BACKGROUND/RATIONALE:
More than 65% of patients traumatic brain injuries report vision problems. Traumatic brain injury (TBI) can damage not only the eye, but the visual (sensory and ocular-motor) pathways and/or cortical processing areas. Thus, the traditional objectives and treatment plans for eye-related blindness or low-vision may not be appropriate for combat and TBI related vision injuries. In 2008, the Veteran Health Administration (VHA) performed evaluations on patients with a diagnosis of TBI admitted to VHA Polytrauma Rehabilitation Centers. Our study is the first known study to investigate this service delivery data.

OBJECTIVE(S):
Aim I: Determine the pattern of access to and utilization of services among Veterans with TBI with visual and ocular deficits.
Q 1.1: What recommendations were made to Veterans by the Optometrist/Ophthalmologist performing the exam?
Q 1.2: What proportion of Veterans attended recommendations had follow up visits at 6, 12, and 24 months?
Q 1.3: How is the type of recommendation made to Veterans dependent on demographic variables, comorbidity, severity of
TBI injury, specific visual and ocular deficits, access, and evaluating facility?
H 1: The type of recommendation made to Veterans is associated with demographic factors, severity of TBI injury, specific
visual and ocular deficits, access, and evaluating facility.
Q 1.4: How is follow up rate dependent on type of recommendation, demographic factors, severity of TBI injury, specific
visual and ocular deficits, access, and evaluating facility?
H 2: The probability that Veterans return for follow up is influenced by the type of recommendation, demographic factors,
severity of TBI injury, specific visual and ocular deficits access, and evaluating facility.
Aim II: Describe rehabilitation service delivery.
Q 2.1 What proportion of rehabilitation follow up visits are attended per specialty clinic?
Q 2.2 What types of interventions are provided in follow up visits per specialty clinic?
Q 2.3 What visual aids and assistive devices are provided per specialty clinic?
Q 2.4 How is type of specialty clinic attended associated with demographic variables, comorbidity, severity of TBI injury,
specific visual and ocular deficits, access, and evaluating facility?
H 3: The type of specialty clinic attended is associated with demographic factors, severity of TBI injury, specific visual and
ocular deficits, access, and evaluating facility.
Aim III: Explore clinical recovery as measured by visual and ocular outcomes.
Q 3.1: For patients who have follow up data, how do outcomes change over time?
Q 3.2: To what extent are demographic variables, comorbidity, severity of TBI injury, presenting visual and ocular deficits,
access, and evaluating facility associated with outcomes?
H 4: Visual and ocular outcomes are associated with demographic factors, severity of TBI injury, presenting visual and ocular
deficits, access, and evaluating facility.

METHODS:
This is a population-based study of all patients with TBI admitted to VHA Polytrauma Rehabilitation Centers since 2008. Both retrospective large data and prospective survey designs will be used. Retrospective data will be extracted from the Corporate Data Warehouse. Natural language processing will be used to extract data from clinical notes. An expert panel will validate extracted data. Geographic Information System tools will be used to evaluate geographic barriers. The final dataset will consist of patient characteristics, treatment recommendations, access factors, facility locations, clinic visits, treatments/assistive devices, and patient-level outcomes. Frequentist and Bayesian Network methods will be used to analyze data.

FINDINGS/RESULTS:
Aim 1
- On average, 23% of Veterans have mandated exam are referred for rehabilitation.
- There is significant variation in rehabilitation recommendations made and follow up between the five VA Polytrauma Rehabilitation Centers (PRCs).
- Visual rehabilitation services available vary across PRCs; however, Veteran needs are being met by treating symptoms regardless of Services available.
- Outpatient follow up was evenly split between VA PRCs and VA community facilities.
- Nearly 40% of Veterans followed up during the first six months compared to 60% following up between 0-24 months, corroborating previous findings that vision symptoms may persist for two years or more beyond the injury.
- Qualitative analysis of the open-ended survey data were organized into six themes: access to services, need for services, responsibility for follow-up, satisfaction with services, communication, and associated problems.
- Access to outpatient vision rehabilitation is limited access due to distance to VA facilities and lack of vision specialists in the community. Thirty percent of respondents were not able to follow-up due to access issues. 83% were satisfied with vision services.
- Persistent problems reported by respondents included double vision, worsening depth perception, headaches, dizziness, dizziness with use of prism, black spot on retina, blind spot on eyeball, black and yellow circle in peripheral vision, eye twitch, driving "sparkling", visual field loss, wrinkled retina, one eye rotating, and cataracts.
Key Outcomes/Other Achievements:
- Two manuscripts published as feature articles.
- The current service-delivery model may be outdated and does not adequately address the TBI-related ocular injuries and visual dysfunction incurred by military personnel serving during the 9-11 and post 9-11 conflicts. The current service delivery model demonstrates a lack of understanding of how the visual system works, i.e., treating afferent versus efferent dysfunction.
- There is a need for vision specialists to be cross trained in TBI/neurologic rehabilitation.

Aim 2
Identify assessments and interventions provided per vision rehabilitation clinic (occupational therapy, polytrauma, blind rehab, low vision) and predictors of being treated at these clinics.
- 72% of vision rehabilitation was in occupational therapy clinics, 33% in blind rehabilitation outpatient services, 12% in low vision, <1% inpatient blind rehabilitation (some Veterans went to more than one clinic).
- Veterans receiving rehabilitation for TBI-related vision dysfunction were most frequently assessed for saccades, accommodation, visual field, and convergence.
- Intervention was provided most frequently for eye-hand coordination, saccades,
accommodation, vergence, and binocular dysfunction.
Key outcomes/Other Achievements:
- The delivery of patient services should be driven by the needs of Veterans and not by system level factors such as availability of specific vision rehabilitation services at specific locations. Traditional low vision and blind rehabilitation programs were not designed to treat the comorbidities and symptoms associated with TBI. To address this challenge, blind rehabilitation and neurologic recovery cross training is needed. Our findings document how five VA Polytrauma Rehabilitation Centers implemented this training post 9-11. The next step is to extend and standardize this new paradigm to community care, where these postdeployment patients now reside.

Aim 3
Reporting of visual acuity in patients with TBI is affected by variation in the definition of normal vision acuity, e.g., 20/60 or better or 20/20, unit of measure of visual acuity, e.g., corrected, uncorrected, medical setting, e.g., inpatient, outpatient, military, veteran, civilian, length of time since injury, e.g., acute, chronic, and severity of TBI.
- Cross sectional findings suggest about half of patients with mild and moderate TBI have normal visual acuity at time of injury compared to 32% of patients with severe TBI.
- Longitudinal findings suggest that visual acuity for those with abnormal visual acuity at baseline did improve over time; magnitude was large.
- More than 40% of active-duty service members and veterans with TBI who are tested for visual field and convergence deficits have an abnormal result. Abnormal results vary by severity of TBI and test administered.
Key Outcomes/Other Achievements:
- We failed to find support for VHA Directive 2008-065 guidelines suggesting a visual field automated test only if the confrontation test is negative, i.e., having only an automated test was more than 45 times more likely to result in an abnormal result than having only a confrontation test (OR = 45.194, p = .0083).
- This study provides evidence to support clinical guidelines to standardize visual field and near point of convergence testing and reporting of results across DoD and VHA clinical environments.

Aim 4
71 symptoms/conditions/referrals/anatomical landmarks have been identified using natural language processing.
- We are in the process of tabling frequencies and percentages by condition, assessment, intervention, subspecialty, and/surgery.
Key outcomes/Other Achievements:
- Our findings describing optometry/ophthalmology service delivery developed at the specialty polytrauma rehabilitation centers during the OEF/OIF conflicts provides evidence to support practice guidelines for service delivery at community-based clinics where this cohort of Veterans now reside.

IMPACT:
The impact of this study on Veterans and the VHA system of care will be the development of recommendations to improve access to and utilization of quality TBI-related vision services. This will be accomplished by translating PRC specialized knowledge to non-specialized VHA facilities closer to the patients' residences.

1. Polytrauma and Blind Rehabilitation Services have implemented telerehabilitation to increase access to vision therapy for Veterans with TBI-related visual dysfunction.
2. Polytrauma and Blind Rehabilitation Services have implemented cross training (Optometry + TBI). The initial OD fellowship program was at the Tampa PRC. A second training OD fellowship has been added at the San Antonio VA. Individual PRC have initiated their own cross-training.
3. The dialogue between DoD and the VA has begun on how standardize vision therapy across DoD and the VA including theDoD to VA transition. The dialogue includes the planning of follow up studies. Leadership and clinician researchers who served on the expert panel have realized that research is hindered by the lack of standardization of content of the clinical notes which has also affected publication of findings. Even the Defense & Veterans Eye Injury and Vision Registry (DVEIVR) database is riddled with error in incorrectly annotated units of measurement. The result is that this research topic will be limited to smaller samples and prospective or retrospective chart review designs.

---

External Links for this Project

NIH Reporter

Grant Number: I01HX002279-01A2
Link: https://reporter.nih.gov/project-details/9502064

---

PUBLICATIONS:

Journal Articles

1. Winkler SL, Finch D, Wang X, Toyinbo P, Marszalek J, Rakoczy CM, Rice CE, Pollard K, Rhodes MA, Eldred K, Llanos I, Peterson M, Williams M, Zuniga E, White H, Delikat J, Ballistrea L, White K, Cockerham GC. Veterans with Traumatic Brain Injury-related Ocular Injury and Vision Dysfunction: Recommendations for Rehabilitation. Optometry and vision science : official publication of the American Academy of Optometry. 2022 Jan 1; 99(1):9-17. [view]
2. Winkler SL, Marszalek J, Wang X, Finch D, Rakoczy C, Delikat J, Kelleher V, Williams M, Zuniga E, Rice C, Pollard K, Cockerham G. Veterans with Traumatic Brain Injury-related Ocular Injury and Vision Dysfunction: Vision Rehabilitation Utilization. Optometry and vision science : official publication of the American Academy of Optometry. 2022 Jan 1; 99(1):3-8. [view]

DRA: Aging, Older Veterans' Health and Care, Acute and Combat-Related Injury, Brain and Spinal Cord Injuries and Disorders
DRE: Diagnosis, Treatment - Comparative Effectiveness, TRL - Development
Keywords: Outcomes - Patient
MeSH Terms: none