Back to Top Skip to main content

Editorial: The Department of Defense/Veterans Affairs Vision Center of Excellence

U.S. Army Spc. Angel Gomez, right, assigned to Charlie Company, 173rd Brigade Support Battalion, wraps the eye of a fellow Soldier with a simulated injury, for a training exercise as part of exercise Saber Junction 16 at the U.S. Army’s Joint Multinational Readiness Center in Hohenfels, Germany, April 5, 2016. Saber Junction is a U.S. Army Europe-led exercise designed to prepare U.S., NATO and international partner forces for unified land operations. The exercise was conducted March 31-April 24. (U.S. Army photo by Pfc. Joshua Morris) U.S. Army Spc. Angel Gomez, right, assigned to Charlie Company, 173rd Brigade Support Battalion, wraps the eye of a fellow Soldier with a simulated injury, for a training exercise as part of exercise Saber Junction 16 at the U.S. Army’s Joint Multinational Readiness Center in Hohenfels, Germany, April 5, 2016. Saber Junction is a U.S. Army Europe-led exercise designed to prepare U.S., NATO and international partner forces for unified land operations. The exercise was conducted March 31-April 24. (U.S. Army photo by Pfc. Joshua Morris)

Recommended Content:

Medical Surveillance Monthly Report

Vision and visual function are essential for performance across multiple activities. When vision is compromised, it can negatively affect behavioral health, social functioning, and overall quality of life.1 Studies have also linked decreased visual function to increased mortality.2 In military populations, optimal visual function is required for demanding tasks ranging from effective weapons utilization3 to aircraft-based flight operations.4

Ocular injuries present a particular problem for service members and the providers charged with their care. These injuries are associated with a substantial cost in terms of resources, rehabilitation, and training.5 In response to the need for increased focus on ocular injuries and their treatment across the continuum of care, the Department of Defense (DoD)/Veterans Affairs (VA) Vision Center of Excellence (VCE) was established by congressional mandate in 2008 under the National Defense Authorization Act (Public Law 110-181, Section 1623) as a center of excellence in the prevention, diagnosis, mitigation, treatment, and rehabilitation of military eye injuries, including visual dysfunction related to traumatic brain injury (TBI).6 Consistent with the requirement of all Defense Centers of Excellence to provide expertise across the entire clinical spectrum of care for a patient, the VCE addresses the full scope of vision care, from the prevention of diseases and treatment of clinical conditions through rehabilitation and transition to civilian life.7

The VCE continually executes initiatives in support of the 2008 mandate. In 2015, the VCE collaborated with the Joint Trauma System (JTS), the Committee on Tactical Combat Casualty Care (TC3), and the Defense Health Agency’s Medical Logistics Division to increase the availability of rigid eye shields in the individual first aid kit. These eye shields are essential for preventing further damage to a traumatized eye until definitive treatment is available. This effort to increase the availability of rigid eye shields resulted in changes to the TC3 card (DD Form 1380) to allow for documentation of eye shield use (check boxes for eye shield use).8 In further collaboration with the JTS, the VCE has initiated and/or contributed to multiple clinical practice guidelines (CPGs) designed to provide best care practices across the spectrum of ocular injuries. For example, the “Ocular Injuries and Vision-Threatening Conditions in Prolonged Field Care” CPG is currently available at https://jts.amedd.army.mil/index.cfm/PI_CPGs/cpgs, and the “Evaluation and Disposition of Temporary Visual Interference and Ocular Injury after Suspected Ocular Laser Exposure” CPG is pending publication on the JTS website.

A specific area of focus mandated to the VCE is visual dysfunction following TBI. To address this complex set of conditions, the VCE, in collaboration with a panel of experts in vision, rehabilitation, and TBI across the DoD, VA, and the civilian sector’s diverse group of subject matter experts, including the Defense and Veterans Brain Injury Center, oversaw the production of clinical recommendations and associated clinical support tools for the care of visual dysfunction after TBI. These aids to clinical care include “Eye and Vision Care Following Blast Exposure and/or Possible Traumatic Brain Injury,” “Care of Visual Field Loss Associated with Traumatic Brain Injury,” and “Care of Oculomotor Dysfunctions Associated with TBI.”9–11 In coordination with the Uniformed Services University of the Health Sciences, the VCE is conducting a review of current visual dysfunction documentation, intervention options, and best practices. The article on visual dysfunction following TBI in this issue of the MSMR was developed to provide additional information on this diverse set of conditions, update current recommendations, and inform future clinical and research efforts.12

The VCE established the World Wide Ocular Trauma and Readiness Curriculum Teleconference to engage international, multiagency, and cross-specialty attendees spanning multiple sites in review of vision cases and identification of clinical process improvements. The monthly calls serve as a key platform for providing feedback and follow-up to deployed providers and for developing and disseminating best practices and clinical lessons learned.

In order to ensure continuity of care from injury through rehabilitation, the VCE developed a collection of reference guides that include vision resources across the DoD and VA as well as at the state and national level. The “Vision Care Coordination Reference Guide” expands network capabilities between stakeholders, increases partnerships, and enables care coordinators to assist in a rapid and thorough response to the patient population requiring trauma and vision care specialties. In addition, the VCE produces fact sheets to educate the care community to assist with engaging a visually impaired patient.

With continued emphasis on military readiness, the VCE is expanding focus beyond combat-related traumatic conditions to include disease and non-battle injuries. Ocular and vision-related conditions can have great impact on readiness and retention. The first article in this issue characterizes the burden of ocular and vision conditions and was developed to provide a broad overview of these conditions.13 This information will provide key information to guide further initiatives and programs across the Military Health System.

The VCE was tasked with implementing and managing a registry of information to track diagnoses, interventions/treatments, and follow-up for each case of significant eye injury sustained by a member of the Armed Forces while serving on active duty. The Defense Vision and Eye Injury and Vision Registry (DVEIVR) was developed to address this requirement. Registry data are available to ophthalmological and optometric personnel of the DoD and VA for purposes of encouraging and facilitating the conduct of research and the development of best practices and clinical education on eye injuries incurred by members of the Armed Forces in combat. Registry data have been used by DoD and academic institutions to better characterize the complex field of ocular trauma. DVEIVR data are also shared with the VA Blind Rehabilitation Service to maximize continuity of care. The VCE is currently incorporating DVEIVR data along with other data sources focused on providing evidence-based care recommendations.

The VCE continually strives to improve the recognition and management of ocular injuries and vision-threatening conditions across military and veteran populations. Such efforts supporting improved care and coordination of care are essential for maintaining the visual performance of U.S. service members and veterans. Additional information on the VCE and its products is available at https://vce.health.mil/. Further inquiries can be sent via email to dha.ncr.dod-va.mbx.vce@mail.mil.

 

REFERENCES

1. Nyman SR, Gosney MA, Victor CR. Psychosocial impact of visual impairment in working-age adults. Br J Ophthalmol. 2010;94(11):1427–1431.

2. Taylor HR, McCarty CA, Nanjan MB. Vision impairment predicts five-year mortality. Trans Am Ophthalmol Soc. 2000;98;91–99.

3. Hatch BC, Hilber DJ, Elledge JB, Stout JW, Lee RB. The effects of visual acuity on target discrimination and shooting performance. Optom Vis Sci. 2009;86(12):e1359–e1367.

4. Tanzer DJ, Brunstetter T, Zeber R, et al. Laser in situ keratomileusis in United States Naval aviators. J Cataract Refract Surg. 2013;39(7):1047–1058.

5. Frick KD, Singman EL. Cost of military eye injury and vision impairment related to traumatic brain injury: 2001–2017. Mil Med. 2019;184(5–6):e338–e343.6. National Defense Authorization Act for Fiscal Year 2008, Public Law 110–181, section 1623. 2008.

7. United States Government Accountability Office. GAO-16-54, Centers of Excellence: DOD and VA Need Better Documentation of Oversight Procedures. https://www.gao.gov/assets/680/673936.pdf. Published 2 December 2015. Accessed 28 August 2019.

8. Defense Health Agency. Procedural Instruction 6040.01. Implementation Guidance for the Utilization of DD Form 1380, Tactical Combat Casualty Care (TCCC) Card, June 2014. 20 January 2017.

9. Department of Defense/Veterans Affairs Vision Center of Excellence. Clinical Recommendations for the Eye Care Provider. Eye and Vision Care Following Blast Exposure and/or Possible Traumatic Brain Injury. https://vce.health.mil/Clinicians-and-Researchers/Clinical-Practice-Recommendations/Eye-Care-and-TBI. Revised 24 November 2015. Accessed 05 August 2019.

10. Department of Defense/Veterans Affairs Vision Center of Excellence. Clinical Recommendation for the Eye Care Provider and Rehabilitation Specialists. Rehabilitation of Patients with Visual Field Loss Associated with Traumatic or Acquired Brain Injury. https://vce.health.mil/Clinicians-and-Researchers/Clinical-Practice-Recommendations/VFL. Revised 27 April 2016. Accessed 05 August 2019.

11. Department of Defense/Veterans Affairs Vision Center of Excellence. Clinical Recommendation for the Eye Care Provider. Assessment and Management of Oculomotor Dysfunctions Associated with Traumatic Brain Injury. https://vce.health.mil/Clinicians-and-Researchers/Clinical-Practice-Recommendations/Oculomotor. Revised 13 December 2016. Accessed 05 August 2019.

12. Reynolds ME, Barker II FM, Merezhinskaya N, Oh G, Stahlman S. Incidence and temporal presentation of visual dysfunction following diagnosis of traumatic brain injury, active component, U.S. Armed Forces, 2006-2017. MSMR. 2019;26(9):13–24.

13. Reynolds ME, Williams VF, Taubman SB, Stahlman S. Absolute and relative morbidity burdens attributable to ocular and vision-related conditions, active component, U.S. Armed Forces, 2018. MSMR. 2019;26(9): 4–11.

You also may be interested in...

Brief Report: Male Infertility, Active Component, U.S. Armed Forces, 2013–2017

Article
3/1/2019
Sperm is the male reproductive cell  Photo: iStock

Infertility, defined as the inability to achieve a successful pregnancy after 1 year or more of unprotected sexual intercourse or therapeutic donor insemination, affects approximately 15% of all couples. Male infertility is diagnosed when, after testing both partners, reproductive problems have been found in the male. A male factor contributes in part or whole to about 50% of cases of infertility. However, determining the true prevalence of male infertility remains elusive, as most estimates are derived from couples seeking assistive reproductive technology in tertiary care or referral centers, population-based surveys, or high-risk occupational cohorts, all of which are likely to underestimate the prevalence of the condition in the general U.S. population.

Recommended Content:

Medical Surveillance Monthly Report

Vasectomy and Vasectomy Reversals, Active Component, U.S. Armed Forces, 2000–2017

Article
3/1/2019
Sperm is the male reproductive cell  Photo: iStock

During 2000–2017, a total of 170,878 active component service members underwent a first-occurring vasectomy, for a crude overall incidence rate of 8.6 cases per 1,000 person-years (p-yrs). Among the men who underwent incident vasectomy, 2.2% had another vasectomy performed during the surveillance period. Compared to their respective counterparts, the overall rates of vasectomy were highest among service men aged 30–39 years, non-Hispanic whites, married men, and those in pilot/air crew occupations. Male Air Force members had the highest overall incidence of vasectomy and men in the Marine Corps, the lowest. Crude annual vasectomy rates among service men increased slightly between 2000 and 2017. The largest increases in rates over the 18-year period occurred among service men aged 35–49 years and among men working as pilots/air crew. Among those who underwent vasectomy, 1.8% also had at least 1 vasectomy reversal during the surveillance period. The likelihood of vasectomy reversal decreased with advancing age. Non-Hispanic black and Hispanic service men were more likely than those of other race/ethnicity groups to undergo vasectomy reversals.

Recommended Content:

Medical Surveillance Monthly Report

Testosterone Replacement Therapy Use Among Active Component Service Men, 2017

Article
3/1/2019
Anopheles merus

This analysis summarizes the prevalence of testosterone replacement therapy (TRT) during 2017 among active component service men by demographic and military characteristics. This analysis also determines the percentage of those receiving TRT in 2017 who had an indication for receiving TRT using the 2018 American Urological Association (AUA) clinical practice guidelines. In 2017, 5,093 of 1,076,633 active component service men filled a prescription for TRT, for a period prevalence of 4.7 per 1,000 male service members. After adjustment for covariates, the prevalence of TRT use remained highest among Army members, senior enlisted members, warrant officers, non-Hispanic whites, American Indians/Alaska Natives, those in combat arms occupations, healthcare workers, those who were married, and those with other/unknown marital status. Among active component male service members who received TRT in 2017, only 44.5% met the 2018 AUA clinical practice guidelines for receiving TRT.

Recommended Content:

Medical Surveillance Monthly Report

Sexually Transmitted Infections, Active Component, U.S. Armed Forces, 2010–2018

Article
3/1/2019
Anopheles merus

This report summarizes incidence rates of the 5 most common sexually transmitted infections (STIs) among active component service members of the U.S. Armed Forces during 2010–2018. Infections with chlamydia were the most common, followed in decreasing order of frequency by infections with genital human papillomavirus (HPV), gonorrhea, genital herpes simplex virus (HSV), and syphilis. Compared to men, women had higher rates of all STIs except for syphilis. In general, compared to their respective counterparts, younger service members, non-Hispanic blacks, soldiers, and enlisted members had higher incidence rates of STIs. During the latter half of the surveillance period, the incidence of chlamydia and gonorrhea increased among both male and female service members. Rates of syphilis increased for male service members but remained relatively stable among female service members. In contrast, the incidence of genital HPV and HSV decreased among both male and female service members. Similarities to and differences from the findings of the last MSMR update on STIs are discussed.

Recommended Content:

Medical Surveillance Monthly Report

Adenovirus

Infographic
3/1/2019
Adenovirus

During August–September 2016, U.S. Naval Academy clinical staff noted an increase in students presenting with acute respiratory illness (ARI). An investigation was conducted to determine the extent and cause of the outbreak.

Recommended Content:

Health Readiness | Armed Forces Health Surveillance Branch | Epidemiology and Analysis | Medical Surveillance Monthly Report | Public Health

Malaria

Infographic
3/1/2019
Malaria

Since 1999, the Medical Surveillance Monthly Report has published regular updates on the incidence of malaria among U.S. service members. The MSMR’s focus on malaria reflects both historical lessons learned about this mosquito-borne disease and the continuing threat that it poses to military operations and service members’ health.

Recommended Content:

Health Readiness | Armed Forces Health Surveillance Branch | Epidemiology and Analysis | Medical Surveillance Monthly Report | Public Health

Glaucoma

Infographic
3/1/2019
Glaucoma

This report describes an analysis using the Defense Medical Surveillance System to identify all active component service members with an incident diagnosis of glaucoma during the period between 2013 and 2017.

Recommended Content:

Health Readiness | Armed Forces Health Surveillance Branch | Epidemiology and Analysis | Medical Surveillance Monthly Report | Public Health

Update: Malaria, U.S. Armed Forces, 2018

Article
2/1/2019
Anopheles merus

Malaria infection remains an important health threat to U.S. service mem­bers who are located in endemic areas because of long-term duty assign­ments, participation in shorter-term contingency operations, or personal travel. In 2018, a total of 58 service members were diagnosed with or reported to have malaria. This represents a 65.7% increase from the 35 cases identi­fied in 2017. The relatively low numbers of cases during 2012–2018 mainly reflect decreases in cases acquired in Afghanistan, a reduction due largely to the progressive withdrawal of U.S. forces from that country. The percentage of cases of malaria caused by unspecified agents (63.8%; n=37) in 2018 was the highest during any given year of the surveillance period. The percent­age of cases identified as having been caused by Plasmodium vivax (10.3%; n=6) in 2018 was the lowest observed during the 10-year surveillance period. The percentage of malaria cases attributed to P. falciparum (25.9 %) in 2018 was similar to that observed in 2017 (25.7%), although the number of cases increased. Malaria was diagnosed at or reported from 31 different medical facilities in the U.S., Afghanistan, Italy, Germany, Djibouti, and Korea. Pro­viders of medical care to military members should be knowledgeable of and vigilant for clinical manifestations of malaria outside of endemic areas.

Recommended Content:

Medical Surveillance Monthly Report

Update: Incidence of Glaucoma Diagnoses, Active Component, U.S. Armed Forces, 2013–2017

Article
2/1/2019
Glaucoma

Glaucoma is an eye disease that involves progressive optic nerve damage and vision loss, leading to blindness if undetected or untreated. This report describes an analysis using the Defense Medical Surveillance System to identify all active component service members with an incident diagnosis of glaucoma during the period between 2013 and 2017. The analysis identified 37,718 incident cases of glaucoma and an overall incidence rate of 5.9 cases per 1,000 person-years (p-yrs). The majority of cases (97.6%) were diagnosed at an early stage as borderline glaucoma; of these borderline cases, 2.2% progressed to open-angle glaucoma during the study period. No incident cases of absolute glaucoma, or total blindness, were identified. Rates of glaucoma were higher among non-Hispanic black (11.0 per 1,000 p-yrs), Asian/Pacific Islander (9.5), and Hispanic (6.9) service members, compared with non-Hispanic white (4.0) service members. Rates among female service members (6.6 per 1,000 p-yrs) were higher than those among male service members (5.8). Between 2013 and 2017, incidence rates of glaucoma diagnoses increased by 75.4% among all service members.

Recommended Content:

Medical Surveillance Monthly Report

Outbreak of Acute Respiratory Illness Associated with Adenovirus Type 4 at the U.S. Naval Academy, 2016

Article
2/1/2019
Malaria case definition

Human adenoviruses (HAdVs) are known to cause respiratory illness outbreaks at basic military training (BMT) sites. HAdV type-4 and -7 vaccines are routinely administered at enlisted BMT sites, but not at military academies. During August–September 2016, U.S. Naval Academy clinical staff noted an increase in students presenting with acute respiratory illness (ARI). An investigation was conducted to determine the extent and cause of the outbreak. During 22 August–11 September 2016, 652 clinic visits for ARI were identified using electronic health records. HAdV-4 was confirmed by real-time polymerase chain reaction assay in 18 out of 33 patient specimens collected and 1 additional HAdV case was detected from hospital records. Two HAdV-4 positive patients were treated for pneumonia including 1 hospitalized patient. Molecular analysis of 4 HAdV-4 isolates identified genome type 4a1, which is considered vaccine-preventable. Understanding the impact of HAdV in congregate settings other than enlisted BMT sites is necessary to inform discussions regarding future HAdV vaccine strategy.

Recommended Content:

Medical Surveillance Monthly Report

Re-evaluation of the MSMR Case Definition for Incident Cases of Malaria

Article
2/1/2019
Anopheles merus

The MSMR has been publishing the results of surveillance studies of malaria since 1995. The standard MSMR case definition uses Medical Event Reports and records of hospitalizations in counting cases of malaria. This report summarizes the performance of the standard MSMR case definition in estimating incident cases of malaria from 2015 through 2017. Also explored was the potential surveillance value of including outpatient encounters with diagnoses of malaria or positive laboratory tests for malaria in the case definition. The study corroborated the relative accuracy of the MSMR case definition in estimating malaria incidence and provided the basis for updating the case definition in 2019 to include positive laboratory tests for malaria antigen within 30 days of an outpatient diagnosis.

Recommended Content:

Medical Surveillance Monthly Report

Non-alcoholic fatty liver disease

Infographic
1/29/2019
HPV

At the time of this report, there were no published studies of non-alcoholic fatty liver disease (NAFLD) incidence over time among active component U.S. military personnel. Examining the incidence rates of NAFLD and their temporal trends among active component U.S. military members can provide insights into the future burden of NAFLD on the MHS.

Recommended Content:

Health Readiness | Armed Forces Health Surveillance Branch | Epidemiology and Analysis | Medical Surveillance Monthly Report | Public Health

Acute Flaccid Myelitis Case Reporting

Infographic
1/29/2019
Acute Flaccid Myelitis Case Reporting

This case highlights important clinical characteristics of acute flaccid myelitis and emphasizes the importance of including AFM in the differential diagnosis when evaluating active duty service members and Military Health System beneficiaries presenting with paralysis.

Recommended Content:

Health Readiness | Armed Forces Health Surveillance Branch | Epidemiology and Analysis | Medical Surveillance Monthly Report | Public Health

Cardiovascular disease-related medical evacuations

Infographic
1/29/2019
Cardiovascular disease-related medical evacuations

This descriptive analysis summarizes the demographic characteristics, counts, rates and temporal trends for Cardiovascular disease-related medical evacuations from the CENTCOM area of responsibility. In addition, the percentage of those evacuated who had received pre-deployment diagnoses indicating cardiovascular risk is summarized. Responses to questions regarding health status and physician referrals on the DD2795 are also summarized.

Recommended Content:

Health Readiness | Armed Forces Health Surveillance Branch | Epidemiology and Analysis | Medical Surveillance Monthly Report | Public Health

Cardiovascular Disease-related Medical Evacuations, Active and Reserve Components, U.S. Armed Forces, 1 October 2001–31 December 2017

Article
1/1/2019
Cardiovascular Diagnoses

From 1 October 2001 through 31 December 2017, a total of 697 medical evacuations of service members from the U.S. Central Command (CENTCOM) area of responsibility were followed by at least one medical encounter in a fixed medical facility outside the operational theater with a diagnosis of a cardiovascular disease (CVD). The vast majority of those (n=660; 94.7%) evacuated were males. More than a third of CVD-related evacuations (n=278, 39.9%) occurred in service members 45 years of age or older; slightly more than half (n=369; 52.9%) occurred in reserve or guard members. The most common CVD risk factors which had been diagnosed among evacuated service members prior to their deployment were hypertension (n=236; 33.9%) and hyperlipidemia (n=241; 34.9%). Much lower percentages had been previously diagnosed with obesity (n=74, 10.6%) or diabetes (n=21, 3.0%). More than 1 in 4 service members with a CVD-related medical evacuation had been diagnosed with more than one risk factor (n=182, 26.1%). Both limitations to the data available and strategies to reduce CVD morbidity in theater are discussed.31.6 per 100,000 active component service members in 2017. Validation of ICD-9/ICD-10 diagnostic codes for MetS using the National Cholesterol Education Program Adult Treatment Panel III criteria is needed to establish the level of agreement between the two methods for identifying this condition.

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 61 - 75 Page 5 of 9

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.