Research, injury registry, vision center may improve treatment of military ocular trauma

With ocular trauma rates rising and traumatic brain injury causing significant visual issues among U.S. service members, research into battlefield and post-conflict care is key to effective treatment of military eye injuries.

That research, in addition to a new military eye injury registry, could also assist the treatment of ocular trauma in the civilian population.

“We have been given the direction to ensure that we link with the civilian community, both academic and industry, in sharing our information sources, our techniques,” Col. Donald A. Gagliano, MD, MHA, the executive director of the Vision Center of Excellence, Washington, D.C., told Ocular Surgery News.

The Military Eye Trauma Treatment Act, which was incorporated into Public Law 110-181 in 2008, created the Vision Center of Excellence. The center is a collaboration between the U.S. Department of Defense and the U.S. Department of Veterans Affairs. The center will, among other projects, establish a military eye trauma registry in order to share data with the American Society of Ocular Trauma and the International Society of Ocular Trauma eye registries.

Col. Donald A. Gagliano, MD, MHA, said that collaboration between military and civilian agencies will bring about significant improvements in eye trauma treatment. Image: Henry D

In addition, Congress has appropriated separate extramural research funds to investigate ocular trauma and traumatic brain injury (TBI). Funds are granted in a competitive, peer-reviewed process to academic institutions across the country for ocular trauma research.

In the 2009 fiscal year, the Peer Reviewed Medical Research-Vision line item was funded at $4 million and placed within the portfolio of the DOD’s Telemedicine and Advanced Technology Research Center for management. The Telemedicine and Advanced Technology Research Center added $1.4 million of its own funds to increase fiscal year 2009 funding for awards to $5.4 million. The funding for fiscal year 2010 is lower, however, with $3.75 million approved by Congress on Dec. 19, as a result of cuts to most defense health programs. The National Alliance for Eye and Vision Research (NAEVR) has requested a funding level of at least $10 million.

Military traumatic eye injuries have been on the rise, James F. Jorkasky, executive director of NAEVR, said. With the deployment of additional troops to Afghanistan, eye trauma will likely continue to increase, especially from improvised explosive devices, he said.

Dedicated defense-related vision research grants are a logical way to fund essential medical research to address immediate battlefield needs, Mr. Jorkasky said.

“Good vision is important on the battlefield,” he said. “It’s also [important] in terms of support functions, such as monitoring equipment or checking out radar scopes.”

According to NAEVR, 16% of recent wartime injuries affected eyes. Optic nerve trauma was the most severe eye injury. Approximately 30% of combat troops in Iraq, out of a total of 320,000 service members, are estimated to have TBI from blasts, with visual symptoms reported in nearly 85% of those subjects.

“Between October 2001 and June 2006, more than 1,000 service members with combat-related eye trauma were evacuated from overseas military operations, making serious ocular injuries one of the most common types of injury experienced by service members serving in Iraq and Afghanistan,” Rebecca Hyder, manager of Public Health and Manpower at the American Academy of Ophthalmology, said.

Eye injury registry

Dr. Gagliano, a former U.S. Army medical commander in Iraq, said the Vision Center of Excellence is creating an information management system called the Defense and Veterans Eye Injury Registry. The registry will be a database of military ocular trauma statistics, and officials will be able to examine data such as the time course of eye trauma injury from incident to rehabilitation.

“The information system allows us to track not just individual patients across the process of the VA and DOD health care continuum, but also to track cohorts of patients who had similar kinds of injuries, and from that source, derive a better understanding of outcomes,” Dr. Gagliano said. “Our whole goal is to improve care and quality of life.”

With the combined total of DOD and VA statistics, he said, the database will be one of the largest ocular trauma eye registries in the world.

Ferenc Kuhn

The center’s eye registry will assist civilian ophthalmologists by establishing a larger database of cases to research eye trauma injuries, according to Ferenc Kuhn, MD, PhD, president of the American Society of Ocular Trauma and executive vice president of the International Society of Ocular Trauma. He said the American eye trauma registry has recorded 17,000 serious injuries, while the international society has 1,000 reported serious injuries.

Dr. Kuhn said the main differences in ocular trauma between military and civilian subjects are the causes and circumstances of eye injuries. As a result, similar questionnaires, report forms and standards of care could be used across all databases, altered only for military confidentiality.

Military eye trauma findings are “100% pertinent to civilian use,” Dr. Kuhn said. The military could also benefit from breakthroughs in civilian research and treatment, which is another reason why the civilian and military eye registries are collaborating.

“Because we have so much in common, whether it’s military or civilian, I think it makes a lot of sense to combine our efforts, both in data collection and also in treatment, to optimize what we do,” he said. “Cooperation between military and civilian ophthalmologists and data collection analysis of outcome data are the key to success.”

Vision Center of Excellence

In addition to operating the military eye trauma registry, the Vision Center of Excellence will help integrate DOD and VA operations in treating military ocular trauma cases, Dr. Gagliano said. This center is one of the recently appointed centers of excellence that Congress mandated for medical military concerns. The other DOD/VA centers of excellence are focusing on psychological health and TBI, hearing, and extremities and amputation.

“It really is quite a phenomenal thing that Congress did because all of us have an interface in some way. The psychological loss of vision is an important part of psychological health, for example,” Dr. Gagliano said.

The vision center will “promote collaboration, facilitate integration and serve as an advocate across the two systems for change,” he said.

“This is … a new kind of organization,” said Dr. Gagliano, who is also DOD principal adviser for vision. “[It] combines both the VA and the DOD, and it will be staffed by both of the organizations and will function as a joint interagency organization that will link what has historically been kind of independently functioning processes.”

Michael W. Brennan, MD, who served as AAO president in 2009, said the AAO is looking forward to the integration of DOD and VA vision care.

Establishing a “common language” between the DOD and the VA will enable the two departments to work together in medical record keeping, he said.

“[It will be] collaboration without duplication and communication without competition,” he said. “There’s too much to be done. We can’t afford to duplicate and we can’t afford to be competing.”

Eye trauma research funds

The Peer Reviewed Medical Research-Vision Program provides extramural research grants for areas such as treatment of eye trauma caused by physical, chemical or biological agents or lasers and vision rehabilitation after battlefield injury.

The 2009 funding was the first time that Congress gave vision research its own specific line item. Before that, $7.5 million in vision research funds were granted by the Peer Reviewed Medical Research Program within the Congressionally Directed Medical Research Program in 2006. In that program, vision was one of 21 areas of research eligible for a pool of $50 million to multiple fields of medical research. The Peer Reviewed Medical Research Program was not funded in 2007, and in 2008, vision researchers received $6 million in awards.

The speed with which vision research received its own line item in defense appropriations is a result of efforts by NAEVR, the Blinded Veterans Association and the AAO in educating Congress about the need for military eye trauma research, Mr. Jorkasky said.

Although the Peer Reviewed Medical Research-Vision line item is funded separately from the Vision Center of Excellence, Dr. Gagliano participates in the Telemedicine and Advanced Technology Research Center’s Program Committee, which manages and oversees distribution of grant awards.

Dr. Gagliano said the unique collaboration between the centers and others on the panel, including representatives from the U.S. Food and Drug Administration, National Institutes of Health/National Eye Institute, NAEVR and the Association for Research in Vision and Ophthalmology, allows for the most appropriate selection of eye trauma issues to research. Dr. Gagliano is also a member of the NEI’s National Advisory Eye Council, ensuring a nexus with civilian vision research.

He said military eye trauma topics that need further investigation include how to “mitigate retinal injury in a blast … preserve ocular integrity in a globe rupture … what are the real mechanisms of blast exposure, the physics of blast exposure.”

Restoration of vision, or artificial vision, is another research topic that is being pursued, Dr. Gagliano said. He said the Vision Center of Excellence is working closely with researchers around the world who are examining ways of restoring vision.

Intact sensory cortex and visual cortex are being explored to determine how the visual cortex might again receive signals to re-establish sight in patients who have lost their sight from severe injuries, he said.

Treating, preventing ocular trauma

Of crucial importance to eye trauma treatment is recognition of eye injury both on and off the battlefield. Dr. Brennan said indirect ocular injury, caused by incidents such as blunt head trauma or blast injuries, can damage the optic nerve.

However, on the battlefield, life-threatening injuries are addressed first, with eye injuries not always immediately detected and treated, he said.

“The [service member] is undergoing surgery for repair of extremity injuries and there’s no visible damage to the head, no visible damage to the eye, but in fact that injury really shook the neurologic system. So these are the other, what we would call indirect injuries, that often don’t get attention until late,” he said.

Dr. Gagliano said the Vision Center of Excellence is looking at ways of standardizing and refreshing the ocular trauma treatment skill set of military physicians because many do not typically treat severe ocular trauma injuries on a regular basis in the U.S.

In combat zones, members of the military are required to wear protective eyewear, Dr. Gagliano said. Military “combat eye armor” — essentially safety glasses — absorb fragments at high speeds. While protective eyewear has reduced serious fragment-induced eye injuries, new battlefield technology is making protection of the eye more challenging.

Dr. Gagliano said that the eye is vulnerable during warfare because it is a fluid-filled compressible organ located in an exposed area.

Dr. Kuhn said that even though the surface area of the eye represents only 0.5% of the total body surface, it is prone to injuries in the battlefield because of a basic human response mechanism.

“We always turn toward where the action is, and that means the eyes are exposed,” he said.

Traumatic brain injury

TBI is a serious condition that often results from improvised explosive device injuries. The visual impact of TBI is sometimes not observed until weeks, months or even years after the blast. TBI can have a major impact on visual quality of life, according to Glenn C. Cockerham, MD.

In a study presented at the joint meeting of the American Academy of Ophthalmology and Pan-American Association of Ophthalmology in San Francisco, Dr. Cockerham and colleagues examined visual function and quality of life of veterans with TBI from combat blast. They looked at 42 TBI patients with a mean age of 28 years. The time from the blast injury was 2 weeks to more than 4 years.

Results of patients’ Visual Function Questionnaire-25 and Neuro-10 Supplement were compared with published results from patients with ocular diseases, as well as disease-free reference groups.

Researchers found that visual quality of life in TBI subjects by both tests was significantly worse than patients who had multiple sclerosis, Dr. Cockerham, chief of ophthalmology at the VA Palo Alto Health Care System, said in an e-mail interview. TBI subjects’ visual quality of life was similar to patients with the burden of cataracts and glaucoma. Many TBI patients with self-reported poor visual quality of life had high-contrast visual acuity of 20/20 or better, indicating that more sensitive measures of visual function may be required to identify this population.

“Blast injury is the most common cause of TBI in the war in Iraq and is increasingly common in Afghanistan,” he said. “Little has been reported in the scientific literature about blast effects on the human eye and vision.”

Dr. Gagliano said more research is needed to determine the cause and proper treatment of TBI. Also, he said that integrated treatment between the DOD and the VA at the Vision Center of Excellence could help TBI patients receive the most effective care. – by Erin L. Boyle

What do civilian ophthalmologists need to know about treating severe ocular trauma that occurs in combat zones?

References:

• Cockerham G. Visual quality of life in veterans with traumatic brain injury after combat blast exposure. Paper presented at: American Academy of Ophthalmology-Pan-American Association of Ophthalmology joint meeting; Oct. 24-27, 2009; San Francisco.
• Mader TH, Carroll RD, Slade CS, George RK, Ritchey JP, Neville SP. Ocular war injuries of the Iraqi insurgency, January-September 2004. Ophthalmology. 2006;113(1):97-104.

• Michael W. Brennan, MD, can be reached at Alamance Eye Center, 1016 Kirkpatrick Road, Burlington, NC 27215; 336-228-0254; e-mail: mbrennan1@triad.rr.com.
• Glenn C. Cockerham, MD, can be reached at VA Palo Alto, Ophthalmology 112-B1, 3801 Miranda Ave., Palo Alto, CA 94304; e-mail: cockerham@stanford.edu.
• Col. Donald A. Gagliano, MD, MHA, can be reached at 5109 Leesburg Pike (Sky 6) Suite 401a, Falls Church, VA 22041; e-mail: donald.gagliano@tma.osd.mil.
• Rebecca Hyder can be reached at American Academy of Ophthalmology, 1101 Vermont Ave. NW, Washington, DC 20005; 202-737-6662; e-mail: rhyder@aaodc.org.
• James F. Jorkasky can be reached at National Alliance for Eye and Vision Research, 12300 Twinbrook Parkway, Suite 250, Rockville, MD 20852; 240-221-2905; e-mail: jamesj@eyeresearch.org.
• Ferenc Kuhn, MD, PhD, can be reached at 1201 11th Ave. South, Suite 300, Birmingham, AL 35205; 205-558-2588; e-mail: fkuhn@mindspring.com.