Office of Research & Development

VA research on

Vision Loss


Introduction

On Jan. 28, 1944, in the midst of World War II, President Franklin D. Roosevelt signed an executive order that stated, in part, that "no blinded servicemen from World War II would be returned to their homes without adequate training to meet the problems of necessity imposed upon them by their blindness."

Today, VA's extensive network of low-vision rehabilitation programs helps many blinded and low-vision Veterans improve their level of functioning. VA's Office of Blind Rehabilitation Services estimates there are approximately 157,000 Veterans in the United States who are legally blind, and more than a million Veterans who have low vision that causes a loss of ability to perform necessary daily activities.

In older Veterans, major causes of vision loss include age-related macular degeneration, glaucoma, cataracts, stroke, and diabetic retinopathy. Among Veterans who have served in Iraq and Afghanistan, blast-related brain injuries can be followed by vision problems such as blurred vision, double vision, sensitivity to light, and difficulty reading. VA estimates that as many as 64 percent of service members with traumatic brain injuries (TBIs) also have a vision problem.

Throughout the nation, VA operates 13 Blind Rehabilitation Centers (BRCs). These are residential inpatient training programs that help Veterans adjust to their blindness. BRCs offer a variety of courses designed to help blinded Veterans achieve a realistic level of independence.

The Visual Impairment Center to Optimize Remaining Sight (VICTORS) program complements existing BRCs to support Veterans who are not blind but have significant visual impairment. VICTORS provides rehabilitation through offering definitive medical diagnosis and functional visual evaluation, prescribing low-vision aids and training Veterans in their use, and providing counseling and follow-up.

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Selected Milestones and Major Events

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Historic VA Research accomplishments

VA's specialized care for blinded Veterans began with the establishment of the first Center for Rehabilitation of the Blind at the Hines VA Hospital in Chicago in 1948. In this program, selected blind Veterans were trained in a variety of skills.

In the early years after World War II, VA researchers began testing obstacle detectors built for the U.S. Army during the war to find ways to use them to help blinded Veterans navigate their environment. These obstacle detectors eventually led to the development of the laser cane, still in use today. Laser canes emit pulses of infrared light and make different sounds to indicate obstacles ahead, or drop-offs such as a street curb.

In the 1950s, '60s, and '70s, VA researchers and research funding helped develop devices that produced speech-like sounds in response to letter shapes. These "reading machines" were the predecessors for technologies now in widespread use.

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New, Ongoing, and Published Research

VA research projects in the area of vision loss and vision restoration cover the entire spectrum of Veterans' needs. In addition to developing vision-restoring treatment, VA investigators are designing and improving assistive devices for those with visual impairments, as well as doing work on a number of innovative wayfinding systems to help Veterans with vision loss navigate in various environments and perform everyday tasks. They are also developing more accurate and efficient methods of vision testing, and are studying the connections between injury and vision loss in eyes that have suffered no overt damage.

VA's Atlanta-based Center for Visual and Neurocognitive Rehabilitation is focused on enhancing Veterans' health by conducting research on the rehabilitation of visual and related neurological impairments.

Researchers at the VA Center for the Prevention and Treatment of Visual Loss, located at the Iowa City VA Health Care System, focus on the early detection of potential blinding disorders of the Veteran and general population. These include retinal disease, glaucoma, and TBI. Researchers at the center test new ways of determining early signs of disease progression and response to treatment. They also develop new treatments.

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➤ Retinal implants

Implantable retinal prosthesis study—VA researchers are part of a team, the Boston Retinal Implant Project, working to help patients with visual impairments. One of the team's major projects has been to develop an implantable retinal prosthesis that could restore sight in blinded Veterans and others. In the eye, the retina contains a million nerve cells that transmit image signals to the vision cortex of the occipital lobe in the back of the brain.

The project uses "smart" eyeglasses that serve as a camera and a transmitter. The images the camera takes are transmitted to a handheld computer and power pack. The computer processes the images, and a signal is then sent to an antenna encircling the iris of the eye.

The antenna directs the signal into a half-inch-square titanium pack atop the eye that contains a computer chip and electronics. It turns the image into impulses sent to specific electrodes implanted in a thin plastic film placed between the retina and back wall of the eye. Those pulses stimulate the proper retinal nerves to send signals of that image to the brain.

The device was approved by the U.S. Food and Drug Administration in 2013. It provides limited eyesight for people with retinitis pigmentosa, a degenerative eye disease that causes severe vision impairment due to a loss of cells in the retina. As currently configured, the prosthesis will not help blinded Veterans whose optic nerve or retinal nerve system has been damaged.

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➤ Improving mobility for blinded Veterans

In 1947, VA researchers introduced the first mobility and orientation rehabilitation training program for blind persons. Today, researchers at VA's Center for Visual and Neurocognitive Rehabilitation are working on a number of projects to help blind people and those with low vision to find their way around independently with greater ease.

Smartphone app—Researchers at the center are developing a smartphone app that fuses data from the Global Positioning System with data from the magnetic compass, gyrocompass, and accelerometers found in most smartphones. The app will provide highly accurate location information that can help users easily find destinations such as a crosswalk or building entrance.

RFID tags—The center is also investigating the use of radio-frequency identification (RFID), the technology that allows people to scan items at a store or drive through a tollbooth with an E-ZPass tag. Researchers are looking at the possibility of placing RFID tags on Braille signs to send information automatically to smartphones that can read the tags. Currently, some Braille signs use low energy Bluetooth transmitters, but the batteries on those must be changed every few years, while RFID tags require no power.

HandSight—Center researchers are working on a Department of Defense-funded project called HandSight, in which a tiny camera small enough to embed in a false fingernail is worn by the user and connected to a smart watch. The watch vibrates to signal that the user has placed his or her finger on a line of text.

Scanning the finger along the text activates software that translates the text into spoken output heard on a Bluetooth earpiece. When the user touches an article of clothing, software in the watch recognizes the colors and patterns and helps with coordinating an ensemble.

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➤ TBI and vision loss

Advances in body armor, medical care, and equipment have enabled more service members to survive devastating blast injuries. Use of polycarbonate eye protection has reduced the number of open-globe eye wounds service members sustain, but this eye protection does not guard against the effect of blast waves. Researchers at the VA Palo Alto Health Care system have completed a number of studies related to the effects of blasts on vision.

Sensory issues—Sensory problems are common among Veterans who have had TBIs. In 2012, Palo Alto researchers reported on a study of 21,000 Veterans evaluated for TBI in VA outpatient clinics. They found that 9.9 percent of them reported vision problems, 31.3 percent reported hearing impairments, and 34.6 percent reported both vision and hearing issues.

Quick visual testing identifies problems—In 2016, the team published a study that indicated that perimetry (visual field testing) for Veterans with TBIs within two months of their combat blast exposure provides a reliable indicator of long-lasting vision problems. These tests also reveal high rates of visual-field deficits among those tested, indicating that blast wave forces may significantly affect both the eye and visual pathways.

Percentage of vision problems in Veterans with TBIs—Another study by the team, published in 2013, looked at 50 Veterans with blast-related TBI. They found that more than 65 percent had vision problems, and 77 percent reported sensitivity to light. Other difficulties included problems with eye movement, blurred vision, and problems focusing. The same number of Veterans with non-blast-related TBI was also studied, and the rates of vision complaints were similar.

Hidden eye injuries also a problem—An additional Palo Alto study, published as a letter to the editor in the New England Journal of Medicine in 2011, found that many Veterans who have had blast injuries also have "hidden eye injuries" that may go undetected without comprehensive eye examinations.

The research team evaluated 46 combat Veterans, 43 men and three women, who had developed TBIs from documented blast injuries, and had not previously reported any injury to their eyes. Of that group 20 (43 percent) suffered what ophthalmologists call "closed eye ocular injuries"—injuries that do not actually penetrate the eye.

The types of injuries the team found included damage to the cornea, the iris, and the optic nerve. They also found injuries to other areas of the eye as well. Accordingly, the researchers recommended that any patient with a TBI diagnosis, including those without current vision problems, have a comprehensive eye examination by an ophthalmologist to check for hidden eye injuries that may cause future problems such as glaucoma.

New screening tool developed—The group led a larger team of VA researchers that developed, in 2013, a clinical tool that can be used by eye-care providers either as a screening tool or as part of a full eye examination when they see a patient with a history of having had a mild TBI. The tool includes guidance for collecting a history of the patient's experiences, and for measuring his or her vision function. The research team hopes the tool will help to provide optimal and uniform vision care for patients who have mild TBI.

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➤ Surgical safety

Cataract surgeries by residents improve sight—According to a 2013 report by VA's Office of the Inspector General (IG), cataract surgery is one of the most common surgeries performed in VA. The report noted that in 2011, VA surgeons performed more than 49,000 cataract surgeries, representing more than 11 percent of all surgeries performed in VA facilities.

Because most VA facilities are teaching hospitals, many cataract surgeries are performed by ophthalmologic residents. (Residents are medical-school graduates engaged in specialized practice under supervision in a hospital.) VA regulations require residents conducting cataract surgery to be directly supervised by an attending ophthalmologist who must be physically present in the operating room, and the IG report found that VA facilities “generally complied" with this requirement.

A 2016 study led by researchers with the VA Boston Health Care System looked at more than 4,200 cataract surgery cases at VA facilities throughout the nation, and found that Veterans who were operated on by residents had an overall significant improvement in visual acuity (the clarity of their vision) and visual function (the ability to discern forms, colors, and movement) compared with before their surgery, even if complications arose as a result of their procedure. Those who had complications, however, showed a less marked improvement in their vision.

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➤ Hospitalization and vision loss

Vision loss linked to worse outcomes—Patients with vision loss who are admitted to the hospital for common disorders spend more time in the hospital, are more likely to be readmitted, and are more likely to use costly emergency department services after discharge than patients who are not visually impaired.

These study findings from 2016 were explained in by researchers with the Jesse Brown VA Medical Center in Chicago, the University of Michigan, and New York University at the annual meeting of the Association for Research in Vision and Ophthalmology. The study was sponsored by the Lighthouse Guild.

The team compared almost 6,000 patients with low vision or blindness from 2001 to 2014 to the same number of patients without vision loss. All patients had been hospitalized for common medical conditions such as heart failure or pneumonia.

The hospital length of stay for patients with blindness was about one day longer than for patients with no vision loss, and emergency department use was 29 percent higher for patients with blindness than for those without vision loss. Readmission rates were 21 percent for those with vision loss compared with less than 15 percent for those without.

The researchers concluded it is essential hospitals develop plans to assist patients with blindness or low vision and their families and caregivers before, doing, and after hospitalization. Focusing on the needs of patients with vision loss, they concluded, will lower costs and may lead to improved patient outcomes.

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➤ Preventing vision loss

Exercise protects against retinal degeneration—A 2014 study by researchers at the Atlanta VA Medical Center and Emory University suggested that physical activity can protect eyes as they age.

The researchers ran mice on a treadmill for two weeks before and after exposing the animals to bright light that causes retinal degeneration. They found that treadmill training preserved photoreceptors and retinal cell function in the mice. The exercised animals lost only half the number of photoreceptor cells as animals that spent the same amount of time on a stationary treadmill.

The researchers believe that their work may one day lead to tailored exercise regimens or combination therapies in treatment of retinal degenerative diseases.

Eye vitamins may not be valuable—In 2001, a landmark non-VA study, the Age-Related Eye Disease Study (AREDS), found that a specific formula of supplements containing high doses of zinc and other antioxidants could slow the deterioration of the eye's macula (the central part of the retina.) Age-related macular degeneration (AMD) is the leading cause of blindness among older adults.

A follow-up study called AREDS2, conducted in 2011, found that the formula remained effective even if one ingredient, beta-carotene, was replaced with related nutrients. Both studies offered formulas that could be used to prepare a compound that might protect against AMD. As a result, a number of vitamin manufacturers have begun to sell ocular nutritional supplements, designed to keep those who use them from developing AMD.

In 2016, a research team from the Providence VA Medical Center and three universities examined 11 different supplements to see if they were prepared in accordance with either the ARED or ARED2 formula.

The team found that while all of the supplements contained some ingredients from either formula, only four of the products contained doses equivalent to those in the study. Another four products contained lower doses, and four included additional vitamins, minerals, or herbal extracts that were not part of the original studies. None of the supplements precisely duplicated either the AREDS or AREDS2 formulas.

The team concluded that without clinical research, it is impossible to determine how those additional ingredients affect the formula, and that ophthalmologists should educate their patients on what to look for in supplements.

Lowering high blood pressure reduces risk—The Durham VA Medical Center-based Hypertension Intervention Nurse Telemedicine Study looked at the effects of telephone-based medication management and behavioral management on high blood pressure in people with diabetes.

In 2013, the study team found that patients whose blood pressure improved due to the intervention also had about half the risk of worsening diabetic retinopathy, compared with those receiving usual care. Diabetic retinopathy damages the retina, and can eventually lead to blindness.

Cost-effectiveness of teleretinal screening—VA researchers have also looked at the department's existing teleretinal screening process, in which special cameras take images of the lining inside the eye. They have found that telemedicine is a cost-effective way to screen Veterans under 80 years of age for signs of diabetic retinopathy, a complication of diabetes that affects the eyes.

A 2013 VA study found, however, that it is not cost-effective to use telemedicine for diabetic retinopathy screening in patients aged 80 or older, or for populations of under 3,500 patients.

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➤ Measuring vision loss

Smartphone app can measure visual acuity—The SightBook app allows patients to test their vision frequently on their smartphones and share their test results with their designated physician in real time.

Tests available on the app address visual acuity; visual disturbances caused by changes in the retina; visual acuity at low light; contrast sensitivity (the ability to see objects that may not be outlined clearly); and several other aspects of vision health.

In 2016, a research team from the Miami VA Healthcare System and the University of Miami tested the accuracy of readings from SightBook compared with readings using a Snellen eye chart, the standard eye chart that is read at a distance of 20 feet (or with mirrors that make it appear to be at a distance of 20 feet); and with near card eye charts, which are designed to be read at shorter distances.

They found that while there were discrepancies in results between each of the methods of testing visual acuity, the results from each method could be successfully reproduced, and that baseline SightBook acuity measures allow for future vision comparisons.

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More on Our Website

Lab study: Exercise wards off retinal damage, VA Research Currents, March 26, 2014

Helping those with vision loss find their way, VA Research Currents, Oct. 21, 2014

Some top-selling eye vitamins don't match scientific evidence, says study, VA Research Currents, Jan. 21, 2015

Video: Vision Loss Research

VA Center for the Prevention and Treatment of Visual Loss

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Selected Scientific Articles by Our Researchers

Closed-eye ocular injuries in the Iraq and Afghanistan wars. Cockerham GC, Rice TA, Hewes EH, Cockerham KP, Lemke S, Wang G, Lin RC, Glynn-Milley C, Zumhagen L. The letter's signers recommend comprehensive ocular evaluation by an ophthalmologist for any Veteran with a diagnosis of TBI of any severity level from blast exposure, including Veterans with normal visual acuity. Such examinations should also be considered for civilian blast casualties. N Engl J Med. 2011 Jun 2;364(22):2172-3.

Prevalence of dual sensory impairment and its association with traumatic brain injury and blast exposure in OEF/OIF Veterans. Lew HL, Pogoda TK, Baker E, Stolzman KL, Meterko M, Cifu DX, Amara J, Hendricks AM. Veterans who self-report clinically significant hearing or vision difficulty during routine TBI evaluation should be evaluated systematically and comprehensively to determine the extent of sensory impairment. J Head Trauma Rehabil. 2011 Nov-Dec;26(6):489-96.

Development of a mild traumatic brain injury-specific vision screening protocol: a Delphi study. Goodrich GL, Martinsen GL, Flyg HM, Kirby J, Asch SM, Brahm KD, Brand JM, Cajamarca D, Cantrell JL, Chong T, Dziedul JA, Hetric BJ, Huang MA, Ihrig C, Ingalls SP, Meltzer BR, Rakoczy CM, Rone A, Schwartz E, Shea JE; U.S. Department of Veterans Affairs. A modified Delphi method was used to derive expert opinions from a panel of 16 optometrists concerning visual examination of patients with mild TBI. This process resulted in a clinical tool containing 17 history questions and 7 examination procedures. J Rehabil Res Dev. 2013;50(6):757-68.

Mechanisms of TBI and visual consequences in military and veteran populations. Goodrich GL, Flyg HM, Kirby JE, Chang CY, Martinsen GL. The rates of vision complaints and defects were high in Veterans with both blast related and non-blast related TBIs, indicating a need for a thorough eye examination for any patient with a history of TBI. Optom Vis Sci. 2013 Feb;90(2):105-12

Progression of diabetic retinopathy in the hypertension intervention nurse telemedicine study. Muir KW, Grubber J, Mruthyunjaya P, McCant F, Bosworth HB. The potential benefit of telemedicine interventions targeting blood pressure control in patients at risk for diabetic eye disease is encouraging and warrants further study. JAMA Ophthalmol. 2013 Jul;131(7):957-8.

Evaluation of telemedicine for screening of diabetic retinopathy in the Veterans Health Administration. Kirkizlar E, Serban N, Sisson JA, Swann JL, Barnes CS, Williams MD. VA's current teleretinal screening program is effective in terms of being cost-effective and increasing population reach. Future screening policies should give consideration to the age of patients receiving screenings and the system's patient pool size. Ophthalmology. 2013 Dec;120(12):2604-10.

Aerobic exercise protects retinal function and structure from light-induced retinal degeneration. Lawson EC, Han MK, Sellers JT, Chrenek MA, Hanif A, Gogniat MA, Boatright JH, Pardue MT. Aerobic exercise helps to protect against retinal degeneration. J Neurosci. 2014 Feb 12;34(7):2406-12.

Chronic visual dysfunction after blast-induced mild traumatic brain injury. Magone MT, Kwon E, Shin SY. Long-term visual dysfunction after mild blast TBI is common even years after injury despite excellent distance visual acuity and is more frequent if more than one incidence of mild blast TBI occurred. J Rehabil Res Dev. 2014;51(1):71-80.

Composition of a vision screen for servicemembers with traumatic brain injury: consensus using a modified nominal group technique. Radomsky MV, Finkelstein M, Llanos I, Schelman M, Wagener SG. An expert panel was charged with specifying the composition of a vision screening protocol for servicemembers with TBI. After considering 29 vision tests, the panel recommended a nine-test vision screening that examines functional performance, self-reported problems, far-near acuity, reading, accommodation, convergence, eye alignment and binocular vision, saccades, pursuits, and visual fields. Am J Occup Ther. 2014 Jul-Aug;68(4):422-9.

Visual function, traumatic brain injury, and posttraumatic stress disorder. Goodrich GL, Martinsen GL, Flyg HM, Kirby J, Garvert DW, Tyler CW. High rates of binocular vision and function deficits were measured in patients with a history of TBI, but no significant differences between patients with or without PTSD were evident. However, compared to patients without PTSD, patients with PTSD had more self-reported visual symptoms in all four assessments and the complaint rates were significantly higher for light sensitivity and reading problems. J Rehabil Res Dev. 2014 Jul;51(4):547-58.

Ocular nutritional supplements: are their ingredients and manufacturers' claims evidence-based? Yong JJ, Scott IU, Greenberg PB. The majority of top-selling ocular nutritional supplements did not contain the identical ingredient dosages of the AREDS or AREDS2 formulas. Ophthalmology. 2015 Mar;122(3):595-9.

Automated perimetry and visual dysfunction in blast-related traumatic brain injury. Lemke S, Cockerham GC, Glynn-Milley C, Lin R, Cockerham KP. 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. Ophthalmology, 2016 Feb;123(2):415-24.

Corneal mechanical thresholds negatively associate with dry eye and ocular pain symptoms. Spierer O, Felix ER, McClellan AL, Parel JM, Gonzalez A, Feuer WJ, Sarantopoulos CD, Levitt RC, Ehrmann K, Galor A. Mechanical detection and pain thresholds measured on the cornea are correlated with dry eye symptoms and ocular pain. Invest Ophthalmol Vis SCi. 2016 Feb;57(2):617-25.

Outcomes of cataract surgery with residents as primary surgeons in the Veterans Affairs Healthcare System. Payal AR, Gonzalez-Gonzalez LA, Chen X, Cakiner-Egilmez T, Chomsky A, Baze E, Vollman D, Lawrence MG, Daly MK. Resident-operated cases with and without events had an overall significant improvement in visual acuity and visual function compared with preoperatively. J Cataract Refract Surg. 2016 Mar;42(3):370-84.

Ophthalmic complications related to chemotherapy in medically complex patients. Harman LE. Recognizing potentially serious ocular complications of cancer therapy before they result in irreversible injury starts with taking a relevant clinical history and performing a basic eye examination. Cancer Control. 2016 Apr:23(2):150-6.

Reproducibility and comparison of visual acuity obtained with Sightbook mobile application to near card and Snellen chart. Phung L, Gregori NZ, Ortiz A, Shi W, Schiffman JC. The SightBook mobile app offers a new portable vision assessment tool for the office and remote patient monitoring. Retina. 2016 May;36(5): 1009-20.

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