such that a prototype to restore sight can be produced within five years? • Goal is to provide prototype technology for human testing within 5 years that provides: – Ability to navigate, identify faces and objects critical to daily life, and read large print; and – Is economically feasible • Public/private partnership – National Eye Institute, Government, academia and industry AMSUS 2015 | December 3, 2015 vce. health. mil | 31
Optical Implants Keratoprosthesis (KPro): Artificial cornea useful in cases where conventional keratoplasty impractical Implantable Mini-Telescope (IMT): Intraocular telescope in use by a number of patients; necessary rehabilitation strategies still being developed AMSUS 2015 | December 3, 2015 vce. health. mil | 32
Retinal Implants Use micro-array chips (either epiretinal or sub-retinal) to stimulate remaining retinal architecture of persons with conditions photoreceptor loss (e. g. : retinitis pigmentosa, macular degeneration Must have intact eye and functioning inner neural layers of the retina. There are now patients who have achieved “score board” vision AMSUS 2015 | December 3, 2015 vce. health. mil | 33
Neural Implants For patients blinded by the loss of the eye it is necessary to approach implanting a prosthesis higher in the visual pathway. • Optic Nerve implants • Thalamic implants • Cortical implants Cortical Blindness will require higher order inputs AMSUS 2015 | December 3, 2015 vce. health. mil | 34
Non-Visual Adaptive Inputs There is evidence that non-visual inputs that are tactile representations of the patient’s mobility arena may be effective and may invoke some aspects of visual reality via a visual memory phenomenon e. g. : Brainport oral electronic vision aid AMSUS 2015 | December 3, 2015 vce. health. mil | 35
Vision Loss Associated with Combat Eye Injury and TBI • Eye injury: blindness and low vision • Optic nerve injury: blindness and low vision • Orbital and eye muscle injury: restricted eye movement and strabismus • Eye lids: disfigurement and future dry eye • Brain focal contusion/hemorrhage: central and or peripheral visual field loss • Diffuse brain injury: eye movement coordination loss AMSUS 2015 | December 3, 2015 vce. health. mil | 36
Eye Injury & TBI Clinical Recommendation for Eye Care Providers AMSUS 2015 | December 3, 2015 37 vce. health. mil | 37
Algorithm of Care Three levels of triage • Urgent medical eye problems • Non-urgent medical eye problems • TBI-related visual dysfunctions AMSUS 2015 | December 3, 2015 vce. health. mil | 38
Recommended Testing • • • History Visual Acuity Refractive Error Ocular examination Internal External Pupil Testing Ocular Alignment Ocular Motility Visual Field Tonometry Gonioscopy AMSUS 2015 | December 3, 2015 vce. health. mil | 39
Management Considerations • • Condition Additional testing Management Referral AMSUS 2015 | December 3, 2015 vce. health. mil | 40
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Typical Causes of Non-Military TBI § There an estimated 1. 7 Million TBIs in the US annually http: //www. cdc. gov/traumaticbraininjury/get_the_facts. html AMSUS 2015 | December 3, 2015 vce. health. mil | 42
Visual Field Loss • • Peripheral Central Hemianopic Monocular AMSUS 2015 | December 3, 2015 vce. health. mil | 43
Eye Movements and TBI Eye movement problems are a signature of concussion. Athletic “sideline” testing for concussion often involves checking eye movements AMSUS 2015 | December 3, 2015 vce. health. mil | 44
Visual Dysfunctions Associated with TBI • Even when vision is normal, TBI is associated with visual dysfunctions such as: – Eye position anomalies due to impaired eye muscle function • Strabismus (crossed eyes) • Heterophorias (tendency for eyes to turn in or out) – Eye movement anomalies due to eye coordination problem • Saccadic dysfunction – Point to point eye movement • Eye Tracking dysfunction – Smooth eye movement – Eye teaming anomalies • Converging to near reading distance • Divergence to distance objects – Accommodation anomalies (eye focusing difficulty) – Photosensitivity – or even an aversion to light AMSUS 2015 | December 3, 2015 vce. health. mil | 45
Visual Complaints in TBI Visual Complaint PRC Inpatient (%) Self-Report Visual Complaint Blind/Severe Visual Impairment (VA < 20/100) Monocular Strabismus Accommodative Insufficiency Convergence Insufficiency Pursuit/Saccade Insufficiency Fixation Insufficiency Diplopia Suppression Visual Neglect Reading Difficulty 75 26 10 32 31 40 29 13 19 11 5 57 PNS Outpatient (%) 75 <2 <2 8 47 48 23 7 6 5 0 63 PNS = Polytrauma Network Site, PRC = Polytrauma Rehabilitation Center. (J Rehabil Res Dev. 2009; 46(6): 811 -8. Eye and visual function in traumatic brain injury. Cockerham GC, Goodrich GL, Weichel ED, Orcutt JC, Rizzo JF, Bower KS, Schuchard. RA). AMSUS 2015 | December 3, 2015 vce. health. mil | 46
Correction/Rehabilitation of Eye Misalignments • Prism correction • Oculomotor Rehabilitation – Orthoptics – Visual training • Surgical management AMSUS 2015 | December 3, 2015 vce. health. mil | 47
Disorders of Accommodation • Focusing issues due to age-related changes – Lens correction • Other treatments for accommodative dysfunction (spasm, insufficiency, infacility) – Accommodation training – Lenses correction AMSUS 2015 | December 3, 2015 vce. health. mil | 48
Eye Movement Coordination Treatment • Eye movement rehabilitation training – Saccadic training – Tracking training • Rehabilitation for convergence/divergence disorders – Computer-based therapy – In-office therapy techniques • Free space activities • Instrument activities – Home therapy – Spectacle/Prism correction AMSUS 2015 | December 3, 2015 vce. health. mil | 49
Photosensitivity • Triggers – Indoor overhead lighting – Outdoor daytime glare – Outdoor night time glare • Treatment/Management – Tinted lenses – Transitional lenses AMSUS 2015 | December 3, 2015 vce. health. mil | 50
Mental Health Considerations § Blast-related injuries - Brain Injury - Eye Injury - PTSD § The overlapping nature of these neuro-traumas often cause: - Diagnostic confusion - Ineffective treatment/rehabilitation AMSUS 2015 | December 3, 2015 vce. health. mil | 51 51
Conclusions • The problem of combat eye injury, concussion and TBI presents a complicated set of evaluation and management requirements • Such injuries range from blindness to low vision as well as non -blinding visual dysfunctions also requiring rehabilitation by a team oriented approach that involves: – – – Optometrists Ophthalmologists Occupational Therapists Vision Rehabilitation Specialists Nurses Other specialists AMSUS 2015 | December 3, 2015 vce. health. mil | 52
Obtaining CME/CE Credit If you would like to receive continuing education credit for this activity, please visit: http: //amsus. cds. pesgce. com AMSUS 2015 | December 3, 2015 vce. health. mil | 53
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