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.