Joint Hearing of the Committee on Homeland Security and Governmental Affairs of the U.S. Senate and the Committee on Veterans’ Affairs of the U.S. House of Representatives at 1:00 p.m. CDT.
Witness Testimony of Thomas Zampieri, Ph.D., Blinded Veterans Association, Director of Government Relations
Chairman Michaud, Ranking Member Miller, and Members of the House Veterans Affairs Subcommittee on Health, on behalf of the Blinded Veterans Association (BVA), thank you for this opportunity to submit our testimony on VA Research Programs. BVA is the only congressionally chartered Veterans Service Organization exclusively dedicated to serving the needs of our Nation’s blinded veterans and their families. BVA has now worked for more than 62 years with VA Blind Rehabilitation Service in order to improve VA’s ability to provide high quality outpatient and inpatient rehabilitation training for blinded veterans.
BVA appreciated the approval granted earlier this year by former Secretary Nicholson and Under Secretary of Health Dr. Kussman for a three-year, $40 million expansion of the full continuum of blind and low vision outpatient rehabilitation services. With the now growing numbers of wounded entering the VA health care and benefits system from both Operation Iraq Freedom (OIF) and Operation Enduring Freedom (OEF), along with the large numbers of aging veterans with degenerative eye diseases, this expansion of clinical services is vital.
As of September 25, 2007, a total of 27,767 servicemen and women had been wounded in Iraq. The number of men and women requiring air medical evacuation from Iraq between March 19, 2003 and September 17, 2007 was 8,298, of which 1,162, or 13 percent, had sustained combat eye trauma. The 13 percent figure represents the highest percentage of eye wounded for any of the American wars of the past 100 years.
The staggering nature of these numbers reflects the probability that young veterans will, in the very near future, depend on VA blind and low-vision services in order to live independently in their own homes and, hopefully, enter the workforce once they have fully recovered from their injuries. According to the Defense Veterans Brain Injury Center (DVBIC), some 3,900 of the Traumatic Brain Injured personnel have sustained injuries sufficiently severe that they are experiencing neurosensory complications. Epidemiological Traumatic Brain Injury (TBI) studies have found that 80 percent of the these 3,900 complain of visual symptoms related to their TBI while 62 percent have associated neurological visual disorders of diplopia, convergence disorder, photophobia, ocular-motor dysfunction, and an inability to interpret print. Some TBIs result in visual field loss with enough loss to meet the standard for legal blindness. Like other generations of disabled veterans who have desired to live independently, the current generation of OIF and OEF veterans deserves the same opportunity.
PREVALENCE AND INCIDENCE OF BLINDNESS
Low vision or blindness affects one in 28 Americans over the age of 40, which amounts to approximately 3.3 million Americans. This 2004 figure, when broken down, consists of 2.3 million Americans with low vision and about one million being legally blind. Every year, 200,000 Americans develop age-related macular degeneration, which is the most common cause of blindness in people over age 65. Diabetic retinopathy is the most frequent cause of new blindness in individuals between 40 and 65. People who move from visual impairment to blindness have a 50 percent greater chance of becoming injured or depressed and a 2.5 to 3 times greater chance of needing skilled nursing or a long-term care facility.
Approximately 648,000 Americans age 80 and older are blind. While only 4.3 percent of the 65 and older population live in nursing homes, 16 percent of those who are visually impaired and 40 percent of those who are legally blind reside in nursing homes with an estimated cost of close to $11 billion in direct nonmedical costs for seniors with visual disorders. By 2020, the number of Americans age 40 and over with low vision or blindness is projected to reach 10.5 million, almost three times what it was in 2004.
VA estimates that there are currently 169,000 legally blinded veterans throughout the country, of which 47,450 are enrolled in Veterans Health Administration (VHA) services. The number is projected to reach 55,000 within ten years. In addition, blindness within the total veteran population of 24 million is expected to increase over the next two decades, just as it is increasing within the general American population from glaucoma, macular degeneration, diabetic retinopathy, and cataracts.
It should be clear to Members of this Committee that a new generation of OIF and OEF blinded and impaired low vision veterans will require specialized research programs to meet their needs. The older veterans who are now beginning to lose their sight have equally important needs. Rehabilitation research programs for both groups and their families must be individualized.
ECONOMIC AND SOCIAL IMPACT
- Of the $68 billion annual cost of vision impairment and eye disease as estimated by the National Eye Institute, the annual financial burden to the American economy of blindness and low vision in adults age 40 and over--driven in large part to advanced macular degeneration, cataracts, diabetic retinopathy, and glaucoma--is estimated at $51.4 billion. This includes $16.2 billion in direct medical costs, $11.2 billion to other direct costs, and $8 billion in lost wages and productivity, as well as $16 billion in excess monetary impact due to vision loss. The following points illustrate the potential importance of vision rehabilitation research in reversing the negative consequences of loss of sight in our veteran population. It is seven times more expensive to provide nursing home care for a blind individual than for one that is trained and able to function independently at home. Falls associated with vision loss is the sixth leading cause of nursing home admissions.
- “The Employment Experience of Persons with Limitations in Physical Functioning,” a University of California study published in 1999, found that even after adjusting for age and gender differences, persons reporting functional limitations are less than half as likely to be in the labor force as those with no functional limitations. Part-time employment and job loss are also more common among persons with functional limitations. Three quarters of those experiencing a job loss reported that the loss created a major problem in their lives. Only half of those with no limitations reported that the problem created by the loss was a major one.
- Literature reviews on employment among persons with disabilities indicate that such persons experience lower labor force participation rates, higher unemployment rates, and higher rates of part-time employment than persons without disabilities (Yelin, 1997; Bennefield & McNeil, 1989). These findings are consistent across numerous national surveys, including the Current Population Survey (CPS), Survey of Income and Program Participation (SIPP), the National Health Interview Survey (NHIS), a survey of Trupin and Armstrong in 1998, and a survey of Trupin, Sebesta, Yelin, and LaPlante in 1997. Disabilities in these studies are defined as factors that limit work capacity and functional activity (McNeil, 1993).
- The National Health Interview Survey (NHIS), conducted by the National Center for Health Statistics (NCHS) and reported in a March 2003 article, revealed that working age individuals with visual impairments had lower employment rates and lower mean household incomes than those without visual impairments. The employment rate was 54 percent for the severely visually impaired age 18-54 in statistics compiled in 1994-95.
- The National Organization on Disability Research found that, despite improvements in transportation during the past decade, inadequate or inaccessible transportation was reported by 30 percent of the disabled. The lack of transportation made employment, social participation, and commercial activities less likely, causing increased depression and medical costs.
- In the aforementioned study, lower mean household incomes and lower employment rates were found among those with disabilities related to mobility (43.3 percent rate of employment), agility (46.0 percent rate of employment), speaking (41.7 percent employment), mental function or ability to learn (47.5 percent employment), hearing loss disability (62.7 percent employment).
- A study by Hendricks, Schiro-Geist, and Broadbent (1997) at the University of Illinois showed a link between disability and employment outcomes for those who had, from 1948 to 1993, completed both a university education and rehabilitation services. Using a regression analysis for those disabled with a degree, the study revealed a salary gap of 8.3 percent between disabled and nondisabled workers. While this and similar other studies have found that the disabled with higher education and rehabilitation earn more than the disabled without this level of education and training, the income levels and earning capacity are still lower in all comparisons with working age non-disabled individuals.
- National Council on Disability (NCD) today October 1, 2007, on the first day of National Disability Employment Awareness month, released a report that presents the best practices in the public and private sectors and the promising public policies and initiatives that increase employment opportunities for people with disabilities. However, the employment rate of working age people with disabilities remains still only half that of people without disabilities (38 percent compared with 78 percent in 2005).
NEUROLOGICAL IMPACT OF TBI DYSFUNCTION
Perception plays a significant role in our ability to live life. It aids in providing information about the properties in our environment and allows us to act in relation to those properties. In other words, our perceptions provide us with the means to experience our environment and live within it. We perceive what is in our environment by a filtered process that occurs through our complex neurological visual system. Although all senses play a significant role, the visual system is one of the most important, providing more than 70 percent of our sensory awareness. With various degrees of visual loss, we are no longer able to clearly adjust and see our environment, resulting in increased risk of injuries, loss of functional ability, and unemployment. Impairments range from an inability to successfully navigate one’s visual field to loss of visual acuity, loss of color vision, photophobia, and difficulty in recognizing faces.
Among the numerous ways one can acquire visual deficits, and a leading one at that, is injury to the brain. Damaging various parts of the brain can lead to specific visual deficits. Although some cases have reported spontaneous recovery, complete recovery is unlikely and early intervention is critical. Currently complex TBI-visual research is being examined in an attempt to improve the likelihood of recovery. The training of certain areas of the brain has been found to improve vision deficits in some disorders. Nevertheless, researchers have stressed that the extent of recovery can be limited and will usually require long term follow-up often with specialized adaptive devices and prescriptive equipment.
The brain is the most intricate organ in the human body. Visual pathways within this vital organ are also very complex. Due to the interconnections between the brain and visual system, damage to the brain can bring about various cerebral visual disorders. The visual cortex has its own specialized organization, causing the likelihood of specific visual disorders if damaged. The occipitotemporal area is connected with the "what" pathway. Thus, injury to this ventral pathway leading to the temporal area of the brain is expected to affect the processing of shape and color. This can make perceiving and identifying objects difficult. The occipitoparietal area (posterior portion of head), on the other hand, relates to the "where," or "action" pathway. Injury to this dorsal pathway leading to the parietal lobe will increase the likelihood of difficulties in position (depth perception) and/or spatial relationships. In cases of injury, one will find it hard to determine an object's location and may also discover impaired visual navigation. It is also highly unlikely that a person with TBI will have only one visual deficit. He/she will usually experience a combination of deficits due to the complexity of the organization between the visual pathway and the brain. The most common cerebral visual disorder after brain injury involves visual field loss. The loss of peripheral vision can be mild to severe enough to result in legal blindness. It requires specific visual field testing to be correctly diagnosed and different prescribed devices to adapt to this loss. While the DVBIC reports about 10% as severe open head injuries, most TBI cases are closed head injuries that can result in a variety of visual deficits from overt to subtle.
In addition to considering these complex neurological effects on the patient, BVA would ask Members of this Subcommittee to consider the huge emotional effects of TBI on the service member or veteran when deciding what level of support should be given to research in this area. These emotional effects may be equaled or even surpassed by those inflicted on the patient's family. Brain injuries are known for causing extreme distress on family members who must take on the role of caregiver in addition to facing the many other challenges associated with this type of injury to a son, daughter, father, mother, brother, sister, or even an extended family member.
VA MEDICAL AND PROSTHETICS RESEARCH
BVA has supported investments in veteran-centered research projects within VHA. Such projects in the past have led to an explosion of knowledge that has advanced the understanding of many different diseases and unlocked strategies for prevention, treatment, and cures. Additional funding is needed to take advantage of the burgeoning opportunities to improve the quality of life for our blinded and low vision veterans and for the Nation as a whole. VA must concurrently address the needs of its longstanding patient base as well as the evolving challenges being presented by our newest war-wounded veterans. With increased directed vision research funds, it is expected that VA will begin pursuing the following in Fiscal Year 2008: new adaptive prosthetics, aging vision diseases, and specialized vision research. This funding increase should also allow for an increase in funding for Rehabilitation Research & Development (RR&D), now so desperately needed with the ever-increasing numbers of combat eye injuries. BVA points to the success of new retinal research of great importance, the continuation of RR&D initiatives in Boston, where investigators are working on the development of artificial retinal implants for those with vision loss due to retinal trauma.
Examples of four separate categories identified by the National Alliance for Eye and Vision Research (NAEVR) as vital vision research are listed below. NAEVR believes that such research is sufficiently significant that it be supported by Members of Congress and utilized by both DoD and VHA.
Eye Trauma, Healing, Infection/Inflammation Control, and Rehabilitation
This research relates to acute and chronic implications of corneal and retinal eye trauma, healing, infection/inflammation control, and associated vision rehabilitation.
- Treatment of eye trauma caused by a physical, chemical, or biological agent insult; associated healing; and infection/inflammation control (including infections associated with skin around the eye, the corneal surface, or within the ocular globe, and the impact of environmental conditions that promote infection).
- Ocular surface reconstruction and treatment of corneal damage by corneal transplantation or through corneal stem cell transplantation.
- Retinal and optic nerve regeneration (through identification of the genes involved and associated gene therapy, or through other biomedical processes).
Visual Function/Visual Acuity
This research relates to the metabolic and physiological processes that relate to visual clarity, contrast sensitivity, and spatial orientation.
- Impact of metabolic modulation or stress on visual acuity and contrast sensitivity (i.e. effect of lowered blood glucose levels on central vision).
- Visual image processing (better understanding of the biological/electrochemical interface in the vision process to improve acuity and advance “artificial vision” and other assistive technology).
- Sensory dysfunction associated with TBI, such as extreme light sensitivity (photophobia).
- Spatial orientation processing (relation of motor control and perception, especially relating to depth perception of objects in a visual field) to enhance peripheral vision.
- Next-generation refractive error correction and vision augmentation research (i.e. LASIK, visual implants/prostheses, and associated corneal healing issues).
Vision Health Disparities
This research relates to characterization of visual disparities based upon gender, race, or age, and determination of the underlying physiological basis to develop treatments and therapies.
- Epidemiological studies of military populations to determine extent/physiological basis of vision health disparities (i.e. greater incidence of glaucoma, cataracts, and diabetic retinopathy in the African American/Native American/Hispanic populations).
- Research into low vision caused by traumatic eye injury or chronic eye diseases such as age-related macular degeneration or glaucoma.
- Age-related macular degeneration research (leading cause of blindness in the United States and the leading cause of blindness in Americans age 60 and over).
Emerging Adaptive Technology Research
- Optimal vision rehabilitation management after acute injury, facilitating the advancement of evidence-based best practices for blind and low vision rehabilitation. This could become possible by the joint funding of RR&D and HSR&D projects that target the development of rigorous, solid best practices guidelines with a strong emphasis on vision loss resulting from neuro-trauma. It would also address visual impairment concerns of minority veterans, rural veterans, and other key target groups.
- Establishment of a Blind Rehabilitation Service-focused technology evaluation and assessment center in conjunction with experienced blind agencies charged with identifying the highest quality of vision rehabilitation through independent, scientific testing on both devices and training. Emphasis would be on quick, timely turn around of results so veterans can access these newly proven adaptive technologies.
Serious combat eye trauma occurring in Operation Iraq Freedom and Operation Enduring Freedom has become the third most common injury in both of these conflicts. Only PTSD and TBI are now more common. We urge all members of this Subcommittee to support H.R. 3558, the Military Eye Trauma Treatment Act of 2007. The act creates a Center of Excellence and Eye Trauma Registry. Already having included the provisions for the establishment of PTSD and TBI Centers of Excellence in the Wounded Warrior Act, Congress could now, with this critical legislation, substantially improve the multidisciplinary coordination, treatment, rehabilitation, and research of eye trauma as it relates to TBI. Visually impaired service members and veterans within both the DoD and VA systems are depending on passage of this bill. We respectfully request that it be passed soon.
BVA supports specialized, directed research programs in the area of vision that will benefit the aging population of blinded and visually impaired veterans. The Association also strongly supports language in the House Armed Services appropriations that includes recommendations for more research for traumatic vision injuries. Together with NAEVR’s advocacy, BVA strongly requests that “Eye and Vision Research” maintain its eligibility for funding within the Congressionally-Directed Medical Research Program (CDMRP) in FY 2008 Department of Defense (DoD) appropriations. BVA also believes that such funding must be significantly increased from the limited $4.8 million appropriated in FY 2007.
Chairman Michaud and Ranking Member Miller, BVA expresses thanks to both of you again for this opportunity to present our testimony. The current need to increase VA research is tremendous when considering the overwhelming numbers of veterans suffering from traumatic visual injuries, traumatic brain injury dysfunction, and age-related causes of blindness. The future strength of our Nation depends on the willingness of young men and women to serve in our military. This willingness depends, in turn and at least in part, on the willingness of our government to meet its full obligation to them as veterans.
Clinical Update: Cataract
Wounds of War: Part One: Eye Surgeons in Iraq and Afghanistan
By Denny Smith, Senior Editor
May 2006 Edition
American Academy of Ophthalmology Web Site: www.aao.org
Original URL: http://www.aao.org/aao/publications/eyenet/200605/comprehensive.cfm
The cost of war is often counted in fallen soldiers. But war’s survivors, both soldier and civilian, may also pay a tremendous price, by enduring traumatic, disfiguring and life-altering injuries. Ophthalmologists, like many other physicians and medical workers, have been tending the wounded in Afghanistan and Iraq for over three years now. More than 17,000 American servicemen and women have been wounded since the U.S.-led invasions began.1
“The survivors often have very bad injuries, and there’s no way to completely repair many of them,” said Thomas H. Mader, MD, a retired U.S. Army colonel who served in Iraq in 2004 and who is the primary author of a recent report in Ophthalmology describing ocular and adnexal injuries treated by U.S. Army ophthalmologists.2 “Occasionally you treat a patient with a relatively minor injury, which can be repaired in 10 minutes and the prognosis is excellent. But then there are explosive globe injuries, and other terribly mutilating trauma, where there is absolutely no chance at all of salvaging the eye.” Dr. Mader is now practicing ophthalmology at the Alaska Native Medical Center in Anchorage.
Eye and brain injuries appear to be more frequent in Afghanistan and Iraq compared with previous U.S. conflicts, even though the number of deaths per injured troops has decreased. This apparent spike in head injuries is partly a statistical illusion: The body armor of troops in Iraq and Afghanistan, much improved over what soldiers had in World War II, Korea and Vietnam, protects internal organs but not faces and limbs. So, ironically, doctors now confront profoundly injured troops who once would have died of massive thoracic or abdominal wounds before nonfatal injuries to eyes and extremities got medical attention.
For Every War, a Dread Weapon
Many of the injuries logged in Iraq result from disastrously effective improvised explosive devices (IEDs). These are simple, homemade bombs, such as artillery shells filled with glass or rocks, that are detonated remotely as troop convoys pass by. The sheer concussive force of IEDs is dangerous in itself, but most injuries are related to debris propelled by the blast. “These fragments can range in size from a grain of sand to something the size of your fist,” said Dr. Mader.
Sean M. Blaydon, MD, is a former lieutenant colonel who commanded the Army’s first eye surgical team to be deployed in the Iraq conflict, in 2003 and 2004. “Roadside bombs became more common as the conflict dragged on,” said Dr. Blaydon. “Many of the injuries were devastating, including large areas of the face or both eyes. It’s very troubling to see young kids with both eyes missing. I don’t know anybody who didn’t get personally affected by it.” Prior to his service in Iraq, Dr. Blaydon was director of ophthalmic plastic, orbital and reconstructive surgery and the ocular trauma service at Brooke Army Medical Center in San Antonio. He is now a clinical assistant professor at the University of Texas, San Antonio, and in private practice in Austin.
A different, but just as troubling, injury profile was described by Lt. Col. Mark F. Torres, MD, who served in Afghanistan in 2003 at Bagram Air Base, north of Kabul. “In Afghanistan there are fewer IED-related injuries and more wounds related to land mines. This is a country with 20 years of recent war, and so there are many, many land mines planted throughout the country. Now, thanks to better armor, they cause fewer injuries to the thorax or abdomen. But that doesn’t save the extremities, head and neck. And the majority of victims are children, who often approach the mines out of curiosity, like they would a toy. These typically cause a lot of damage to the face and limbs.” Dr. Torres is now assistant chief of ophthalmology at Madigan Army Medical Center in Tacoma.
Care for the Globe
Physicians witnessing modern warfare are standing at a frontier of visually appalling and medically daunting trauma. But the goal for treating a battle-related ocular wound is the same as it would be for any big-city ER trauma: Save the globe and preserve vision.
“We always erred on the side of attempting to preserve badly damaged globes,” said Dr. Mader. “Even when it looked like an injury was so severe that the chance of the eye’s survival was minimal, we always brought them into the OR and tried to do the best repair possible. There are times when an injury is so drastic that you just cannot anatomically put the eye back together. When that happens you have to know when to call it quits. But we always tried to salvage the eye even if the prognosis for useful vision seemed poor.”
Dr. Blaydon concurred. “The philosophy of my team was to do as much as we could to salvage the globe. No matter how severe the injury, if we could put the globe together somehow, we did. We knew that in a good 50 percent of severely injured eyes there was little chance that vision was going to be saved, and very likely the eyes would eventually be enucleated. But these soldiers were badly injured, and sedated, and not able to give consent. If they were enucleated right then, they might later second-guess what was done. They may wonder, ‘I came in with 10 other guys and maybe they just didn’t have time to save my eye.’ We wanted them to be able, later on, to understand how serious the injury was and how every effort was made to save the eye. After that, psychologically, they do better if they have an enucleation.”
Working shoulder to shoulder. The care given in the first minutes and hours after an injury must be intensely organized even in the middle of chaos. Dr. Mader described a typical scene. “Our team worked in Baghdad in the heavily fortified Green Zone. We had a general ophthalmologist, an oculoplastics specialist, neurosurgeons and maxillofacial surgeons. We all worked together, often on the same patients, because so many troops with eye injuries had other wounds of the face and brain.”
Dr. Blaydon shared a similar picture. “These soldiers often had multiple injuries. On top of a wounded eye, a guy could have had traumatic amputation below the knee on one side, lost a foot on the other, and they’re still trying to save one arm. Many times we had to delay our surgery because the orthopedic surgeons were trying to save arms and legs.”
When assessing a newly injured soldier, Dr. Mader hoped to be able to communicate with him or her. “Some were unconscious, suffering from horrible head wounds. For others, it was helpful if they were still conscious, because you could question them, assess their visual loss, ask if they could see light or moving fingers.” Sometimes, grimly, the prognosis was obvious, even to the patient. “One young fellow who had lost both eyes in a blast came in fully conscious and was talking clearly to me. He knew what had happened to him.”
Dr. Blaydon described wounds that seemed almost impossible to approach. “You may see ruptured globes in civilian practice, but in combat trauma it could be hard even to distinguish pieces of sclera. In everyday urban trauma, a bad rupture is usually stellate, with sharp edges, and it’s straightforward to repair. In combat-related, high-velocity injuries, not only do you have complex cornea and sclera lacerations and intraocular contents coming out, but the edges are so necrotic it’s hard to even sew them back together.”
Neither bombs nor balm discriminated. Army ophthalmologists have been treating soldiers and civilians in almost equal numbers. “We treated both American and allied troops, as well as Afghan military and enemy combatants. The majority of casualties we saw were actually Afghan civilians,” said Dr. Torres.
The same was true for Dr. Mader. “An injured person could randomly be an American or an Iraqi, soldier or civilian. When someone was brought into the hospital, we treated everybody the same, whether a civilian, a child or enemy combatant.”
2 Mader, T. H. et al. Ophthalmology 2006; 113(1):97–104.
EDITOR'S NOTE: As the conflict in Iraq enters its fourth year, Army ophthalmologists continue treating wounded troops there and in Afghanistan. EyeNet presents the first of two reports on the experiences of Eye M.D.s confronting combat-related ocular injuries. NEXT MONTH: Soldiers Journey Home for Recovery.
Clinical Update: The Wounds of War: Part Two
Soldiers Journey Home for Recovery
By Denny Smith, Senior Editor
June 2006 Edition
American Academy of Ophthalmology Web Site: www.aao.org
Original URL: http://www.aao.org/aao/publications/eyenet/200606/comprehensive.cfm
Even as the conflicts in Afghanistan and Iraq roll on, wounded servicemen and women are returning home with injuries that may require years of medical and psychological rehabilitation. Last month EyeNet featured the experiences of Thomas H. Mader, MD, Sean M. Blaydon, MD, and Mark F. Torres, MD, each of whom served on Army surgical teams close to combat zones. The soldiers they treated are now filling polytrauma facilities in the United States.
Whisked Away From Warar
Troops wounded in Iraq or Afghanistan undergo emergent primary repairs to life- and sight-threatening injuries often within minutes of sustaining the injury. When stable enough, they are transported several times to various levels of care.
The first stop is Landstuhl Army Medical Center in Germany, then on to Walter Reed Army Medical Center in Washington, D.C., or Brooke Army Medical Center in San Antonio, and finally on to tertiary-care hospitals around the country.
These later stages of care can be the hardest part for both doctors and patients. “It’s one thing to sew somebody up as best we could do, and it’s another thing to provide the follow-up care,” said Dr. Mader. “That is a very, very difficult job, both professionally and emotionally. As you can imagine, the psychological impact of a young man losing one or both eyes has to be dealt with by both patient and physician.”
Physicians and families take a long view.w. The community ophthalmologist may be seeing more such veterans, and they will need multiple levels of care for many years, according to Glenn C. Cockerham, MD, chief of ophthalmology at the VA Palo Alto Health Care System and clinical associate professor of ophthalmology at Stanford University.
“When they come to us they are entering a period in which late complications, including retinal detachments, corneal decompensation, traumatic cataracts or posterior capsular opacifications, may present,” said Dr. Cockerham. “If one eye, usually on the side of the blast, is severely damaged, it is extremely important to take special care of their better-seeing eye. But many of them have head injuries and resulting memory problems, so we include families in the rehabilitation process to watch over their loved one and make sure they get to appointments. Their families are usually very supportive, having been there for them throughout.”
Collaborative care is key. Dr. Torres explained how the community ophthalmologist can offer veterans care. “There are a lot of joint arrangements between military hospitals and the VA, and between the VA and civilian academic medical centers. The average comprehensive ophthalmologist offering long-term management of a combat-related trauma should, pretty easily, be able to consult with combat-experienced ophthalmologists.”
Dr. Blaydon agreed. “The general ophthalmologists can manage these returning vets, but they might be seeing a different trauma than they would in an emergency room. Much of it is explosive, high-velocity, blunt trauma to the face, which means there’s a lot of soft-tissue damage and underlying skeletal damage. Many had globe ruptures that were severe and complex, and there are often fine, foreign bodies embedded in the cornea. Even if the rupture is repaired perfectly, the patient remains corneally blind. Many of these will go on to corneal transplant. Some of them have bad retinal injuries from just blunt trauma.”
Courage and Candor Beyond the War
Most returning veterans are very young, between their late teens and early 20s. Dr. Blaydon maintains a deep regard for their emotional well-being. “I am in awe of the attitude and the motivation of these young guys. Before you address their specific injury, it’s important to consider the psychology of the veteran. They went over there to serve their country and to serve alongside their comrades, and they want us to respect the fact that they were doing their job when they got their injury. These patients need a lot of physical and emotional therapy to get back into society.”
Americans are deeply divided over the Iraq conflict. And yet, Dr. Blaydon has observed that the soldiers are coming home to a country that cares for them. “This war is as divisive as any we’ve had in the past. The difference now is that returning vets are receiving support from both sides of the fence. That’s an important part of welcoming these soldiers home.”
Hope for vision preempted. Conceivably, some of these soldiers could benefit from research into artificial retinas, research that has received significant funding from the Department of Energy. But Dr. Blaydon said the devastating nature of many injuries means that few of these veterans would be good artificial retina candidates. “The anterior visual camera, the optic nerve and visual pathway must all be intact for an artificial retina to be considered.” These crucial structures are obliterated in many vets.
Precautions slow to appear. One of the questions now haunting the military is whether U.S. troops were provided adequate protection for battle. Since the Afghanistan and Iraq conflicts began, Army ophthalmologists have repeatedly asked for troops to be given better eyewear. While no form of protection can eliminate all injuries, many could have been prevented or lessened in severity. In fact, Dr. Mader writes in Ophthalmology, “Polycarbonate ballistic eyewear could have prevented many, but not all of the ocular injuries we report.”1
Dr. Blaydon noted that ophthalmologists had long lobbied the Army for the type of ballistic eyewear that protects against low-velocity projectiles. The Army had developed eye armor known as Ballistic/Laser Protective Spectacles, but almost none of the soldiers had them. “The Army, as far as we could tell, did not issue them. Eye armor just was not part of the issue,” Dr. Blaydon said.
The Army did issue Sun, Wind and Dust Goggles, which can protect the eye against some minor injuries. But they are cumbersome, and can often impair clear, full peripheral vision. “Soldiers just do not like to wear them. What they do like to wear are Wiley X ballistic goggles that fit closely to the face. But the soldiers had to purchase these on their own. The Army soon realized how severe and frequent the eye injuries were and began purchasing these goggles and mandating that they be worn,” Dr. Blaydon said. Even these goggles cannot protect against the most potent improvised explosive devices, but, he noted, “The incidence of injuries has since gone down, depending on the tempo of operations.”2
From a distance. These physicians tend to deflect credit for their own heroic service into recognition of others still working in the combat zones. “Many soldiers would have died had it not been for the premier care they got in Baghdad. The surgeons there are the top-of-the-line and that care is as good as you’re going to get in a critical care hospital,” said Dr. Blaydon.
Dr. Mader regards his experience with equanimity. “If there was any positive thing about being there, I would say I worked with some of the finest young people I’ve ever met in my life. Had I been wounded and brought to that 31st Combat Support Hospital, I would have had complete faith in the medical personnel working there.”
Dr. Torres shared a similar sentiment. “It’s a rewarding experience in unfortunate circumstances. You feel like you’re doing something positive, even if the world around you is not.”
At the Joint Meeting in November, Herbert P. Fechter, MD, will moderate a panel of military ophthalmologists who will share their experiences in Afghanistan and Iraq. Photos and videos will demonstrate the special considerations of ophthalmic war surgery and will address a variety of combat-related injuries (Instruction Course #590).