New DoD/VA Center to Improve Eye Care

By Matt Pueschel
FHP&R Staff Writer

February 15, 2010 - The new Vision Center of Excellence (VCE) is beginning to take flight since it was formed at the behest of Congress to track eye injuries emanating from the war theater and improve treatment outcomes across the services and VA.

“It’s important to look at how injuries are occurring, what can we do to mitigate the extent of morbidity when doing treatment, and how can we enhance treatment and research and improve the rehabilitation process to bring better functioning in life to patients,” said Col. Donald A. Gagliano, M.D., M.H.A., DoD principal advisor for vision and VCE’s executive director, during a presentation in January before a group of military and veterans service organizations at the FHP&R offices in Falls Church, Va.

VCE was formed after the fiscal year 2008 National Defense Authorization Act directed DoD and VA to establish a center of excellence in the prevention, diagnosis, mitigation, treatment, and rehabilitation of military eye injuries, and to better coordinate visual rehabilitative care and benefits for service members’ continuum of care between the agencies.

The need for the VCE is evidenced in the variety of injuries that impact soldiers’ vision, from traumatic eye injury as a result of explosive devices and projectiles, to vision disorders associated with TBI, and eye injury caused by exposure to chemicals, biohazards, lasers or extreme environmental conditions. VCE is facilitating collaborative efforts that support optimal DoD/VA vision care transition, such as a process developed at Walter Reed Army Medical Center for blind rehabilitation care.

Gagliano said there are increasing numbers of eye injuries occurring among service members from OEF/OIF compared with previous conflicts. According to the November 2008 Medical Surveillance Monthly Report of the Armed Forces Health Surveillance Center, more than 1,000 ocular injuries caused by war, guns and explosives were treated in fixed hospitals from 2003 to 2007.

“We’re also starting to see visual disorders with TBI, so we’re looking at that,” he said. “Part of the problem is that patients are moving back and forth between VA and DoD [and] there is a very broad care and recovery program instituted. VA has visual impairment support teams [and] there are vision care capabilities in DoD and VA that I can influence, advocate for, integrate and collaborate with [toward] a purpose of trying to find ways to bring some answers.”

About 60-70 percent of severe and moderate TBI cases and 40 percent of mild TBI cases include some form of visual impairment, such as nerve damage from concussive events. VCE is looking at capturing reports from the Defense and Veterans Brain Injury Center, which collects intake information on visual issues caused by mild TBI.

“Mild TBI is still an enigma,” Gagliano said. “We’re looking at clinical symptoms and maybe some cognitive testing. Some of the blast exposure injuries are injuries to the globe. When a blast wave hits your eye, it causes tissue, retinal, nerve, and zonular injury and we don’t understand it well. It’s like two times the force of being punched. The eye is compressible, so we’re looking at how to mitigate it.”

Better Tracking

VCE is spearheading development of a new database to track eye injuries across the DoD and VA systems of care and to integrate pertinent information from all of the services. The new Defense and Veterans Eye Injury Registry (DVEIR) will record and follow the occurrence, treatment and outcomes of all eye injuries experienced by active duty service members since 9/11.

Gagliano said this will show how patients with the same types of injuries were treated and allow the VCE to focus research more effectively, evaluate DoD and VA health care processes and establish treatment guidelines. “It will allow us to manage both individuals and cohorts of patients and analyze outcomes and improve care and enact change,” he said.

A key goal with the database is to develop a common documentation strategy for vision care among DoD’s and VA’s varying health records. “We spent two years developing the database and getting the DoD electronic health records from nine different systems to talk to each other,” Gagliano said. “We want to track outcomes, but we need incidence data in order to get to outcomes. We think we’re getting closer [with] VA and DoD sharing information. When we first started, there were two separate registry projects, and now there is one joint registry.”

Gagliano said VA and DoD are working on ways to share more patient information, and DoD is looking at redesigning an electronic health record to make its records more user friendly. “If you don’t fix these technical issues you won’t have the ability to impact patient care,” he said. “If we make more information available to providers, we think we’ll be able to improve care.”

The aim is to follow service members from the point of injury in theater through joint medical and patient tracking systems until they get to the U.S. Because of the little information that is available on eye injuries in theater, VCE is also developing an eye module for trauma wounds.

“We have a lot of ophthalmologists in theater who worked on [recording eye injuries in] spreadsheets, so we’re bringing that information in,” Gagliano said. “My goal is to gather all information [on eye injuries and care] back to ’01. In another couple months, we’ll be able to collect [and input] databases from theater and combat registries into our registry on incidents and identification of casualties that have occurred in theater. After that, we’ll go back to the first Gulf War.”

The joint registry will also provide a synergy with other centers of excellence being developed for service members exposed to blasts, such as one on hearing issues. Blast injuries can cause hearing and vision problems, as well as limited sense of smell and taste.

“This is why Congress put together this grouping of registries [to look at] how do we bring people with sensory deficits to function better in life, so it’s an excellent idea [to bring all the pieces together],” Gagliano said. “There will be some cross communication between registries. The vision registry will be for performance improvement with patient tracking and vision research, which will pool information from other databases, such as on TBI.”

Looking Ahead

Another component of the VCE is to focus vision research on eye trauma, TBI post-traumatic visual syndrome, refractive surgery, and degenerative eye diseases. Gagliano sits on a joint committee that establishes priorities for the new Vision Research Program.

With a limited amount of funds ($3.75 million this year) and many research proposals to consider, the program has a focus on five topic areas: developing treatments for TBI-associated visual dysfunction; treatments to slow or stop vision loss in traumatic optic neuropathies; computational models of mechanisms of primary blast injury to the eye and vision system; methods to test visual dysfunction in the presence of cognitive impairment; and treatments for blast and burn injury to ocular structures.

“Our real priority is the blast model and how we mitigate that and direct research efforts towards fixing that problem,” Gagliano said.

VA only funds intramural vision research, but has special centers focused on TBI-related vision disorders, researching the use of implants and artificial mechanical means to restore some vision, and developing new techniques for visual rehabilitation. Meanwhile DoD jointly funds other vision research projects with the National Eye Institute, and is also working with the Food and Drug Administration to examine refractive surgery outcomes and set a baseline standard.

“We do more refractive surgery in DoD than any other entity in the country,” Gagliano said. “Our outcomes and satisfaction are very high, but DoD requirements are different. It’s an operational requirement, so I want to capture that information on refractive surgery outcomes and track them through to VA.”

Gagliano said that combat eye care education should be enhanced. “We have a lot of eye care providers with no trauma experience,” he said. “We want to build simulation models for trauma training. There is no recognized capability in DoD for blind rehab specialists, so we’re trying to get that as a recognized specialty.”

Furthermore, through development of combat protective eyewear, the line has reduced the amount of eye injuries in the field, Gagliano said. “That has really impacted on ballistics protection, but not blast protection,” he advised. “We’ll have to redesign facial protection.”

VCE is in the process of building its staff and spaces and will have a deputy director from the VA as part of an organizational office scheduled to open in Crystal City, Va., in a few months. Eventually there will be a mix of optometrists, ophthalmologists and vision rehabilitation specialists as part of a 25-member staff based in a clinical component that will serve as VCE’s headquarters at the new Walter Reed Medical Center in Bethesda in 2011.

The VCE received $4 million from Congress to carry out the needed renovations for the space over the next 12-18 months. “We’ll be opening the new VCE at the new hospital and it will be co-located with an optometry and ophthalmology and refractive surgery center, and we’ll build a space for outreach, [including] computer stations for visually impaired service members and veterans so they can use it as a resource for information,” Gagliano said, adding that VCE will have six cells with nurse vision care coordinators and capabilities that support MTFs throughout the country.

VA has further agreed to fund several VA visual clinical care and policy positions in the VCE, but both the DoD and VA positions for the VCE are being filled deliberately, pending funding. “We’ve been excited to get going,” Gagliano said. “We are making progress where we can.”

For more information, please visit http://www.visioncenterofexcellence/

Australia's 'Shipyard of Future'

By Jim Garamone
American Forces Press Service

Feb. 15, 2010 - Deputy Defense Secretary William J. Lynn III observed the opening of the heart of one of the most modern shipbuilding plants in the world here today.

Techport is a $300 million investment in Australia's defense. The shipyard is where the nation of 22 million people will build the country's next class of air warfare destroyers and its next-generation submarine fleet.

The shipyard; on the banks of the Port River; is a state-of-the-art facility. Lynn observed the opening of Techport's common-user facility; a huge expanse that includes a wharf, a ship runway, a dry berth, a transfer system and the largest shiplift in the Southern Hemisphere.

To symbolize the opening of the facility, South Australia Premier Mike Rann pushed a button starting the shiplift. A klaxon sounded, and the more-than-500-foot lift began descending into the water. The lift has a capacity of 9,300 tons, and may in years to come expand to nearly 700 feet with a lift capacity of 22,000 tons, officials said.

"Great to see such a fabulous facility and see the enormous capability that you have here in an area so important to your security," Lynn said during a short media availability following the opening. "It's very hopeful that our closest allies are moving in such strength in the naval area. We're just glad to be a part of it."

Lynn put on a hard hat and a yellow reflective vest to tour the facility. He saw buildings and shops where plates of steel will turn into the hulls of new ships. He saw where skilled workers will put together the modules of Australia's next-generation warships.

Everything was new and gleaming. There wasn't a speck of rust or misplaced brick in the whole shipyard, and the Australian workers in the area obviously are proud of what they have built.

The plan to build three destroyers is part of an Australian push to replace about 80 percent of the equipment in its military forces that stems from the Australian Defense White Paper published in May.

"They've got a financial plan that matches their strategy," Lynn said during a later interview. "It's got 3 percent real growth. Even with that kind of growth, it's an aggressive plan, but they have thought it through."

Techport; and many other decisions; backs up the defense White Paper, Lynn said. Techport is part of "a really strong industrial foundation that supports the maritime emphasis in the strategy," he said.

While the shipyard is an Australian capability, it integrates U.S. defense industry partners. Bath Iron Works and Lockheed are working with the Australians, "and I'm sure if the U.S. Navy needed it to support our operations, it would be available, and it's an option for the Pacific Command to examine," Lynn said.

Australian reporters asked Lynn about the U.S. program to build the F-35 Lightning II joint strike fighter for use by its Navy, Air Force and Marine Corps and its allies. "We've taken some steps to strengthen the program," Lynn said. "We took a look at it when we came into office last year. We thought the costs were underestimated in terms of production, and we thought the development was going to last longer than originally projected."

The U.S. Defense Department "re-costed" the production to a better estimate, Lynn said. Officials also strengthened the aircraft's development with additional test aircraft.

"With those steps, the F-35 will continue on the path to be the backbone of tactical aviation for both the United States and Australia," he said.