The wars in Iraq and Afghanistan have increased public awareness of traumatic brain injury (TBI) and the life-long rehabilitative challenges patients face. TBI is even referred to as the signature injury of these wars.

However, TBI is not just associated with military conflicts; it is also prevalent in the civilian population. Indeed, TBI accounts for more than 50,000 deaths in the United States each year, and nearly half of all injury-related deaths.1,2

Additionally, TBI remains the leading cause of injury-related death and disability among children and young adults.1 If left undiagnosed and untreated, TBI-related conditions can have devastating effects on the patients quality of life and rehabilitative progress.

O.D.s can play an important role in the care of patients with TBI, such as diagnosing and treating related visual conditions, working as part of an interdisciplinary team in a hospital or clinic, conducting research or simply making the appropriate referral for patients with related signs and symptoms. Furthermore, optometrists already know how to assess and treat TBI-related visual and ocular disorders, such as oculomotor dysfunctions. O.D.s can make significant differences in patients rehabilitative progress and quality of life.


Craniocerebral Trauma

The Centers for Disease Control and Prevention defines TBI as craniocerebral traumaan injury to the head due to blunt or penetrating trauma or acceleration/ deceleration forces. It is associated with a decreased level of consciousness, amnesia, other neurological or neuropsychological abnormalities, skull fractures, diagnosed intracranial lesions or death.3

Irwin B. Suchoff, O.D., Neera Kapoor, O.D., M.S., and Kenneth Ciuffreda, O.D., Ph.D., further classify brain injuries by different components.4 They use the umbrella term acquired brain injury (ABI) to describe those conditions that appear suddenly and result in a neurological dysfunction. Then, they further divide ABI into two main categories:

External insult (TBI)
, which is further divided into closed brain injuries and penetrating injuries. The Glasgow Coma Scale categorizes closed and penetrating injuries as severe, moderate or mild.
Penetrating injuries are normally identified and treated immediately. Closed brain injuries may be missed when accompanied by other life-threatening injuries.

  Internal insult, which is further divided into cerebrovascular accident (stroke), brain surgery and arteriovenous malformations (AVM).
Severity of injury is an important determinant of outcome. The Department of Veteran Affairs and Department of Defense rate it as mild, moderate or severe by measuring it on the Glasgow Coma Scale, length of loss of consciousness and length of post-traumatic amnesia.5

Brain injuries can cause diffuse axonal injuries, focal lesions or both, depending on the mechanism of the injury and the individuals response. Diffuse axonal injury results from rotational acceleration-deceleration forces. It is thought to be a result of calcium influx and subsequent cytoskeletal damage. Injury to cell metabolism can cause axonal death in days; symptoms may appear soon after the TBI. Focal injuries, such as subdural hematoma, epidural hematoma, subarachanoid hemorrhage, intracerebral hemorrhage and cortical contusion, normally result from a direct blow to the head.


Increasing Numbers

More than 1.5 million Americans suffer a TBI per year; 250,000 of these are hospitalized for a TBI per year.6,7 Some 80,000 to 90,000 of those hospitalized experience long-term disability.8 About 5.3 million Americans live with TBI-related disabilities.7 In 1995, the total direct and indirect costs of TBI in America were an estimated $56.3 billion.9

Recent military conflicts have added to these numbers:

Some 30,327 service members have been wounded in action (and 3,423 killed in action) in Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) as of November 23, 2007.10,11

Between January 2003 and October 2007, 31% of the patients who required medical evacuation to Walter Reed Army Medical Center (WRAMC) for battle-related injuries had a TBI.12

The Defense and Veterans Brain Injury Centers (DVBIC) have seen 4,744 TBI patients at different sites.12 Between January 2003 and October 2007, the DVBIC at Walter Reed evaluated and treated 1,358 TBI patients from both conflicts, and the DVBIC lead VA polytrauma centers (Minneapolis; Palo Alto, Calif.; Richmond, Va.; and Tampa, Fla.) have seen a total of 883 TBI patients, also from both conflicts.10

Some 88% of the TBI patients seen at Walter Reed had closed brain injuries that were mainly due to blasts.13 The causes, from most common to least frequent, are improvised explosive devices (IEDs) and explosive-formed projectiles/ penetrators (EFPs), mortars; gun shot wounds, rocket-propelled grenades, vehicle-borne IEDs and motor vehicle accidents. (See Optometrists and TBI at Walter Reed, below.)


Even if the patient reports no signs or symptoms, an assessment is necessary as early as possible whenever a patient sustains an injury known to cause TBI. Patients may not realize that they are experiencing visual dysfunctions from a TBI or that they may have sustained an ocular injury.

Optometrists and TBI at Walter Reed

When I learned that TBI patients who are either currently in or were previously in Walter Reed Army Medical Center had related visual conditions that needed attention, I sought the help of other professionals. Support and assistance came from a variety of sources, including federal service providers (Veterans Administration and Department of Defense), private practitioners, educators, researchers, and optometric societies and associations.

A group of individuals met at the 2005 meeting of the American Academy of Optometry (AAO) to discuss the needs facing our TBI patients and providers. Some of these participants began participating in regular teleconference calls with WRAMC optometrists to address what was needed to assess and treat these patients. Members of this concerned group conducted a TBI Symposium at the 2006 AAO meeting; their lectures were printed in the Journal of Behavioral Optometry.

Many things were needed to further our care of TBI patients. Our goals:

Attempt to examine every TBI, blast and amputee patient admitted to WRAMC.

Get involved with the interdisciplinary provider workgroup that regularly discusses these patients conditions and treatment.

Educate our interdisciplinary practitioners by engaging experienced consultants and attending and conducting continuing education programs.

Document the care provided.

Publish scientific research with the ultimate goal of establishing relevant clinical practice guidelines.

Optometrists soon became members of the WRAMC interdisciplinary team, which also consists of neurologists, orthopedists, physiatrists, psychiatrists, psychologists, physical therapists, occupational therapists, physician assistants and others. Since the summer of 2006, our optometrist has tried to examine all TBI, blast and amputee patients admitted to WRAMC. At times, patients were not physically or mentally ready to be assessed, or they may have left our hospital before we could see them. But, these instances have been rare, as we repeatedly visit the patients to assess and provide the care they need when they are ready.

We soon found that by helping patients with their visual dysfunctions (accommodative dysfunctions, diplopia, visual field defects, visual midline shift or refractive correction) that other rehabilitative modalitiessuch as occupational, physical, and speech therapybenefited as well. Other members of the interdisciplinary team began referring more patients to optometry for evaluation.

The WRAMC optometrists have attended and lectured at several interdisciplinary continuing education programs, published an article and commentary in the Journal of Behavioral Optometry, encouraged other optometrists to get involved in the treatment of TBI patients, and are currently working with key VA individuals to help chart the future in this area of care.

While recovery takes place for at least 18 to 36 months, an estimated 80% to 85% of the recovery occurs within the first six monthsa finding that underscores the importance of early assessment and treatment.5 (However, it may never be too late to assess and treat these patients.1)

Conditions and symptoms include visual, cognitive, auditory, vestibular, physical, emotional and/or behavioral dysfunctions. For example, post-concussion symptoms reported by patients in one VA clinic include sleep disturbances (84%), irritability (84%), attention/concentration problems (79%), mood swings (76%), memory problems (76%), headaches (71%), light/noise sensitivity (69%), depression (66%), visual disturbances (66%), tinnitus (58%), excessive fatigue (58%), balance problems (42%) and dizziness (40%).

At the same site, 75% of patients with TBI reported visual problems including photosensitivity (59%), even though most patients showed normal to near-normal corrected visual acuity and visual fields. They also found oculomotor problems in 70% of the patientsconvergence dysfunctions (46%), pursuit and/or saccadic dysfunction (25%), accommodative dysfunction (21%), strabismus (11%) and fixation dysfunction or nystagmus (5%). And, 84% of the patients reported problems reading since their concussive injury.

Other symptoms of vision problems following a TBI include blurred vision, confusion when doing visual tasks, dizziness/vertigo, double vision, eye strain, headache, reduced attention on visual tasks and visual fatigue.15,16 Signs may include abnormal body posture, closing or covering one eye, head tilts or turns, poor judgment of depth or a reduced ability to accurately locate objects.

The Palo Alto team also found that polytrauma due to blast injuries more than doubled the risk of visual impairment compared with all other polytrauma causes (i.e., motor vehicle accidents, gunshot/shrapnel, assaults, falls or anoxia). The rate of visual impairment from blast-related injuries was 52%, compared to 20% for all other sources of injury.

Another study found that a significant percentage of eyes exposed to a blast-induced TBI demonstrated angle recessions, cataracts and a reduction in the number of endothelial cells.


Evaluation and Management

These findings highlight the importance of a comprehensive binocular vision and ocular health exam. The comprehensive eye and vision evaluation should include refractive error, ocular motility disorders, binocular anomalies, accommodative disorders, ocular health and visual information processing.15 The optometric evaluation may include extended sensorimotor evaluation, higher cerebral function assessment of visual information processing, low vision evaluation, extended visual field evaluation and electrodiagnostic testing.15

William Padula, O.D., stated that the rehabilitation of a TBI patient requires understanding of how neurological dysfunctions interfere with motor, sensory and cognitive processes.3 Neuro-optometric rehabilitation, he says, is especially important when evaluating binocularity and spatial and perceptual motor function, especially as each relates to dysfunction between ambient and focal visual processing.

Rehabilitation for TBI patients often requires providers of different disciplines to work together. Optometrists are an important part of the management teame.g., when dealing with vestibular dysfunction.18 A.H. Cohen concluded that the impact of visual sensory motor function on vestibular function and associated rehabilitation are apparent, and he suggests integrating vision and vestibular therapies to fully restore balance function.

Management options for patients with acquired brain injury include:

Treatment of the visual dysfunction. This may involve using lenses, prisms, occlusion, low vision devices, and/or yoked prisms, bi-nasal occlusion, vision therapy and prismatic visual field expansion devices.

Treatment of ocular disease or injury. This may involve treating the patient or comanaging him or her with other healthcare professionals.

Counseling and consultation. You will need to educate the patient and his or her family or caregiver about the problem, functional implications, goals, prognosis, and management options. Also, youll need to consult with others about rehabilitation and health care.15

Several studies using objective eye movement recording and subjective rating of reading ability investigated the effects of systematic, oculomotor rehabilitation in subjects with acquired brain injuries.19,20 In one study, two subjects improved objectively in terms of basic versional oculomotor accuracy and reading ability. These findings concurred with their subjective impressions.19

More research about visual dysfunctions related to TBI must be undertaken. There are many case studies, but they have few subjects, and there are very few randomized controlled trials or well-designed controlled trials without randomization.

And, the causes and treatment of visual dysfunctions were not universally agreed upon. Studies that have evaluated and reported on some of the existing interventions might be more widely accepted if they were included in translational and randomized control studies. (See The Need for Additional Research, below.)

The Need for Additional Research

This population of patients presents unique methodological challenges, such as recruitment, population characteristics, follow-up and the conducting of double-blind randomized controlled trials. Randomized clinical trials are the highest research level by which researchers test the efficacy and safety of interventions, but there is a lack of such research in many areas, including visual dysfunctions related to TBI. This creates a dilemma, since it takes about 17 years to go from first discovery at the bench to changing care for all.21

Translational research is an approach that may shorten the 17-year time line. Its goal is to consolidate resources from clinical and translational science, which, in turn, will:

Captivate, advance, and nurture a cadre of well-trained multi- and interdisciplinary investigators and research teams.

Create an incubator for innovative research tools and information technologies.

Synergize multi- and interdisciplinary clinical and translational researchers to catalyze the application of new knowledge and techniques at the front lines of patient care.

The National Institutes of Health is trying to increase interaction between clinicians and scientists and generate studies able to translate research findings into health care changes.


Brain Injury Conference

Following the December 2007 Veterans Administration (VA)/Department of Defense Visual Consequences of Acquired Brain Injury Conference, a group of optometrists, ophthalmologists, and members of other disciplines met and agreed to develop an evidence-review process for TBI. This review process of evidence and literature is modeled on the approach of the U.S. Preventative Services Task Force. It focuses on preparing a meta-analytical review, which relies on a specific analytical framework that clearly specifies key linkages with patient outcomes and presents both clear guidance on admissible levels of evidence and specific population inclusion/exclusion criteria for the literature/studies in question. Part of this process will be to evaluate the individual study, ranging from randomized controlled trials to opinions of respected authorities, based on clinical experience, descriptive studies and case reports, or reports of expert committees.

Another outcome of this meeting: Representatives agreed that a TBI Registry is necessary to record and share visual and ocular findings and treatments among the DOD, VA and civilian individuals. This registry would allow us to better understand the relationship between the visual and ocular conditions of TBI and the efficacy of the prescribed treatment.

O.D.s can play an important role in diagnosing and treating TBI-related visual conditions and working with other providers. There will be both opportunities and responsibilities in taking care of our returning injured service men and women in addition to the millions of civilian TBI patients. As part of the interdisciplinary team, O.D.s can enhance the rehabilitative progress and the quality of life of these patients.

Dr. Francis L. McVeigh, a retired U.S. Army colonel, is the former chief of the Walter Reed Army Medical Centers Optometry Service and the Director of the Clinical Informatics Division. He is co-founder of the WRAMC Optometry TBI Program. He is currently a Senior Clinical Consultant to the Telemedicine and Advanced Technology Research Center concentrating in TBI for multi-specialties, eye injury repair and the hospital of the future clinical and research areas.


1. MacKenzie EJ. Epidemiology of injuries: current trends and future challenges. Epidemiol Rev 2000;22(1):112-9.

2. Thurman D, Guerrero J. Trends in hospitalization associated with traumatic brain injury. JAMA 1999 Sep 8;282(10):954-7.

3. Zasler ND. Brain Injury Medicine, Principles and Practice. 1st ed. New York: Demos Medical Publishing LLC, 2007:45-6.

4. Suchoff IB, Ciuffreda KJ, Kapoor N. Visual and Vestibular Consequences of Acquired Brain Injury. 1st ed. Santa Ana: Optometric Extension Program Foundation, Inc.;2001:1-3.

5. Traumatic Brain Injury, Veteran Health Initiative: Department of Veterans Affairs, Employee Education System; January 2004.

6. Traumatic Brain Injury in the United States: A report to Congress. Atlanta Center for Disease Control, 1999.

7. McGarry LJ, Thompson D, Millham FH, et al. Outcomes and costs of acute treatment of traumatic brain injury. J Trauma 2002 Dec;53(6):1152-9.

8. Thurman DJ, Alverson C, Dunn KA, et al. Traumatic brain injury in the United States: A public health perspective. J Head Trauma Rehabil 1999 Dec;14(6):602-15.

9. Thurman D. The epidemiology and economics of head trauma. In: Miller L, Hayes R (eds). Head Trauma: Basic, Preclinical, and Clinical Directions. New York: Wiley and Sons, 2001.

10. Defense and Veterans Brain Injury Center. Defense and Veterans Brain Injury Centers (DVBIC) Fact Sheet for Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF). October 2007 Report.

11. U.S. Department of Defense. Available at: (Accessed October 23rd, 2007).

12. Defense and Veterans Brain Injury Center. Available at: (Accessed October 23rd, 2007).

13. Warden DL, Ryan LM, Helmick KM, et al. War neurotrauma:  The Defense and Veterans Brain Injury Center (DVBIC) experience at Walter Reed Army Medical Center (WRAMC) (abstract). J Neurotrauma 2005 Oct;22(10):1178.

14. Lew HL, Poole JH, Vanderploeg RD, et al. Program development and defining characteristics of returning military in a VA Polytrauma Network Site. J Rehabil Res Dev 2007;44(7):1027-34.

15. Optometric care of the patient with acquired brain injury for eye care practitioners and the lay public. A joint organizational policy statement of the American Academy of Optometry and American Optometric Association. Available at: (Accessed March 11th, 2008).

16. Optometric Extension Program. Acquired brain injuries and hidden visual problems. Available at: (Accessed March 11th, 2008).

17. Sabates NR, Gonce MA, Farris BK. Neuro-ophthalmological findings in closed head trauma. J Clin Neuroophthalmol 1991 Dec;11(4):273-7.

18. Cohen AH. The role of optometry in the management of vestibular disorders. J Brain Injury 2005; 2(3):8-10.

19. Kapoor N, Ciuffreda KJ, Han Y. Oculomotor rehabilitation in acquired brain injury: a case series. Arch Phys Med Rehabil 2004 Oct;85(10):1667-78.

20. Han Y, Ciuffreda KJ, and Kapoor N. Reading-related oculomotor testing and training protocols for acquired brain injury in humans. Brain Res Brain Res Protoc 2004 Nov;14(1):1-12.

21. Gonzalez-Rothi LJ. Cognitive Therapy: is there such a thing? Paper presented at the VA/DoD Visual Consequences of Acquired Brain Injury Conference, December 5, 2007: San Antonio, TX.

Vol. No: 145:04Issue: 4/15/2008