Apr112013
Hearing Transcript on Traumatic Brain Injury Related Vision Issues.
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TRAUMATIC BRAIN INJURY RELATED VISION ISSUES
HEARING BEFORE THE SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS OF THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED TENTH CONGRESS SECOND SESSION APRIL 2, 2008 SERIAL No. 110-79 Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE For sale by the Superintendent of Documents, U.S. Government Printing Office
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CORRINE BROWN, Florida |
STEVE BUYER, Indiana, Ranking |
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Malcom A. Shorter, Staff Director SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined. |
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C O N T E N T S
April 2, 2008
Traumatic Brain Injury Related Vision Issues
OPENING STATEMENTS
Chairman Harry E. Mitchell
Prepared statement of Chairman Mitchell
Hon. Ginny Brown-Waite, Ranking Republican Member
Prepared statement of Congresswoman Brown-Waite
Hon. Zachary T. Space
Hon. Eric Cantor
Hon. David L. Hobson
Hon. Corrine Brown
Prepared statement of Congresswoman Brown
WITNESSES
U.S. Department of Veterans Affairs:
James Orcutt, M.D., Chief of Ophthalmology, Office of Patient Care Services, Veterans Health Administration
Prepared statement of Dr. Orcutt
Glenn Cockerham, M.D., Chief of Ophthalmology, Veterans Affairs Palo Alto Health Care System, Veterans Health Administration, U.S. Department of Veterans Affairs
Prepared statement of Dr. Cockerham
U.S. Department of Defense:
Colonel (P) Loree K. Sutton, M.D., USA, Special Assistant to the Assistant Secretary of Defense (Health Affairs), Psychological Health and Traumatic Brain Injury, and Director, Department of Defense Center of Excellence for Psychological Health and Traumatic Brain Injury, Department of the Army
Prepared statement of Colonel Sutton
Major General Gale S. Pollock, Deputy Surgeon General for Force Management, and Chief, United States Army Nurse Corps, Department of the Army
Blinded Veterans Association, Thomas Zampieri, Ph.D., Director of Government Relations
Prepared statement of Dr. Zampieri
Minney, Petty Officer Glenn, USN (Ret.), Frankfort, OH
Prepared statement of Petty Officer Minney
Neuro Vision Technology Pty. Ltd., Torrensville, Australia, Gayle Clarke, Chief Executive Officer
Prepared statement of Ms. Clark
NovaVision, Inc., Randolph S. Marshall, M.D., M.S., Associate Professor of Clinical Neurology, and Chief, Division of Cerebrovascular Diseases, and Program Director, Vascular Neurology Fellowship Training Program, The Neurological Institute, Columbia-Presbyterian Medical Center, New York, NY
Prepared statement of Dr. Marshall
Pearce, Staff Sergeant Brian K., USA (Ret.), and Angela M. Pearce, Mechanicsville, VA
Prepared statement of Staff Sergeant Pearce
Performance Enterprises and Dynavision 2000, Ontario, Canada, Mary Warren, M.S., OTR/L, SCLV, FAOTA, Associate Professor of Occupational Therapy, and, Director, Graduate Certification in Low Vision Rehabilitation Program, University of Alabama at Birmingham, School of Health Professions
Prepared statement of Ms. Warren
TRAUMATIC BRAIN INJURY RELATED VISION ISSUES
Wednesday, April 2, 2008
U. S. House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:07 a.m., in Room 334, Cannon House Office Building, Hon. Harry E. Mitchell [Chairman of the Subcommittee] presiding.
Present: Representatives Mitchell, Space, Walz, and Brown-Waite.
Also Present: Representatives Brown of Florida and Boozman.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. MITCHELL. Good morning and welcome to the Subcommittee on Oversight and Investigations. This is a hearing on traumatic brain injury (TBI) related vision issues. This hearing will come to order.
We are here today to hear from veterans and the U.S. Department of Veterans Affairs (VA) about a very serious problem in the care of wounded servicemembers that has been overlooked for too long. Traumatic brain injury, TBI, is one of the signature issues of the wars in Iraq and Afghanistan. I am afraid that vision problems are becoming the unrecognized result of that injury.
Research being conducted by physicians, psychologists, and blind rehabilitation specialists at the VA Palo Alto Polytrauma Rehabilitation Center and the VA Western Blind Rehabilitation Center shows that TBI causes serious vision disturbances in a large number of cases even when the veteran retains 20/20 vision, and without any obvious injury to the eye. We will be hearing today from Staff Sergeant Brian Pearce and Petty Officer Glenn Minney, Iraq veterans who are legally blind as a result of TBI.
Staff Sergeant Pearce and Petty Officer Minney do not have happy stories to tell us about their experiences after they were injured. We owe these two a great deal of debt for their service. Both of their TBI-related vision issues went unrecognized and untreated for a long time.
The wars in Iraq and Afghanistan have forced us to deal with unexpected and often unpleasant realities. But we know now that military and VA healthcare providers must be especially alert to vision defects resulting from TBI—even when there is no obvious physical injury to the eye.
This is not only critical so that these vision deficits can be addressed, but also because undiagnosed vision problems can seriously interfere with TBI rehabilitation and also rehabilitation for other injuries that often occur along with TBI.
Following our first panel, we will be hearing from several companies that are working with the VA to provide innovative treatment for TBI-related vision deficits. Our third panel consists of witnesses that are from the U.S. Department of Defense (DoD) and the VA.
Two of the researchers from the Palo Alto VA are leading efforts to better identify and diagnose vision deficits in TBI patients. They are to be commended for their cutting edge work. In the 2008 National Defense Authorization Act, Congress directed DoD and VA to create a cooperative program specifically to address TBI-related vision issues. We are looking forward to hearing exactly what it is that the Departments are doing, how they are directing funds for their efforts, and when they expect to have a fully-functional program.
I am also very interested to see whether DoD and VA are currently doing all they can to identify and track these patients, not just at Palo Alto but everywhere. Because the seriousness and the extent of vision problems resulting from TBI are just now becoming better known, we would like to hear from the Departments what they are doing to identify and contact TBI patients whose vision issues may have been overlooked.
Our veterans served honorably to protect our Nation. We have a responsibility to take care of them when they come back home.
[The statement of Chairman Mitchell appears in the Appendix.]
Mr. MITCHELL. Before I recognize the Ranking Republican Member for her remarks, I would like to swear in our witnesses. I would ask that all witnesses please stand and rise from all three panels.
[Witnesses sworn.]
Thank you.
Next I ask unanimous consent that Ms. Brown and Mr. Boozman be invited to sit at the dais at the Subcommittee hearing today.
Hearing no objection, so ordered.
I now recognize Ms. Brown-Waite for her opening remarks.
OPENING STATEMENT OF HON. GINNY BROWN-WAITE
Ms. BROWN-WAITE. Good morning and I certainly thank the Chairman for recognizing me.
I appreciate your calling this hearing to allow us to review how the Department of Veterans Affairs and the Department of Defense are evaluating and treating vision problems encountered by Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) soldiers and veterans returning home with traumatic brain injuries.
As we know, this was is different in many ways from those of the past. Soldiers who sustain injuries that would have resulted in death in previous conflicts now have a much greater survival rate. However, survival does not necessarily mean returning home to a normal way of life.
Improvised Explosive Devices, IEDs, and now Explosive Forced Projectiles, EFPs, cause some of the most serious injuries among OIF/OEF soldiers. Because of these types of attacks, many of our most severely injured veterans experience traumatic brain injury and require treatment at one of the four Polytrauma Centers around the country.
The Polytrauma Rehabilitation Center (PRC) nearest my district is at James A. Haley Medical Center in Tampa. Where I visit there frequently, I see firsthand the tremendous strides that wounded soldiers make.
I am also very pleased that the VA has made a commitment to expand the PRC Network to include a facility in San Antonio, Texas.
Treating these severely wounded servicemembers has been a learning process. As our physicians treat the various and previously unseen injuries from IEDs/EFP blasts, we learn more about the resulting co-morbid conditions, such as visual impairments suffered by our servicemembers. From information that I have obtained over 44,000 veterans have utilized the services of VHA’s blind rehabilitation program.
We here on the Committee need to be assured that these veterans are receiving the care and services that they desire and are deserving of. I look forward to hearing the opinions of our first panel as to the evaluation, treatment, and care they received while moving from the battlefield through to the VA.
I have read the testimony, and again the transitions you made going from the Department of Defense to VA have not been an easy road to follow. I would like to ask the administration officials sitting behind you to listen very closely to your testimonies. The situations you have encountered along your path to recovery need to be resolved by both departments so that others do not face similar problems in the future. We appreciate you coming forth with the individual stories that you have and experiences that you had.
I also look forward to hearing from officials from the Palo Alto VAMC on the research they are doing with respect to vision issues related to a Polytrauma. I would hope that they are sharing their experiences, methodologies and treatment plans with the other PRCs.
As I have stated in the past, all medical centers need to be sharing their best practices with one another so that our veterans and servicemembers receive the very best possible care. This is particularly critical in the area of TBI where treatments are often on the cutting edge.
I would like to commend the work of the BVA, the Blinded Veterans Association, for their efforts. I look forward to hearing what they and their members have encountered when helping veterans navigate the system.
Thank you again, Mr. Chairman, for calling this hearing and at this point I yield back the balance of my time.
[The statement of Congresswoman Brown-Waite appears in the Appendix.]
Mr. MITCHELL. Thank you. Mr. Space?
OPENING STATEMENT OF HON. ZACHARY T. SPACE
Mr. SPACE. Thank you, Mr. Chairman. I am pleased to welcome Glenn Minney from my region, along with my colleague Dave Hobson whose district abuts my district in Ohio, and of course Mr. Zampieri as well. We are happy to have him here today to testify regarding the somewhat unseen results of this war. And I use that word with a tone of irony.
Mr. Minney is here to tell us about his experiences in Iraq. I was honored to have him in my office last night with Mr. Zampieri to talk very candidly about both the problems associated with the transition from DoD to the VA, as well as the problems associated with those coming back from this war with traumatic brain injury, which in many cases leads to attendant eye injury. We are again honored to have Mr. Minney here. I know it took an act of courage to come and testify today and I would like to thank him for that. Welcome.
Mr. MITCHELL. I ask unanimous consent that all Members have five legislative days to submit a statement for the record. Hearing no objection, so ordered.
At this time I would like to recognize Congressman Eric Cantor of Virginia, who is here to introduce his constituent, Staff Sergeant Brian Pearce, and his wife Angela.
Congressman Cantor?
OPENING STATEMENT OF HON. ERIC CANTOR
Mr. CANTOR. Thank you, Mr. Chairman. Chairman Mitchell, and Ranking Member Brown-Waite, I want to thank you very much for having this hearing and thank you for having me here this morning.
It is my privilege to introduce Sergeant Brian Pearce a resident of my district who is a combat veteran of the U.S. Army and an honorable patriot.
He and his wife Angie came up yesterday from Mechanicsville, Virginia, to lend their story to the proceedings here this morning.
Sergeant Pearce was injured in 2006 while serving with the Army near Bagdad. The vision loss, which occurred from his injuries is unique in that his eyes are fine. It is his brain which sustained the injury and which caused the optic nerve within the brain to stop working. While his eyes see 20/20 his brain cannot receive and process those images in full. In his words, he sees as if he is looking through a drinking straw. His recovery and transition back to civilian life has not been easy. His service to our country is admirable. His courage amidst new challenges is inspirational. I have no doubt that his testimony will help us understand how we can better serve the needs of our returning soldiers from the hospital bed and beyond as they recover from the loss of vision due to brain related injuries. I would also like to thank again, his wife, Angie, who has been a tireless advocate for his care throughout this arduous process and I thank you again and yield back.
Mr. MITCHELL. Thank you. Next I would like to recognize Congressman Dave Hobson of Ohio who is here to introduce his constituent Petty Officer Glenn Minney.
Congressman Hobson?
OPENING STATEMENT OF HON. DAVID L. HOBSON
Mr. HOBSON. Thank you Mr. Chairman and Members of the Subcommittee. I appreciate the opportunity to introduce a constituent of mine who is appearing before you today. As mentioned his name is Glenn Minney and he is a retired Navy medic who served in Lima Company, a Marine reserve unit of the 3rd Battalion, 25th Regiment, based in my district. I just missed him when I was in Iraq with Mr. Murtha at the Haditha Dam, and he pointed out to me that the mortar hole in the dam was the one that caused his injury. Lima Company was assigned to Haditha, Iraq, and while he worked to treat medical needs of his unit he himself was injured by a mortar blast, as I talked about.
It is that blast had caused a traumatic brain injury and a severe visual problems that he is here to talk about today. And while Glenn is appearing today as an Iraqi combat veteran, he is also a patient advocate for the VA Medical Center in Chillicothe, Ohio, in my district and I think it is a county that Mr. Space and I both share there.
I met with Glenn in my office yesterday and I asked him if there was anything that he wanted me say. He said that he was just a man who was trying to make a difference for other soldiers who have suffered from traumatic brain injuries that have left them with severe visual problems.
During our conversation, I learned that there is a problem with the Department of Defense and maybe a certain official there in moving forward with the Military Eye Trauma Center of Excellence and Eye Trauma Registry. I am glad that this problem was brought to my attention. I am having my staff check this out from the funding side, as I am a Member of the Defense Appropriations Committee and working with Dr. Tom Zampieri from the Blinded Veterans Association on this issue, I assure you that I’m going to bring it to my Chairman’s attention and my Ranking Member’s attention on the Defense Appropriations Committee.
I’m sorry I can’t stay for this hearing because I’m supposed to be the Ranking Member at the Energy and Water hearing that is going on right now on nuclear weapons. So I need to get there. But I hope this is an issue that we can bring a successful conclusion because these people are our heroes and we need to take care of them.
Thank you, Mr. Chairman.
Mr. MITCHELL. Thank you. At this time I would like to recognize in this order, Sergeant Pearce, Petty Officer Minney and Dr. Zampieri for five minutes each.
STATEMENTS OF STAFF SERGEANT BRIAN K. PEARCE, USA (RET.) (U.S. ARMY COMBAT VETERAN), AND ANGELA M. PEARCE, MECHANICSVILLE, VA; PETTY OFFICER GLENN MINNEY, USN (RET.), FRANKFORT, OH (U.S. NAVY COMBAT VETERAN); AND THOMAS ZAMPIERI, PH.D., DIRECTOR OF GOVERNMENT RELATIONS, BLINDED VETERANS ASSOCIATION
STATEMENT OF STAFF SERGEANT BRIAN K. PEARCE
Staff Sergeant BRIAN PEARCE. Chairman Mitchell, Members of the Subcommittee, thank you for the opportunity to speak to you today regarding our experiences following my injuries in Iraq and during my medical care to date.
I joined the Army in June of 1992 and served until March of 2000, joining the West Virginia Army Reserve and National Guard. After a three year service break, I returned to active duty in January of 2004. Joining my new duty station in Alaska, which was the 172nd Stryker Brigade Combat Team from of Ft. Wainwright. I was then assigned to 4-11th Field Artillery as the brigade’s Survey/Targeting Acquisition Chief. After an intense training period we deployed in July of 2005. My brigade combat team spent August of 2005 through August 2006 operating in the Mosul area of Iraq.
As the brigade prepared to re-deploy home to Ft. Wainwright in July we were extended for 120 days. I had already been returned to Alaska in June to prepare for the brigade’s homecoming. Then I was called back to Iraq in August of 2006, in our new area of responsibility in the Sunni Triangle.
On October 20, 2006, I was severely injured by an IED blast that caused shrapnel to penetrate the right occipital lobe of my skull. Once the blast zone had been secured and I was air evacuated to the field hospital in Balad, there I underwent an emergency craniotomy to the right occipital lobe and posterior fossa with duraplasty. I also retained foreign body and was considered to have cortical blindness. Later we learned it was the cause of more complex visual impairments such as post traumatic stress disorder (PTSD), hearing loss, pulmonary embolism, seizures and rapid eye movement sleep and seizure disorders.
During this time my wife was contacted in Alaska and told that I had been involved in an IED blast and was in stable condition complaining of neck injuries. Roughly three hours later she was contacted by my commander who was in Iraq with me and he then told her that I had come through the brain surgery fine, and was listed in very critical condition and—excuse me, I lost my place and my wife has got to help me here.
Ms. ANGELA PEARCE. He was listed in critical condition and at that time we didn’t realize that there was any blindness until his PA’s wife came over to the house to talk to me to see how I was and bring dinner. At that time she informed me that my husband had no vision and of course I didn’t know what was going on.
So I initially got back in contact with the doctor in Balad. On 21 October, he informed me that my husband was diagnosed with cordial blindness and that we did not know whether his eyesight would come back or not. That was all that was said.
Then they evacuated him to Landstuhl, Germany, on the 21st. He had to go through another surgery there to clean out—where he had a bleed out. And so, he was there until they transferred him to Bethesda, Maryland, to the hospital first. He had to have an angiogram done there and then on to Walter Reed.
So from 25 October until December 5, 2006, he was in an ICU unit at Walter Reed.
All this time I was asking about his vision, I kept being told, his vision does not matter at this time, we need to take care of his traumatic brain injury. And so he was transferred to Richmond at that point. I made that decision to transfer him to Richmond McGuire’s VA at that time. So then he continued to go on with his care.
They did have a BROS there and they did work with him, but the BROS got frustrated with all the bureaucracy and he left.
So we went from—he left in June of 2007, and so Brian went from 2007 of June until October when he went to West Haven, Connecticut, to the Blind Rehab Center before he had any more care. And so there was a big lapse there. And we kept being told that, you know, his vision is the last thing that needs to be worried about at this time. So we had no idea what was going on with his vision.
Once he got to Connecticut, we found out that his vision was a lot more extensive than what we were told.
So, therefore, my big question is, had we been given the appropriate information from the very get go, would I have gotten better care for him elsewhere and would he have strived better in other therapies along with getting visual therapy. And there is no—as far as I know it is not being documented anywhere how many visual impairments that there are. And I would ask you here; do any of you know how many are coming out of the combat zone that have visual impairments and if you do not, I challenge you to find out and start with getting documentation for this to get care for these soldiers. There has to be something documented somewhere. And not to take away from the amputees or any other signature wound, but we need to get stuff for traumatic brain injury with visual impairments.
Most people do not understand that the vision and the brain go hand-in-hand. And with my husband’s injury it is not from his eyes, it is from his brain injury. His brain will not allow his eyes to function to see. He can see straight ahead of him about eight degrees, no more. There is nothing on either side of him.
So I really strongly encourage that this panel makes something happen and it starts getting documented and money is out there to take care of these guys.
And again, I thank you for your time.
[The statement of Staff Sergeant Pearce appears in the Appendix.]
Mr. MITCHELL. Thank you.
Petty Officer Minney?
STATEMENT OF PETTY OFFICER GLENN MINNEY
Petty Officer MINNEY. Once again I would like to thank you, Mr. Mitchell and the rest of the panel for allowing me to speak today. It is easier to see this way.
I first joined the Navy on September 4, 1985, where I attended Basic Training and Naval Hospital Corps School in Great Lakes, Illinois. After doing a tour of active duty, I came back to Ohio and I joined the Reserves in Columbus, Ohio. At that point I was attached to Lima Company 3rd Battalion, 25th Marines.
On January 3rd of 2005, 3rd Battalion, 25th Marines was called to active duty to serve in Iraq. After spending two months at 29 Palms, California, doing a train up, we left for Iraq.
The 3/25 was assigned to Haditha, Iraq, and also to Hit. The majority of the battalion was assigned to Haditha Dam. A 10-story hydroelectric dam that was used as a firm base.
We had to make makeshift chow halls, sleeping quarters inside engine rooms, and a Battalion Aid Station in a electrical elevator room.
On April 18, 2005, at approximately 16:30, I was on the 10th story of the dam. While I was out trying to obtain medical supplies from a Conex Box, a mortar round hit the dam. At that point I was propelled backwards thrown up against the railing. Thank goodness there was a railing there, or I would have plummeted ten stories down. But I hit the rail. The next thing I remember, I was running towards the Battalion Aid Station. I remember a flash of light and that is it. I went back to the battalion aid station ready to assist in taking casualties.
Well the next day, I noticed my eyes were a little scratchy and a little red. I went to the battalion Aid Station and they told me, you have pinkeye. So they treated me for pinkeye. It continued on. A few months later I went back with the same symptoms. You have got pinkeye. I logged this into the sick call log. I was given Motrin and Erythromycin. But the primitive equipment that we had at the Battalion Aid Station just an ophthalmoscope was not really able to detect what was going on in the back of my eye.
At that point I noticed that I was becoming more of a liability than an asset because I would go out on patrols and I could not see well enough to fire my weapon.
I went to my battalion surgeon and I told him, I am losing my sight. He then notified Al Asad. I was medivaced Al Asad in August. From Al Asad to Balad to Homburg or to Landstuhl, Germany. Then from Landstuhl they sent me to the German hospital at Homburg, Germany, where I underwent two eye surgeries on the 16th and 17th of August.
You have got to excuse me for a moment.
After having my surgeries I was then sent home to Bethesda, Bethesda Naval Medical Center. From Bethesda they said I am still in the healing process, you have to go back to Ohio, and from there I was put on convalescent leave.
The second day I was home my eyes reattached. I lost my vision. I went to Grant Medical Center. They preformed another surgery that evening on me to help save my sight. From there I went back home and I had to lay face down for almost a month. I was not able to do anything. At that point no one knew who I belonged to. What unit does he belong to, because I am on convalescent leave and now I am passed my 30 days convalescent leave. No one wanted to take care of who I was so I was in limbo.
All this time I was at home. I went back to my VA to ask for care. I was told, you are active duty. You can not get care here. You have TRICARE. Well from that point I got upset and went to the associate directory who at that point said, you get all the care you need here Chillicothe VA.
I am instrumental for the Chillicothe VA for the simple fact they done something. They recommended I get an MRI of my head. But before they could do that I was sent back to Camp Lejeune to the Wounded Warrior Barracks for therapy and then that is where I had an magnetic resonance imaging (MRI) .
Ladies and gentlemen, Homburg, Germany, Landstuhl, Bethesda, Grant, none of these major medical facilities bothered to look inside my head. The VA did in there and that is when they were able to discover that I had a traumatic brain injury. I had lost a portion of my parietal and occipital lobe which works my eyes. They could not figure out, you have had three surgeries, how come your eyes are not getting any better. because you never bothered to look outside the box and look at my brain. Maybe that is where the problem was and that is why I am here today with Mr. Zampieri and Sergeant Pearce. We need to start looking, you know, look outside the box. There are other injuries that cause traumatic brain injuries.
And I would like to say this, at no time while I was in Iraq did I ever go on patrol or any of my marines and we said it is too costly to go down that alley, or go on this patrol because it is too risky or it is too costly.
Well now how come DoD and the VA can come back and say, well we cannot provide this care of that care because it is too costly. I never said it was ever too costly so why should these agencies say the same to me.
Thank you.
[The statement of Petty Officer Minney appears in the Appendix.]
Mr. MITCHELL. Thank you. Finally Dr. Zampieri is the Director of Government Affairs for the Blinded Veterans Association (BVA) and is here to discuss the nationwide implication of TBI related vision problems. Thank you.
STATEMENT OF THOMAS ZAMPIERI, PH.D.
Dr. ZAMPIERI. Thank you, Mr. Chairman and Ranking Member and other Members of the Subcommittee for having this hearing today.
The Blinded Veterans Association has been in existence for 63 years. Since the end of World War II and we’re trying to dedicate ourselves to helping all of our Nation’s blinded veterans and their families.
It is an honor for me to be here today with these two witnesses who served their country and did a great job. And it is sad though that in preparing for this hearing when I was asked how many witnesses do you have possibly to come and speak, there is at least 12 others with similar stories. And that should be very disturbing to the Members in this room.
These are not a couple, quote, accidents that fell through the cracks. And there are other cases out there that are very similar to this. And so hopefully, at the conclusion of this hearing today, there will be some major steps taken towards fixing this in regards to administratively and clinically better coordination between the Department of Defense and the VA in regards to all of the eye injured casualties returning.
The numbers seem to be a moving target here. When I first started this job three years ago, I was just asking people how many eye injured have come from either Iraq or Afghanistan? No one seemed to be able to tell me. And if you go back and look at some of my earlier testimonies from a couple of years ago, they were drastically lower. And in reality, if people had really started to look at this issue earlier, they would have realized from looking at the International Classification of Diseases (ICD)-9 codes that the VA had, and also DoD, that the numbers were growing rapidly as early as in 2005. Here we are in 2008, the most recent numbers that I can come up with is close to 1,400 combat-eye injured, battle-injured eyes. And there is another component, which is the reason for this hearing is the traumatic brain injuries and the visual impairments associated with TBI.
So individuals who can have the penetrating eye injuries from battle-related injuries, they are obvious. But the ones that come back who have had repeated head concussions and have suffered from a traumatic brain injury like with Glenn Minney and Sergeant Pearce, their injury is in the back of the brain are effecting their vision. And with their other emphasis on other types of manifestations neurologically of these TBIs, I think what happens is a lot of times the initial assessment is, well, your eyes appear normal. And both of these gentlemen have been told by people who have come up to them and said, well your eyes look okay there must not be anything else wrong.
The neurological pathways in the brain — I put a lot in my testimony, not to overwhelm anybody, but I think it is important that people understand one critical thing here today. That vision is 70 percent of our awareness of our environment. The other senses that you learned about in school as far as hearing, touch, smell, taste, we are visual animals. And so if you have a traumatic brain injury and any of these different pathways are disrupted as in my written testimony, it can cause a huge number of different types of visual problems. Anywhere from color blindness to loss of peripheral field vision, depth perception and all of these various neurological complications from TBI that effect vision will effect everything else. Rehabilitation, vocational training, it is certainly is going to have a negative impact on employment. And so we worked with Congress last year to get the Military Eye Trauma Center of Excellence included in the National Defense Authorization Bill as part of the Wounded Warrior legislation and I appreciate and thank the Members in this room who helped get that passed.
I think it was everybody’s intent that the DoD would establish a TBI Center of Excellence, a PTSD Center of Excellence and a Military Eye Trauma Center of Excellence. And that these centers would collaborate, work jointly, provide follow-up, best practices, look at what is going on in regards to the specific types of neurological research, both in eye and vision research, but also in other areas. They would be educators of the different practitioners that are dealing with these types of injured casualties coming into the VA and the DoD facilities. And importantly, also work with the families. One of the things that has bothered me the most about this is when I meet with a lot of these servicemembers families who have had eye injuries they are rarely given much information about what is low vision. You know, what would happen if Glenn Minney or Sergeant Pearce is—if they are transferred into the blind rehabilitative centers.
You know, the good news is, there is always—I try any way to balance bad news with good news. The VA—and I thank former Secretary Nicholson, and Dr. Kussman. The VA started planning a couple of years ago for the full continuum of care for low vision and blind veterans. And they have implemented and started to open a large number of outpatient specialized clinics with ophthalmologists and optometrists and with blind rehabilitative specialist and vision specialists and they are in the process of hiring these people. There are about 54 different VA Medical Centers that have been identified to have these new types of programs and so they are ideal for not only the aging population of veterans that they were created for with degenerative eye diseases, but for this generation who have different types of visual impairments that need care and services.
Again, you ask though, does DoD know where these sites are, are they working collaboratively, are they providing accurate numbers to the VA people. I doubt it. And so my experience has been that the moving numbers here are amazing.
Basically, I included a lot of recommendations and hopefully you’ll look at those and consider them. I do want to stress again that my interaction with the VA and DoD ophthalmologist and optometrist is, I am amazed and impressed at their abilities. And if you go back historically and look at the results of eye trauma from World War II, most of those soldiers just lost their eyes. They were surgically removed. And today due to advanced skills of the ophthalmologist serving in Iraq and in Landstuhl, Germany, and the surgeons at Walter Reed and Bethesda, I have the greatest respect for what they are doing. It is just simply amazing.
So this is not a hearing about a healthcare problem in the sense of are they not doing something medically that they should be doing. And I just wanted to stress that. This is about the age old problems of two bureaucracies talking to each other facilitating the implementation of this Military Eye Trauma Center of Excellence as Congressman Boozman and I had hoped, and make this work. And so again, I appreciate this opportunity to testify today and will be willing to answer any questions and thank you all again for having this hearing.
[The statement of Dr. Zampieri, appears in the Appendix.]
Mr. MITCHELL. Thank you. I have a question of Mr. Pearce. Is there any care that you are currently receiving that you need? Let me put it this way. Is there any care that you are not currently receiving but need, or could it be better?
Ms. ANGELA PEARCE. I would like to answer that if you do not mind. The care that we received—that Brian has received from the VA has been excellent. I was left with the decision of where do I take my husband after he comes out of the ICU Unit. He spent 47 days being in the ICU Unit and one day on the floor at Walter Reed. We didn’t have a good experience at Walter Reed.
So, you know, and I had heard all these horror stories about VA. So then it was left up to me to make a decision where do I take my husband now. And so I chose Richmond. The only reason I had chose Richmond is I had had a friend there previously. I had to go off and leave my seven and eight year old, at the time, in Alaska to come be by his bedside. So we are originally from Ohio. We were going to send the kids to Ohio with family. Okay, Richmond is the closest place for me to be able to get with my kids if I need to. I am glad that I made the decision to take him to Richmond. He has received wonderful care there. And I did take him there knowing that they did not have a full-blown blind rehab center. But again, you have got to remember, I was told, do not worry about his vision, that is the last thing we need to worry about. Had I been told more, I would have probably chose somewhere different to take him and that is the question I have to ask, and I will continue to ask. Had I known ahead of time more about his visual impairment would I have chose Richmond? Probably not. He got good care there, but not for his vision.
So that makes me wonder, did we—was he able to get and gain all the therapy that he really needed? If I would have taken him to Palo Alto would he have gained more from there and be further along now?
So as far as your question, we received great care there. And we still continue to receive great care there. Brian.
Staff Sergeant BRIAN PEARCE. The only thing I will add is that, and it is kind of—it goes away from your question a little bit, but it goes back to the same thing with the eyes and the vision and not knowing. When we left Walter Reed and we went to Richmond the answer was or their statement was, do not worry about the vision, the main problem is the TBI. That is the main thing we kept hearing all the time. Do not worry about your vision, worry about your TBI. Do not worry about your vision, worry about the TBI.
Well I spent 16 years in the Army, and learned from day one to know that bad news does not get any better with time. You are not going to wake up on the fifth day and all of a sudden it is good news. It is not going to happen.
Telling me at day one, son, you are blind. I got it. Okay, let me move on and live with it. And they did not do that. They need to start being up-front about what is there, and what you have got to live with. I have a whole new norm now I have to deal with and an eight and a nine year old and—well they are now nine and ten—a nine and a ten year old and a wife that I have to try and figure out how I am going live a new norm for a lifetime with.
Mr. MITCHELL. Thank you. Mr. Minney can you give us some suggestions that could improve the VA outreach to veterans who have been injured with TBI that later are experiencing vision problems?
Petty Officer MINNEY. The one thing that I can see is there needs to be more of a communication between DoD and VA. When an individual is in the military they have a health record jacket. I had mine, so the VA was able to go back and look at that. But there are guys that come in to the VA system that do not have a health record so when they start their process, their transition from DoD to the VA, there is no health record. So the VA has to start from ground zero and this servicemember has to go through every physical exam, every bit of treatment that he went through through DoD once again through the VA. If those records were just taken from DoD—if DoD would just share them completely with the VA there would be a better seamless transition there. That is one thing that I can see that could help with the visually impaired. Because every eye exam, which some of them are painful, that I have had to go through, I had to go through three and four times, because the VA said well we do not have copies of your military health record we have to do it all over again. Well it just so happens being a good corpsman, I kept copies so I didn’t have to go through every eye exam. But there are guys out there that do. They have to go through every physical evaluation all over again.
Mr. MITCHELL. Thank you. We have heard that same story since we have been having these hearings.
Ms. Brown-Waite?
Ms. BROWN-WAITE. Thank you, Mr. Chairman. Dr. Zampieri when I look through your testimony there were different estimates in there of the number of blinded veterans as a result of serving in Iraq and Afghanistan. What is the final number, I mean, as of maybe the beginning of this year even? Because there seems to be conflicting percentages and numbers and is—and in your testimony, I think, you mentioned that there was an official report. What was that number and is it an official report? I think it said “estimated to be.”
Dr. ZAMPIERI. Yes, thank you. The numbers, I think, are like trying to get the accurate numbers on traumatic brain injuries at large and unfortunately, you know, I have been told recently that the number last September was this number that I put in there of 1,162 as of September 17, 2007. Now these are not all blind and I am glad you asked that question. The VA is aware of approximately 100 to 104 OIF/OEF veterans who are legally blind, which is 2200 or less or 20 degrees of peripheral vision loss or less.
So the actual number who are blind is a small percentage, really of the total number though have suffered major eye injuries. And what one of our biggest fears is that the ones that had initially successful surgeries the other 1,100, are at risk if they get lost between the systems and do not get follow up of complications. And there is three common complications, to make a short answer long, that most ophthalmologists are very concerned with this population of veterans and that is traumatic cataracts, glaucoma and detached retinas that can occur seemingly almost at anytime after somebody has sustained a traumatic injury. And these are types of things that normally in the private sector ophthalmologists or optometrists would see in a very old population of individuals.
We think of glaucoma as something that our parents get. We think of cataracts as something a 70-year old gets. But I met a 24-year old Army sergeant with cataracts. I met a 28-year old Army lieutenant who was blinded in his right eye. His right eye was enucleated in Iraq, and surgically removed. His left eye was, quote, normal but they found at Walter Reed fortunately when they tested him just before he was to be discharged he had glaucoma with pressures equivalent to what a 65 year old might have.
So the actual number of blinded individuals that are enrolled in the VA Visual Impairment Service Team Program is about 104, but there is these other 1,100 or 1,200 out there that have sustained major eye injuries. And then the experts who will testify later may tell you that there are neuro-ophthalmologists who believe looking at the TBI data and private research numbers that as many as 7,000 TBI patients probably, which is in my testimony, have some type of visual TBI impairment. And when you look at hearing loss and vision loss combined, I would say that this is sort of like the silent epidemic from the war that most people have not really started to add up and look at. So thank you.
Ms. BROWN-WAITE. Thank you very much. The conditions you described, the cataract condition, the glaucoma, and detached retina, when you have those technically that is where you are considered legally blind. In most States that would be the definition of legally blind, am I correct?
Dr. ZAMPIERI. Yes. They can result in blindness especially the detached retinas and the glaucoma.
Ms. BROWN-WAITE. Right.
Dr. ZAMPIERI. In fact, there was recently a survey. The National Eye Institute did a survey of Americans and they asked them, you know, like do you recognize information or do you know about glaucoma. And only eight percent of the Americans that they surveyed said that they had any idea that glaucoma does not cause any symptoms. There is no pain. There is initially no problems that the person is going to be aware of. And then suddenly the pressures-–if they last long enough on the optic nerve they will go blind.
Whereas cataracts can be operated on and removed and the vision will return. I guess one of the interesting things about cataracts though is when you do cataract surgery in a 70-year old, most ophthalmologist are well aware of, you know, ten years later what might happen. I do not think many people have a lot of experience with 24-year old who have had cataract surgery what will happen to them when they are 45 years old or 60 years old.,
So there is a great need here for a lot of long-term longitudinal research on all of these types eye injured casualties. And those are great questions.
Ms. BROWN-WAITE. Thank you very much doctor. I yield back the balance of my time.
Mr. MITCHELL. Thank you. Mr. Space?
Mr. SPACE. I thank you, Mr. Chairman. Mr. Minney how much time expired between the date of your injury and the date that you were diagnosed with traumatic brain injury?
Petty Officer MINNEY. My injury was in April of 2005 and I want to say I was diagnosed with a traumatic brain injury in February of 2006.
Mr. SPACE. So roughly ten months?
Petty Officer MINNEY. Yes.
Mr. SPACE. And that would have been after the magnetic resonance imaging (MRI)?
Petty Officer MINNEY. No the MRI is what discovered the brain injury.
Mr. SPACE. Right. But you were not diagnosed until you had the MRI done?
Petty Officer MINNEY. Right.
Mr. SPACE. I understand that was recommended by a VA facility.
Petty Officer MINNEY. Yes, they had recommended it but I was at Camp Lejeune so—
Mr. SPACE. It was within the jurisdiction of the Department of Defense. And you had been in a number of medical providers prior to that under the ambit of the DoD and not once had anyone recommended an MRI until the VA recommended it?
Petty Officer MINNEY. No MRI, no CAT Scan, no X-ray. No one even bothered looking at my head. Everyone was focused on my eyes.
Mr. SPACE. And they were obviously aware that you had been subjected to a blast and were having vision problems throughout that entire period. A deteriorating condition, no less, correct?
Petty Officer MINNEY. Yes.
Mr. SPACE. Do you have any idea as to why no one thought of doing an MRI prior to 2006?
Petty Officer MINNEY. No, I do not. I just think that they were just focused on the eyes and they did not want to think outside the box and think that maybe there was a brain injury that was related to the eyes. They did not put two and two together.
Mr. SPACE. Alright. Do you think cost might have been a factor?
Petty Officer MINNEY. I do not know.
Mr. SPACE. Okay. Had the Department of Defense diagnosed TBI, let us say within six weeks or a month or a week after your injury, would that have had an affect on your condition or made a difference in your prognosis for recovery?
Petty Officer MINNEY. It may have made a difference in my recovery. I could have started my speech therapy sooner. I could have started my cognitive therapy sooner.
Mr. SPACE. So you were delayed essentially for ten or 11 months in all that?
Petty Officer MINNEY. Yes.
Mr. SPACE. Apart from the eye conditions that you suffer from, did the brain injury manifest itself in any other ways?
Petty Officer MINNEY. Yes. I have cognitive thinking disorder. I have short-term memory loss. There are things that happened before my injury in my life that I do not remember now. And I have some associative disorders that I have to go through speech therapy with. I can be speaking and sometimes forget the next word. So I am going through therapy to help me learn to speak and basically to think all over again in a different way.
Mr. SPACE. I thank you again, Mr. Minney for your testimony.
Dr. Zampieri, I have one or two brief questions for you. What can the VA do better, or the Department of Defense for that matter, in tracking or effectively screening and/or diagnosing TBI and/or ophthalmological conditions that might not otherwise be readily apparent from a visual inspection?
Dr. ZAMPIERI. Thank you. I guess sort of the gold standard that I have really been impressed with is what is going on a Palo Alto. They are just doing some exceptionally great screening out there. And, you know, I guess if I were wave the magic wand and be up in a high enough level in DoD of VA I would say, okay, we need to replicate the types of optometry/ophthalmology/blind rehabilitative specialist that are at Palo Alto that are working and screening all these TBI patients at least initially through all of the VA Polytrauma Centers.
Mr. SPACE. Would the implementation of the Military Eye Trauma Center of Excellence that you referred to in your testimony be of assistance in that regard?
Dr. ZAMPIERI. Yes, it would be huge.
Mr. SPACE. Okay.
Dr. ZAMPIERI. Because, you know, I think most people envision that the Eye Trauma Center of Excellence would be sort of the lead coordinator of this and make sure that people like Angie and Glenn Minney’s wife, Gretchen, that they get information. Again families need to have information about where in the VA they can get help and assistance. The Eye Trauma Center of Excellence should not be viewed though is like all patients with eye injuries are going to go to one place.
Mr. SPACE. Right.
Dr. ZAMPIERI. But it should be, you know, I mean, they are setting up the TBI Center of Excellence and the PTSD Centers of Excellence to facilitate and coordinate those injuries and someone telling me, well we will send them to the eye clinic for the eye part. No.
Mr. SPACE. Right. And I have exceeded my time, but I just, with the consent of the Chairman, would like to ask one additional question?
Thank you, Mr. Chairman. Is there, in your opinion, one specific factor that you can point to that represents a barrier to the establishment or the implementation of that Center of Excellence?
Dr. ZAMPIERI. I hate to say this, you know, because you fund the VA a huge amount and you funded DoD a large amount but I have been sort of told that well the $5 million wasn’t included to cover the Military Eye Trauma Center of Excellence, therefore, we are going to set up a computer registry which is an important part of this. And there are actually DoD and VA ophthalmologists and optometrists that are working from a clinical standpoint to develop the computer registry. But that is not the end of this. I mean, these guys will tell you, I am not a number in the computer registry with a diagnoses and peripheral field measurements and a surgical op note, you know or whatever other various things that are in that registry which is important. But these other things. The research and the best practices and the continuing education of the other providers.
So I am just stunned when I am told, well Congress did not include the $5 million so, therefore, we are not going to implement this but we will set up the computer part. No. And I am embarrassed to have to ask, well could you guys put the $5 million in somewhere. I just cannot believe I am even saying that in front of you. It is terrible.
Mr. SPACE. I appreciate your candor. Thank you Doctor, thank you Mr. Minney and Sergeant Pearce.
Mr. MITCHELL. I thank you. Mr. Boozman?
Mr. BOOZMAN. Thank you, Mr. Chairman. I am an optometrist, an eye doctor, and I have dealt with low-vision patients, people that had impaired vision for a long time. I actually set up the low-vision clinic at the Blind School in Arkansas. The very first one, so I really do have a lot of experience in that regard.
I can say that what you all went through early on, being somebody that treats folks in that—I am not a surgeon, but again being in a position of trying to figure out what is going on. I think with the literature that was available there, our experience that is available you could almost look at your care and understand what was going on. Now, there is a difference because of the fact that we do now understand exactly what we did not understand exactly then. But we understand that there is a mechanism associated with TBI that very much effects vision and because of the prevalence of TBI this is something that, you know, we have got to pursue. As a result, we were able to work with most of the Committee and several others. Dr. Zampieri has been wonderful in helping us establish the Department of Defense Excellence—the Center, you know, what we have been talking about. The problem again is funding. And so the law is in place. I really, you know, I appreciate your testimony.
Sergeant Pearce, your six things that we need to do, you know, this does that. Okay. Exactly, and a lot of other things. You know, we need to follow up and get you guys fixed up. I am not real upset that what happened to you happened in the way it did in the sense that, you know, generally recognized things were practiced. Where I am going to be very upset is the guys that this happened to since this law has passed. And as Dr. Zampieri referred to, it has not been funded and is not being done then that is where we are going to get upset. There is no excuse now. Again, based on what we have learned from you guys there is no excuse now not to follow up on that. And this particular law actually came from the ophthalmologists and optometrists that are out there fighting the battle. They came to us and said, look, we need to do this. And so I really do appreciate your testimony. Hopefully at this point, you know, we will go forward and make sure that individuals that have run through the same problem because of the fact that we have identified the problems that you have had now that we can forward and then also continue to get the treatment that you need.
Let me ask one thing and you might address this Dr. Zampieri. There is a little bit—in the testimony we learned that there is a discrepancy in the different Polytrauma Centers as far as what they have got available to treat eye injuries. Can you address that? Is that acceptable in the sense that we are better off kind of clustering folks that need the intensive low-vision treatments or this or that or do we need to have the same care at every center? Does that make sense? In other words, Richmond did not offer one thing. Should all of these be offering the same thing or are we better off having this specialized at some centers versus the others?
Dr. ZAMPIERI. Yes. I guess again the model—and to be fair Palo Alto had the infrastructure because they had the Blind Center there. So they did have additional staff that the other three VA Polytrauma Centers would not normally have. And they were able to draw upon som
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