Development of a mild traumatic brain injury-specific vision screening protocol: a Delphi study.

Although traumatic brain injury (TBI) can happen to anyone at any time, the wars in Iraq and Afghanistan have brought it renewed attention. Fortunately, most cases of TBI from the recent conflicts are mild TBI (mTBI). Still, many physical, psychological, and social problems are associated with mTBI. Among the difficulties encountered are oculomotor and vision problems, many of which can impede daily activities such as reading. Therefore, correct diagnosis and treatment of these mTBI-related vision problems is an important part of patient recovery. Numerous eye care providers in the Department of Veterans Affairs, in military settings, and in civilian practices specialize and are proficient in examining patients who have a history of TBI. However, many do not have this level of experience working with and treating patients with mTBI. Recognizing this, we used a modified Delphi method to derive expert opinions from a panel of 16 optometrists concerning visual examination of the patient with mTBI. This process resulted in a clinical tool containing 17 history questions and 7 examination procedures. This tool provides a set of clinical guidelines that can be used as desired by any eye care provider either as a screening tool or adjunct to a full eye examination when seeing a patient with a history of mTBI. The goal of this process was to provide optimal and uniform vision care for the patient with mTBI.

Visual impairment and dysfunction in combat-injured servicemembers with traumatic brain injury.

PURPOSE: The purpose of this study was to determine the frequencies of visual impairment and dysfunction among combat-injured Polytrauma Rehabilitation Center (PRC) inpatient and Polytrauma Network Site (PNS) outpatient military personnel with traumatic brain injury (TBI). METHODS: A retrospective analysis of data from vision screenings of 68 PRC-inpatients with moderate to severe levels of TBI and 124 PNS-outpatients with mild TBI at the VA Palo Alto Health Care System was conducted. RESULTS: Eighty-four percent of PRC-inpatients and 90% of PNS-outpatients had TBIs associated with a blast event. The majority of patients in both the PRC and PNS populations had visual acuities of 20/60 or better (77.8% PRC, 98.4% PNS). Visual dysfunctions (e.g., convergence, accommodative, and oculomotor dysfunction) were common in both PRC and PNS populations. In the PRC-inpatient population, acuity loss of 20/100 to no light perception (13%) and visual field defects (32.3%) were found. In the PNS-outpatient population, acuity loss of 20/100 to no light perception (1.6%) and visual field defects (3.2%) were infrequently found. In both the PRC and PNS populations, visual field defects were more often associated with blast than non-blast events. CONCLUSIONS: Blast events were the most frequent mechanism of injury associated with TBI in combat-injured servicemembers. The vision findings suggest that combat troops exposed to blast with a resulting mild TBI are at risk for visual dysfunction, and combat troops with polytrauma injuries are at risk for visual dysfunction and/or visual impairment. The visual consequences of such injuries necessitate further study and support the need for appropriate evaluation and treatment in all severities of TBI.