Visual Dysfunction in Patients with Traumatic Brain Injury: A Systematic Review

Given that visual function depends on complex brain interactions, it's reasonable to consider when and whether traumatic brain injury (TBI) is related to visual dysfunction. Such questions are particularly pertinent to the VA since an estimated 15% of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Service Members (390,000 of 2.6 million) have incurred TBI during deployment. By comparison, just more than 1% of the U.S. population sought treatment for TBI in 2009.

In an attempt to discover the frequency and type of visual problems among those with TBI, the VA Evidence-Based Synthesis Program (ESP) located at the Portland VA Medical Center recently conducted an evidence review to examine these questions. The review discovered that visual dysfunction is infrequently diagnosed in unscreened U.S. Service populations with previous history of TBI, occurring in less than 1% in most cases (although accommodation and refraction disorders reached 7.3%). However, the review also noted that among Veterans being seen at Polytrauma Rehabilitation Centers (PRCs) and Polytrauma Network Sites (PNSs) who have active TBI symptoms, visual dysfunction often afflicted more than 50% depending on the type of visual disorder. Table 1 shows a summary of the findings.

The findings from this body of evidence are very applicable to the VA population, as the majority of the included studies were conducted in VA or U.S. military healthcare settings. Prevalence estimates of a broad group of unscreened U.S. Service Members suggest that clinically significant, diagnosed visual dysfunction is uncommon in this general population, though this is based on data from 2004 through 2007; it is likely that as the OEF/OIF/OND conflicts progressed, clinicians and Veterans became more aware of both TBI and potential associations with visual dysfunctions. Therefore, an examination of more recent data on these populations and outcomes is likely warranted to ensure comprehensiveness and generalizability of the results. Results from studies of patients screened for visual problems at VA PNSs or PRCs suggest that visual dysfunction is quite common for this group of Veterans who often have histories of severe injuries and multiple comorbid conditions.

This topic was submitted to the ESP Coordinating Center for development by Mary G. Lawrence, MD, MPH Interim Director, VA/DoD Vision Center of Excellence (VCE) in collaboration with other key stakeholders Felix Barker, Associate Director, Research, Rehabilitation and Reintegration, Vision Center of Excellence, Salisbury VAMC; Christopher Moore, PhD, VA Scientific Program Manager for Sensory Systems and Communication Disorders Program; and Stuart W. Hoffman, Ph.D., Scientific Program Manager for Brain Injury, Rehabilitation Research and Development Service, TBI Point of Contact and Subject Matter Expert, Office of Research and Development. The reviewers also received input from a technical expert panel.

Research on effective treatments for visual problems experienced by individuals with TBI history was outside the scope of this review, though this information could help guide VA treatment options for affected Veterans, and additional research may be needed to establish referral guidelines for visual symptom complaints for Veterans with TBI history.

Reference:
O'Neil ME, Gleitsmann K, Motu'apuaka M, Freeman M, Kondo K, Storzbach D, Kansagara D, Carlson KF. Visual Dysfunction in Patients with Traumatic Brain Injury: A Systematic Review. VA ESP Project #05-225; 2014.

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This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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