Veterans with Traumatic Brain Injury-related Ocular Injury and Vision Dysfunction: Recommendations for Rehabilitation.

SIGNIFICANCE: We know the prevalence of traumatic brain injury (TBI)-related vision impairment and ocular injury symptoms. Lacking is an understanding of health care utilization to treat these symptoms. Utilization knowledge is important to structuring access to treatment, identifying clinical training needs, and providing evidence of the effectiveness of treatment. PURPOSE: This article reports rehabilitation, glasses/contacts, and imaging/photography/video recommendations made by optometrists and ophthalmologists as part of the Department of Veterans Affairs-mandated Performance of Traumatic Brain Injury Specific Ocular Health and Visual Functioning Examination administered to veterans with TBI at Department of Veterans Affairs polytrauma specialty facilities. METHODS: Using a retrospective design, natural language processing, and descriptive and regression statistics, data were analyzed for 2458 Operation Enduring Freedom/Operation Iraqi Freedom veterans who were administered the mandated examination between 2008 and 2017. RESULTS: Of the 2458 veterans, vision rehabilitation was recommended for 24%, glasses/contacts were recommended for 57%, and further imaging/photography/video testing was recommended for 58%. Using key words in the referral, we determined that 37% of veterans were referred to blind rehabilitation, 16% to occupational therapy, and 3% to low-vision clinics. More than 50% of the referrals could have been treated by blind rehabilitation, occupational therapy, or low-vision clinics. Rehabilitation referrals were significantly associated with younger age, floaters, photosensitivity, double vision, visual field and balance deficits, dizziness, and difficulty reading. In comparison, prescriptions for glasses and contacts were associated with older age, photosensitivity, blurred vision, decreased visual field and night vision, difficulty reading, and dry eye. Imaging/photography/video testing was associated with floaters, photosensitivity, and headache. CONCLUSIONS: Findings delineate service delivery models available to veterans with TBI-related vision impairment. The challenge these data address is the lack of clear paths from diagnosis of TBI to identification of vision dysfunction deficits to specialized vision rehabilitation, and finally to community reintegration and community based-vision rehabilitation.

Automated Perimetry and Visual Dysfunction in Blast-Related Traumatic Brain Injury.

PURPOSE: To evaluate feasibility and results of automated perimetry in veterans with combat blast neurotrauma. DESIGN: Prospective, longitudinal, observational case series. PARTICIPANTS: Sixty-one patients in a Veterans Affairs Polytrauma Center diagnosed with traumatic brain injury (TBI) from combat blast exposure. METHODS: Study participants underwent automated perimetry at baseline (median interval, 2 months after injury) (Humphrey Field Analyzer, Carl Zeiss Meditec, Dublin, CA, Swedish Interactive Threshold Algorithm 30-2 Standard or Fast), and 36 of them were followed up (median interval, 10 months after baseline). Presence of significant mean deviation and pattern standard deviation was determined for testing with reliability indices ≤20% for fixation loss, 15% for false-positives, and 33% for false-negatives. Test-retest stability of global visual field indices was assessed for tests with these cutoffs or with elevated fixation loss. Associations between global visual field defects and predictors were examined. MAIN OUTCOME MEASURES: Global visual field indices (mean deviation and pattern standard deviation). RESULTS: Among 61 study participants (109 study eyes) with baseline testing, a field that met reliability cutoffs was obtained for 48 participants (79%) and 78 eyes (72%). Fixation loss was found in 29% of eyes in initial testing. Nine study participants (15%) demonstrated hemianopia or quadrantanopia, and an additional 36% had an abnormal global visual field index. Global indices were relatively stable at follow-up testing for tests meeting fixation-loss cutoffs and tests that did not. Visual scotomas due to post-chiasmal lesions were associated with moderate to severe TBI or penetrating head injury, but other visual field deficits were prevalent across the range of mild to severe TBI. Ocular injury to the retina or choroid, poorer visual acuity, and pupillary defect were associated with visual field defects. Participants with depressed visual field sensitivity reported lower visual quality of life. CONCLUSIONS: Reliable automated perimetry can be accomplished in most patients with TBI from combat blast exposure and reveals high rates of visual field deficits, indicating that blast forces may significantly affect the eye and visual pathways.

Closed-globe injuries of the ocular surface associated with combat blast exposure.

PURPOSE: To describe closed-globe conjunctival and corneal injuries and endothelial cell abnormalities associated with blast exposure and their relationships to other closed-globe injuries and blast-event characteristics. DESIGN: Observational cross-sectional study. PARTICIPANTS: Veterans with a history of blast-related traumatic brain injury (TBI). METHODS: History and ocular examination, including slit-lamp biomicroscopy, gonioscopy, specular microscopy. MAIN OUTCOME MEASURES: Type and location of blast injuries to the conjunctiva and cornea. RESULTS: Ocular surface injuries were present in 25% (16 of 65) of blast-exposed veterans with TBI. Injuries included partial-thickness anterior stromal corneal scars (15 eyes), Descemet membrane ruptures (6 eyes), and conjunctival or corneal foreign bodies (7 eyes). Based on normative information from an age-matched comparison group, endothelial cell abnormalities were identified in 37% of participants. Eyes with ocular surface injury were more likely to have lower endothelial cell density, higher coefficient of variation of cell area, and lower percentage of hexagonal cells compared with eyes without injury. Presence of ocular surface injury or endothelial cell abnormalities was associated with elevated rates of other anterior and posterior segment injuries, as well as impairment of visual acuity. We found no relationship between ballistic eyewear use or severity level of TBI and presence of ocular surface injuries from blast. CONCLUSIONS: Independent of TBI severity or use of protective eyewear, ocular surface injuries and endothelial cell abnormalities were found in significant numbers of veterans with blast-related brain injury. Descemet membrane ruptures from blast exposure were described. Ocular surface trauma was associated with other ocular injuries throughout the globe. Potential mechanisms for the types and locations of ocular injuries seen were discussed. Any corneal or conjunctival injury in a blast survivor should prompt a thorough ocular trauma examination, including gonioscopy and specular microscopy, with appropriate follow-up for associated injuries. Longitudinal studies are required to determine long-term visual outcomes after blast exposure.

Visual performance and the ocular surface in traumatic brain injury.

The pathophysiology of neurotrauma is reviewed and an original study investigating the prevalence of dry eye disease in a sample of veterans with traumatic brain injury (TBI) is presented. Fifty-three veterans with TBI were evaluated by history of injury, past ocular history, and medication use. Ocular Disease Surface Index (OSDI), ocular examination, cranial nerve evaluation, tear osmolarity, tear film break-up time (TFBUT), ocular surface staining and tear production testing were performed. A matched comparison group underwent similar testing. TBI causes were blast (44) or non-blast (9). TBI subjects scored significantly worse on the OSDI (P<.001), and ocular surface staining by Oxford scale (P<.001) than non-TBI subjects. Scores for tear film breakup (P=.6), basal tear production less than 3 mm (P=.13), and tear osmolarity greater than 314 mOsm/L (P=.15) were all higher in TBI subjects; significantly more TBI subjects had at least one abnormal dry eye measure than comparisons (P<.001). The OSDI related to presence of dry eye symptoms (P<.01). These effects were present in both blast and non-blast TBI. Seventy percent of TBI subjects were taking at least one medication in the following classes: antidepressant, atypical antipsychotic, anticonvulsant, or h1-antihistamine. There was no association between any medication class and the OSDI or dry eye measures. Reduced corneal sensation in 21 TBI subjects was not associated with OSDI, tear production, or TFBUT, but did correlate with reduced tear osmolarity (P=.05). History of refractive surgery, previous contact lens wear, facial nerve weakness, or meibomian gland dysfunction was not associated with DED. In summary, we found a higher prevalence of DED in subjects with TBI, both subjectively and objectively. This effect is unrelated to medication use, and it may persist for months to years. We recommend that patients with TBI from any cause be evaluated for DED using a battery of standard testing methods described in a protocol presented in this article. Further research into the pathophysiology and outcomes of DED in neurotrauma is needed.

Retrospective Analysis of Vision Rehabilitation for Veterans With Traumatic Brain Injury-Related Vision Dysfunction.

INTRODUCTION: Traumatic brain injury (TBI) can trigger vision-based sequelae such as oculomotor and accommodative abnormalities, visual-vestibular integrative dysfunction, visual field loss, and photosensitivity. The need for diagnosis and management of TBI-related vision impairment has increased because of the increasing frequencies of combat warfighters returning from Iraq and Afghanistan with TBIs. The purpose of this research was to learn the sequelae of rehabilitation service delivery to veterans with TBI-related visual dysfunction after they are diagnosed. To accomplish this, we investigated vision rehabilitation assessments and interventions provided to veterans with TBI-related visual dysfunction at the Department of Veterans Affairs (VA) specialty polytrauma facilities for the 2 years following their injury. The research questions asked what assessments, interventions, and prescribed assistive devices were provided by VA specialty clinics (e.g., occupational therapy, polytrauma, and blind rehabilitation) and how service delivery was affected by demographic and clinical variables. MATERIALS AND METHODS: A retrospective design was used to analyze VA data using natural language processing of unstructured clinician notes and logistic regression of structured data. Participants included 350 veterans with TBI who received rehabilitation at one of the five VA Polytrauma Rehabilitation Centers (Tampa, FL; Richmond, VA; Minneapolis, MN; San Antonio, TX; and Palo Alto, CA) between 2008 and 2017 and who were administered the 2008 congressionally mandated "Traumatic Brain Injury Specific Ocular Health and Visual Functioning Exam." The outcome variables were vision assessments, interventions, and prescribed assistive technology discovered via natural language processing of clinician notes as well as the vision rehabilitation specialty clinics providing the clinical care (polytrauma, occupational therapy, outpatient blind rehabilitation, inpatient blind rehabilitation, optometry, and low vision) extracted from VA structured administrative data. RESULTS: 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. Technology provided included eyeglasses, wheelchair/scooter, walker/cane, aids for the blind, and computer. There was an overlap in the services provided by specialty clinics. Services available and delivered were significantly associated with the comorbidities of each patient and the specialty clinics available at each VA Polytrauma Rehabilitation Center. CONCLUSIONS: The delivery of patient services should be driven by the needs of veterans and not by system-level factors such as the 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 in 2008. The next step is to extend and standardize this new paradigm to community care, where these post-deployment patients now reside.

Multicenter, Head-to-Head, Real-World Validation Study of Seven Automated Artificial Intelligence Diabetic Retinopathy Screening Systems.

OBJECTIVE: With rising global prevalence of diabetic retinopathy (DR), automated DR screening is needed for primary care settings. Two automated artificial intelligence (AI)-based DR screening algorithms have U.S. Food and Drug Administration (FDA) approval. Several others are under consideration while in clinical use in other countries, but their real-world performance has not been evaluated systematically. We compared the performance of seven automated AI-based DR screening algorithms (including one FDA-approved algorithm) against human graders when analyzing real-world retinal imaging data. RESEARCH DESIGN AND METHODS: This was a multicenter, noninterventional device validation study evaluating a total of 311,604 retinal images from 23,724 veterans who presented for teleretinal DR screening at the Veterans Affairs (VA) Puget Sound Health Care System (HCS) or Atlanta VA HCS from 2006 to 2018. Five companies provided seven algorithms, including one with FDA approval, that independently analyzed all scans, regardless of image quality. The sensitivity/specificity of each algorithm when classifying images as referable DR or not were compared with original VA teleretinal grades and a regraded arbitrated data set. Value per encounter was estimated. RESULTS: Although high negative predictive values (82.72-93.69%) were observed, sensitivities varied widely (50.98-85.90%). Most algorithms performed no better than humans against the arbitrated data set, but two achieved higher sensitivities, and one yielded comparable sensitivity (80.47%, P = 0.441) and specificity (81.28%, P = 0.195). Notably, one had lower sensitivity (74.42%) for proliferative DR (P = 9.77 × 10-4) than the VA teleretinal graders. Value per encounter varied at $15.14-$18.06 for ophthalmologists and $7.74-$9.24 for optometrists. CONCLUSIONS: The DR screening algorithms showed significant performance differences. These results argue for rigorous testing of all such algorithms on real-world data before clinical implementation.

A Survey of Glaucoma Surgery Practice Patterns in the Veterans Health Administration.

INTRODUCTION: Glaucoma surgical practice patterns are not well described in the United States (US). This study aims to evaluate the indications for and potential barriers to glaucoma surgery in the Veterans Health Administration (VHA). MATERIALS AND METHODS: An anonymous 10-question survey using REDCap (Nashville, TN) software was sent by mail (with web link) and email to ophthalmology chiefs at the 86 academically affiliated Veterans Affairs Medical Centers (VAMCs). Academic-affiliated VAMCs were selected because of their patient range and role in ophthalmic education. Non-responders received two reminder e-mails and two phone calls; the survey was closed after 6 weeks. The data were analyzed using descriptive statistics. RESULTS: The response rate was 45% (39/86). Most respondents (92%) worked in an integrated eye clinic with both ophthalmology and optometry services. Almost half of the respondents (49%; 19/39) believed that laser trabeculoplasty (LTP) was an option for initial glaucoma therapy. Noncompliance was a commonly reported indication for LTP (95%), tube shunt procedures (65%), micro-invasive glaucoma surgery (59%), and trabeculectomy (48.7%). One third of the respondents believed that there were delays in glaucoma care. The respondents noted that significant barriers in access to surgery included lack of transportation (69%), scheduling challenges (62%), and delayed referral (62%). CONCLUSION: This survey of glaucoma surgery practice patterns highlights the growing role of LTP and suggests that non-compliance and access remain significant barriers to glaucoma surgical care within the VHA.

Comparing cataract surgery complication rates in veterans receiving VA and community care.

OBJECTIVES: To compare 90-day postoperative complication rates between Veterans receiving cataract surgery in VA vs Community Care (CC) during the first year of implementation of the Veterans Choice Act. DATA SOURCES: Fiscal Year (FY) 2015 VA and CC outpatient data from VA's Corporate Data Warehouse (CDW) 10/01/14-9/30/15). FY14 data were used to obtain baseline clinical information prior to surgery. STUDY DESIGN: Retrospective one-year study using secondary data to compare 90-day complication rates following cataract surgery (measured using National Quality Forum (NQF) criteria) in VA vs CC. NQF defines major complications from a specified list of Current Procedural Terminology (CPT) codes. We ran a series of logistic regression models to predict 90-day complication rates, adjusting for Veterans' sociodemographic characteristics, comorbidities, preoperative ocular conditions, eye risk group, and type of cataract surgery (classified as routine vs complex). DATA COLLECTION: We linked VA and CC users through patient identifiers obtained from the CDW files. Our sample included all enrolled Veterans who received outpatient cataract surgery either in the VA or through CC during FY15. Cataract surgeries were identified through CPT codes 66 984 (routine) and 66 982 (complex). PRINCIPAL FINDINGS: Of the 83,879 cataract surgeries performed in FY15, 31 percent occurred through CC. Undergoing complex surgery and having a high-risk eye (based on preoperative ocular conditions) were the strongest clinical predictors of 90-day postoperative complications. Overall, we found low complication rates, ranging from 1.1 percent in low-risk eyes to 3.6 percent in high-risk eyes. After adjustment for important confounders (eg, race, rurality, and preoperative ocular conditions), there were no statistically significant differences in 90-day complication rates between Veterans receiving cataract surgery in VA vs CC. CONCLUSIONS: As more Veterans seek care through CC, future studies should continue to monitor quality of care across the two care settings to help inform VA's "make vs buy decisions."

Comparative effectiveness and harms of intravitreal antivascular endothelial growth factor agents for three retinal conditions: a systematic review and meta-analysis.

Intravitreal antivascular endothelial growth factor (VEGF) agents are widely used to treat ocular conditions but the benefits and harms of these treatments are uncertain. We conducted a systematic review to compare the effects of aflibercept, bevacizumab and ranibizumab on best-corrected visual acuity (BCVA) changes, quality of life and ocular or systemic adverse events in patients with neovascular age-related macular degeneration (NVAMD), diabetic macular oedema (DME) and central or branch retinal vein occlusion (RVO). We searched published and unpublished literature sources to February 2017 for randomised controlled trials and cohort or modelling studies reporting comparative costs in the USA. Two reviewers extracted data and graded the strength of the evidence using established methods. Of 17 included trials, none reported a clinically important difference (≥ 5 letters) in visual acuity gains between agents. Nine trials provide high-strength evidence of no difference between bevacizumab and ranibizumab for NVAMD. Three trials provide moderate-strength evidence of no difference between bevacizumab and ranibizumab for DME. There was low-strength evidence of similar effects between aflibercept and ranibizumab for NVAMD, aflibercept and bevacizumab for RVO and all three agents for DME. There was insufficient evidence to compare bevacizumab and ranibizumab for RVO. Rates of ocular adverse events were low, and systemic harms were generally similar between groups, although 1 DME trial reported more arterial thrombotic events with ranibizumab versus aflibercept. Overall, no agent had a clear advantage over another for effectiveness or safety. Aflibercept and ranibizumab were significantly less cost-effective than repackaged bevacizumab in two trials. Systematic review registration number: CRD42016034076.

Eye Care Productivity and Access in the Veterans Affairs Health Care System.

OBJECTIVES: Eye care in the Veterans Affairs Health Care System is challenged with increasing demand and higher prevalence of patients with complex ocular conditions. Understanding factors that impact eye care productivity and access is necessary for appropriate allocation of resources. The purpose of this study was to determine the impact of various eye clinic personnel on eye care provider productivity and patient access. METHODS: Utilizing data from the Veterans Health Administration National Data Warehouse, workload and level of staffing were analyzed. Trends in the data were analyzed using descriptive and regression analyses employing both linear and curve fitting modeling methods. RESULTS: There was a significant positive correlation between ophthalmology technicians and ophthalmologist productivity (p < 0.001), number of unique patients seen per year per provider (p = 0.047), and total yearly number of office visits per provider (p < 0.001). Similarly, there was a significant positive correlation between number of ophthalmology residents and productivity (p = 0.046) and number of clinic visits per provider (p < 0.001) but not the number of unique patients seen. Positive correlation was found between optometry technicians and the number of unique patients' seen by optometrists (p = 0.041) and total number of clinic visits per provider (p < 0.001) but not optometrist productivity. No significant correlations were present for nurses, nurse practitioners, physician assistants, or clerical staff. CONCLUSION: Eye care technicians provide a cost-effective multiplier effect for provider productivity, especially in ophthalmology clinics, allowing significant increases in total clinic visits and number of unique patients seen per year.

Cataract surgery practices in the United States Veterans Health Administration.

PURPOSE: To describe current cataract surgery practices within the United States Veterans Health Administration (VHA). SETTING: Veterans Health Administration hospitals in the U.S. DESIGN: Retrospective data analysis. METHODS: An initial e-mail containing a link to an anonymous 32-question survey of cataract surgery practices was sent to participants in May 2016. Two reminder e-mails were sent to nonresponders 1 week and 2 weeks after the initial survey was sent; the remaining nonresponders were called twice over a 2-week period. The data were analyzed using descriptive statistics. RESULTS: The response rate was 75% (67/89). Cataract surgeons routinely ordered preoperative testing in 29 (45%) of 65 sections and preoperative consultations in 26 (39%) of 66 sections. In 22 (33%) of 66 sections, cataract surgeons administered intracameral antibiotics. In 61 (92%) of 66 sections, cataract surgeons used toric intraocular lenses (IOLs). In 20 (30%) of 66 sections, cataract surgeons used multifocal IOLs. Cataract surgeons in 6 (9%) of 66 sections performed femtosecond laser-assisted cataract surgery. In 6 (9%) of 66 sections, cataract surgeons performed immediate sequential bilateral cataract surgery. Forty-nine (74%) ophthalmology chiefs reported a high level of satisfaction with Veterans Affairs ophthalmology. CONCLUSIONS: The survey results indicate that in cataract surgery in the VHA, routine preoperative testing is commonly performed and emerging practices, such as femtosecond laser-assisted cataract surgery and immediate sequential bilateral cataract surgery, have limited roles. The results of this survey could benchmark future trends in U.S. cataract surgery practices, especially in teaching hospital settings.

Epithelial metaplasia of the corneal endothelium in Fuchs endothelial dystrophy.

PURPOSE: To evaluate the immunohistochemical characteristics of human corneas with the diagnosis of Fuchs endothelial dystrophy (FED). METHODS: Formalin-fixed, paraffin-embedded sections of corneas with the diagnosis of FED (15 patients) and 10 control corneas were stained with hematoxylin-eosin and periodic acid-Schiff (PAS). Adjacent histologic sections were stained with monoclonal antibodies that react with epithelial antigens: pancytokeratin, cytokeratins (CK) 7 and 20 CAM 5.2, epithelial membrane antigen (EMA), and Ber EP4. Eight corneas were stained with antibodies to vimentin, smooth-muscle actin (SMA), and CD 68. RESULTS: The endothelial cells in FED were attenuated and atrophic; some contained pigment consistent with melanin. The endothelial cells stained for pancytokeratin, CK 7, and vimentin in all corneas of FED, whereas variable staining was noted with CAM 5.2. No staining of endothelium was noted with CK 20, EMA, BerEP4, SMA, or CD 68. CONCLUSION: Some cytokeratins that are normally restricted to true epithelium are present in the endothelium of FED. Epithelial metaplasia of endothelium in FED may represent a nonspecific response of distressed endothelial cells, as previously reported in posterior polymorphous dystrophy, congenital hereditary endothelial dystrophy, and iridocorneal endothelial syndrome.

Emerging Cataract Surgery Practice Patterns in the Veterans Health Administration.

A survey finds low rates for femtosecond laser-assisted cataract surgery, intracameral antibiotics, and immediate sequential bilateral cataract surgery in cataract surgery practice.

An immunohistochemical analysis and comparison of posterior polymorphous dystrophy with congenital hereditary endothelial dystrophy.

PURPOSE: To evaluate the immunohistochemical profiles of the abnormal endothelial cells of posterior polymorphous dystrophy (PPMD) and congenital hereditary endothelial dystrophy (CHED). METHODS: Formalin-fixed, paraffin-embedded sections of seven corneas with the diagnosis of PPMD (seven patients), six corneas with the diagnosis of CHED (four patients), and five control corneas were stained with hematoxylin-eosin. Adjacent histologic sections were stained with monoclonal antibodies that react with pancytokeratin, AE1/AE3, cytokeratin (CK) 7, CK 20, CAM 5.2, and epithelial membrane antigen. The immunoreactivity of the corneal endothelium was assessed by light microscopy. RESULTS: The endothelial cells stained positive for pancytokeratin and CK 7 in seven of seven corneas of patients with PPMD and five of six corneas of patients with CHED; variable positivity was seen to AE1, AE3, and CAM 5.2. The endothelium was uniformly negative to staining by CK 20. The epithelium stained positive with pancytokeratin, AE1, and AE3. All control corneas were negative for pancytokeratin, CK 7, and CK 20. CONCLUSION: The abnormal endothelium in both PPMD and CHED expresses similar CKs, including CK 7, which is not present in normal endothelium or surface epithelium. This may indicate a shared developmental abnormality in these conditions, as previously suggested by ultrastructural studies and genetic mapping.

Abiotrophia defectiva causing infectious crystalline keratopathy and corneal ulcer after penetrating keratoplasty: a case report.

BACKGROUND: Infectious crystalline keratopathy is commonly caused by Streptococcus viridans and other gram positive organisms. We present the first case of infectious crystalline keratopathy that developed into a corneal ulcer and grew Abiotrophia defectiva which responded well to topical and systemic antimicrobial therapy and did not require re-grafting. A 78-year-old man underwent penetrating keratoplasty for pseudophakic bullous keratopathy. He presented 1.5 years later with infectious crystalline keratopathy which progressed to a corneal ulcer. The patient received topical fortified vancomycin and moxifloxacin, as well as oral moxifloxacin. FINDINGS: The corneal ulcer base was cultured and grew A. defectiva, or nutritionally deficient streptococcus. Complete resolution of the corneal infiltrates was obtained within three months. CONCLUSIONS: Nutritionally deficient streptococcus has been implicated in numerous human diseases, including endocarditis, and is increasingly being recognized as an important pathogen. This represents the second reported case of A. defectiva causing infectious crystalline keratopathy in humans and the first case of A. defectiva successfully treated with antibiotics. This case shows that aggressive antibiotic therapy can be effective in A. defectiva-associated infectious crystalline keratopathy.

Visual quality of life in veterans with blast-induced traumatic brain injury.

IMPORTANCE: Traumatic brain injury (TBI) is an important cause of morbidity worldwide, with increasing awareness of the role of blast exposure in military and civilian casualties. Visual problems have been reported in TBI and may affect functioning and quality of life. OBJECTIVE: To evaluate the 25-item National Eye Institute Visual Functioning Questionnaire and Neuro-Ophthalmic Supplement for utility in assessing the effect of blast exposure on perceived visual functioning among veterans with TBI. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study from a tertiary care Veterans Health Administration hospital. Reported visual quality of life was compared with existing norms, and relationships between perceived visual quality and ocular injury, diplopia, visual performance, and blast exposure characteristics were examined. Participants included inpatients with blast-induced TBI who underwent baseline examination between December 7, 2006, and January 11, 2012, at a multiple-trauma rehabilitation center and who had at least 1 intact eye and were able to undergo psychometric testing and ocular examination. Among 64 sequentially eligible patients, 60 completed visual quality testing, 1 declined study participation, and 3 were evaluated prior to inclusion of visual quality testing in the protocol. Thirty-nine patients returned for outpatient follow-up, with a median test-retest interval of 11 months. EXPOSURE: Combat blast exposure with documented TBI. MAIN OUTCOMES AND MEASURES: Composite and subscale scores on the 25-item National Eye Institute Visual Functioning Questionnaire and Neuro-Ophthalmic Supplement. RESULTS: Both tests had high test-retest reliability. Blast-exposed veterans reported significantly poorer visual quality compared with healthy samples and some patient samples with known eye disease. Scores tended to be worse for participants with identified visual performance deficits (poorer visual acuity or spatial contrast sensitivity, visual field depression or defects). Scores were not related to the extent of ocular injury or to blast exposure characteristics such as use of protective eyewear or TBI severity level. CONCLUSIONS AND RELEVANCE: Individuals with blast-induced TBI reliably completed both tests and reported significant decrements in their subjective visual experiences. Measures of subjective visual quality may be useful to identify patients needing additional visual or neurologic evaluation and to monitor the effect of visual rehabilitation on patients with blast-related visual disabilities.

IgG4-positive sclerosing orbital inflammation involving the conjunctiva: a case report.

PURPOSE: To describe IgG4-positive sclerosing orbital inflammation with prominent conjunctival and scleral involvement. DESIGN: Case report. METHODS: Clinical, radiologic, and pathologic correlation. RESULTS: A 66-year-old man presented with right eye redness and irritation. Examination revealed unilateral scleritis and nongranulomatous anterior uveitis with elevated p-ANCA and CRP. Orbital CT scan showed inferotemporal scleral thickening. Biopsy revealed sclerosis and IgG4-positive plasma cells in the conjunctiva and inferior rectus. CONCLUSIONS: IgG4-mediated sclerosing inflammation is well-recognized in the orbit and adnexa, particularly the lacrimal gland. Scleritis with anterior uveitis should be recognized as a possible presentation for this entity, which has important systemic associations.

Eye and visual function in traumatic brain injury.

Combat blast is an important cause of traumatic brain injury (TBI) in the Department of Veterans Affairs polytrauma population, whereas common causes of TBI in the civilian sector include motor vehicle accidents and falls. Known visual consequences of civilian TBI include compromised visual acuity, visual fields, and oculomotor function. The visual consequences of TBI related to blast remain largely unknown. Blast injury may include open globe (eye) injury, which is usually detected and managed early in the rehabilitation journey. The incidence, locations, and types of ocular damage in eyes without open globe injury after exposure to powerful blast have not been systematically studied. Initial reports and preliminary data suggest that binocular function, visual fields, and other aspects of visual function may be impaired after blast-related TBI, despite relatively normal visual acuity. Damage to the ocular tissues may occur from blunt trauma without rupture or penetration (closed globe injury). Possible areas for research are development of common taxonomy and assessment tools across services, surgical management, and outcomes for blast-related eye injury; the incidence, locations, and natural history of closed globe injury; binocular and visual function impairment; quality of life in affected service members; pharmacological and visual therapies; and practice patterns for screening, management, and rehabilitation.

Radiosensitive orbital inflammation associated with temporal arteritis.

A 75-year-old woman developed acute loss of vision in the OD, ipsilateral periocular pain, an afferent pupillary defect, sectoral optic disc edema, and later ipsilateral proptosis and an intraconal mass. She denied any symptoms of temporal arteritis, and a sedimentation rate was normal. Orbital biopsy demonstrated chronic granulomatous inflammation with perivasculitis. A temporal artery biopsy disclosed findings consistent with temporal arteritis. Following 2000 cGy of external beam radiation, her visual function and orbitopathy completely resolved. This unusual presentation of orbital inflammation in association with temporal arteritis demonstrates that pathologic findings of temporal arteritis may be clinically nonspecific and that external beam radiation may be an effective therapy in this setting.