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Visual dysfunctions common in even mild TBI patients

Image of Military health personnel examining a picture of an eye. An optometry technician examines a picture of a patient’s eye at the Optometry Clinic at Cannon Air Force Base, New Mexico. Optometry specialists are trained to prescribe and fit lenses that will improve a patient’s vision as well as treat various eye diseases and disorders (Photo by: Air Force Airman 1st Class Ericka Engblom)

In 2008, the National Defense Authorization Act authorized the Secretary of Defense to "establish a Center of Excellence to address the full scope of vision care including prevention, diagnosis, mitigation, treatment, research and rehabilitation of military eye injuries and diseases..."

That year, the Vision Center of Excellence was established to address the full scope of vision care, including prevention, diagnosis, mitigation, treatment, research, and rehabilitation of military eye injuries and diseases including visual dysfunctions related to traumatic brain injury.

Although the Bethesda, Maryland-based center is not a treatment facility, it works to improve vision health, optimize readiness, and enhance quality of life for service members and veterans by promoting collaboration, facilitating integration, and serving as an advocate for vision across the departments of Defense's and Veterans Affairs' health care systems.

"We are an advocacy organization that drives consensus documentation to the provider communities out in the field that do deliver care," said Dr. Felix Barker VCE's director of rehabilitation and reintegration. "We engage large groups of multidisciplinary provider experts, who actively engage in the care delivery process for affected individuals."

Reporting to the Research and Development Directorate of the Defense Health Agency and the Office of Patient Care Services within the VA, VCE integrates DOD and VA-funded research related to vision health with a strong focus on ocular blast injury and traumatic brain injury (TBI) to improve operational readiness.

Service members can sustain TBI during day-to-day activities, such as sports or recreational events, as well as during military training and deployment. While the majority of TBIs sustained by U.S. service members are mild, also known as mTBI or concussion, they are also the most difficult to diagnose and the least well understood, according to a 2014 National Institutes of Health study on military-related TBI. Yet, in the first three quarters of 2020, 12,310 service members were diagnosed with TBI, most of them (85.7%) mild.

Concussion occurs when someone suffers a severe blow to the head or a violent jolting of the head and body, such as during a blast, explained Barker. Most service members who sustain mTBI return to full duty within 10 to 14 days through rest and a progressive return to activity, but further treatment is available when symptoms persist after the initial recovery period, he said.

"Military personnel who undergo blast exposure may be concussed by direct contact with a projectile or by being thrown against a rigid surface," said Barker. "Another unique feature of blast exposure is that some individuals have exhibited signs of TBI without direct concussive contact and are thought to have been affected by the direct effects of the blast wave itself."

However, vision-related problems associated with TBI are often overlooked during initial treatment of a brain injury, said Dr. Michael Pattison, VCE's program manager of readiness and operations optometry. "In some cases, symptoms may not be present until sometime following the injury - sometimes the eye itself is injured during the head injury or blast exposure and can result in conditions such as cataracts and retinal damage."

Additionally, "while vision is usually not affected by TBI unless there is a concurrent eye injury, patients with even with the most common mTBI have high rates of other visual dysfunctions which can dramatically affect job performance in terms of ability to read for extended periods, concentrate, and maintain clear and single vision," Barker explained.

"Other vision problems occur due to injuries in the brain," said Pattison. "Studies show that up to 90% of TBI patients suffer from some type of visual dysfunction."

These include blurred vision, sensitivity to light, reading difficulty, headaches with visual tasks, reduction or loss of visual field, and difficulties with eye movements. While many symptoms often go away over time, it is important service members don't ignore them, said Pattison.

"Any post-traumatic vision effect or visual symptom can be a result of concussion or TBI,” said Barker. "A TBI injury affecting visual acuity or visual field is indicative of a more serious brain injury and should be carefully evaluated as such by competent vision and neurology providers, who should engage as part of the rehabilitation team early in the process."

Additionally, he highlighted that the biggest issue with treating TBI is that each person must be treated individually because it is rare that all patients will have the same symptoms.

Photo of military personnel getting a slit lamp examination Air Force Senior Airman Troy Dibley, 61st Fighter Squadron F-35A Lightning II avionics journeyman, receives a slit lamp examination June 9, 2020, at Luke Air Force Base, Arizona. Slit lamp examinations are performed to check for ocular health and abnormalities. The Luke AFB optometry clinic treats more than 4,000 patients every year (Photo by: Air Force Airman 1st Class Brooke Moeder).

Therapy

"Some patients will not get better without therapy or intervention, and some will not get better even with treatment, becoming chronically affected patients," said Barker.

For oculomotor visual dysfunctions - which include difficulty visually tracking moving objects, losing your place, or skipping words or sentences and the sense that words float on a page while reading - and photophobia (light sensitivity), treatment includes using lenses, tints, prisms, and rehabilitative therapy, which have a good record of success, added Barker.

Lenses help with focus dysfunctions, prisms help treat problems with eye alignment, and tints help patients suffering from photophobia.

"Photophobia tends to improve a lot within the first three months, and tints used early in the process can be crucial to get the patient through the early stages but may need to be reduced or removed later in the process to avoid dependency that can interfere with fuller recovery," he added.

Other visual dysfunctions commonly associated with TBI include ocular misalignment, or not being able to look in the same direction or focus on the same object with both eyes in the lateral and vertical dimension as well as in efficient general eye movements, added Barker.

To help treat those, occupational therapy - such as interventions to improve visual attention, search and speed, and efficiency in visual processing - is a common treatment, as is working with optometrists and ophthalmologists to ensure that TBI patients can compensate for deficits in acuity, visual field, and eye movements to complete important daily activities safely and effectively.

"Accommodative (focus) dysfunctions and convergence insufficiencies (the inability to keep both eyes working together) are commonly managed using near focal and convergence demand training, sort of like calisthenics for near vision," said Barker. "Patients with difficulties related to eye tracking can also benefit from tracking exercises that usually involve automated tracking devices."

He explained that since many of the issues patients experience after TBI tend to improve with time, these types of therapies are supportive and usually hasten recovery by creating direct improvement early in the recovery process. Treatment and rehabilitation can also aid rehabilitation because patients can get discouraged early in the process, especially since so much human activity is visually guided.

"Currently, there is a lot of research on what are the most effective treatment and therapeutic strategies available to determine the most effective ways to return service members to full duty status and improve their quality of life as quickly as possible," said Pattison.

The prognosis depends on the severity of the injury, he explained. "With a concussion, most people recover most or all of their brain function within three months of the injury," said Pattison. "Most recover sooner, but each service member's recovery may not follow the norms, which is why proper evaluation is important."

However, "if vision - visual acuity - is impaired due to brain injury, the prognosis for return of vision is poor," said Barker. "On the other hand, optical and rehabilitation management of the visual dysfunctions is highly successful in restoring normal function."

Both experts agreed that the most important aspect for service members to keep in mind is paying attention to the signs and symptoms and seeking proper care for any issues they have. "In most cases, rest and a slow return to full activities are necessary, but in some cases, members will need additional time and treatment to get to a fully functional state," said Pattison.

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