TBI, PTSD Strong Indicators of Vision Problems for Veterans

Staff
12/10/2012

Many veterans of the United States armed forces who have traumatic brain injury or post-traumatic stress disorder also have undiagnosed, chronic vision problems, according to two recent studies.

In a study conducted at the Veterans Affairs Medical Center, in Washington, D.C., researchers found that vision problems in veterans with mild traumatic brain injury are much more common and persistent than previously recognized, with 67 percent of the 31 patients studied reporting chronic vision disorders. Though none of the affected veterans had suffered direct eye wounds, their vision continued to be impaired more than a year after they endured the injuries that caused their TBI. 

The vision problems most frequently reported by the veterans in the study were convergence and sensitivity to light. Veterans’ ability to accommodate was also reduced. Other complaints included double vision and floaters. Full recovery of visual function took five years or more in many of the veterans, which is much longer than is typically seen in sports concussions and other non-blast-related TBI.

Blast-related TBI is the most frequent injury of the Iraq and Afghanistan wars. From 2000, the Department of Defense reported 194,561 cases of mild TBI, or about 76 percent of all TBI injuries. 

“Physicians who care for veterans with TBI need to know that many of them have vision problems,” said M. Teresa Magone, MD, staff ophthalmologist with the Washington, D.C. Veterans Affairs Medical Center, who led the study. “It is critical that these patients receive vision assessment and when appropriate, be referred to ophthalmologists to make sure they get the eye care they need, for as long as they need it.” 

Another study of war veterans, conducted at the Miami Veterans Affairs Medical Center and the Bascom Palmer Eye Institute at the University of Miami, found that veterans who have post-traumatic stress disorder or depression are much more likely to develop dry-eye syndrome than veterans who do not have these psychological diagnoses. In their review of more than two million veterans’ medical records, the research team found that about 20 percent of those diagnosed with PTSD or depression have dry-eye syndrome, a disorder that disrupts the tear glands’ normal ability to keep the eyes moist. 

The disorder’s impact on vision can range from mild to severe, causing the sufferer’s eyes to feel scratchy or irritated, to become overly watery, or secrete stringy mucus. Treatment options include simple warm compresses, artificial tears and surgical insertion of plugs to retain tears. In the general U.S. population, the risk of dry-eye syndrome increases with age, affecting about 3.2 million women age 50 and older and 1.68 million men age 50 and older. 

The average age of the veterans with dry eye in this VAMC study is younger than is typical for dry-eye patients in the civilian population. It was unclear from the study whether the veterans’ dry eye was directly caused by PTSD or depression, or the medications given for these conditions, or perhaps a combination of factors was to blame. Estimates of the prevalence of PTSD in all U.S. veterans range from 2 to 17 percent. 

“Many vets won’t mention that their eyes always feel gritty or seem to water for no reason, unless they’re asked,” said Anat Galor, MD, an assistant professor of clinical ophthalmology with Bascom Palmer Eye Institute, who led the study. “Since dry eye can escalate and permanently damage vision if untreated, it’s crucial that health professionals who care for veterans with psychiatric diagnoses ask them about specific dry-eye symptoms and refer them to an ophthalmologist if needed.” 

Anti-VEGF Works Even in Presence of Macular Traction
Anti-VEGF injections, the primary treatment for wet macular degeneration, a chronic eye condition that causes vision loss, are effective even if patients have macular traction problems, a Mayo Clinic study shows.

It has not been clear whether this treatment would also serve patients experiencing other symptoms, such as vitreomacular interface disease. Mayo researchers retrospectively studied 178 patients, of whom 18 percent had VMID over an average of 2.5 years.

Findings showed that while eyes with some kind of macular traction required more injections, they still showed improvement (best-corrected visual acuity) to similar eyes without VMID. 

“This finding is significant,” says senior author Sophie J. Bakri, MD, “because it showed that patients with VMID are not necessarily treatment resistant for AMD.” She also says it may help physicians not give up on treating such patients, and understand the need for more doses of medication for those with VMID. Researchers say more study is needed, including a prospective clinical trial.

Kids’ Headaches Not Connected to Need for Glasses
A new study provides the first clear evidence that vision or eye problems are rarely the cause of recurring headaches in children, even if the headaches usually strike while the child is doing schoolwork or other visual tasks. Many parents assume that frequent headaches mean their child needs glasses, so they ask their doctor to refer their child for an eye exam. This study was conducted by pediatric ophthalmologists who wanted to find reliable answers for parents, family doctors and pediatricians facing this common health question.

In this retrospective study, which was conducted at the ophthalmology clinic of Albany Medical Center in New York state, researchers reviewed the medical records of 158 children under age 18 who were seen at the clinic for frequent headaches from 2002 to 2011. All of the children received complete eye exams by the clinic’s ophthalmologists. 

No significant correlation was found between their frequent headaches and a need for vision correction. The researchers reached this conclusion by comparing the results of the clinic’s exams of the children with headaches to the records of their previous eye exams and other relevant medical care. Eye health and vision test results remained unchanged from earlier exams for 75 percent of the children. Also, children who already had eyeglasses were not found to need new prescriptions at the time they were seen at the clinic for headaches. Although about 14 percent of the children reported that their headaches occurred while doing visual tasks like homework, and about 9 percent reported visual symptoms associated with their headaches, a need for vision correction did not appear to be the primary cause or a significant factor in any of these cases, according to the study.

The researchers considered it positive that most of the children’s headaches resolved over time. Follow-up reports from parents showed that headaches improved in 76.4 percent of all study subjects, including those who did and those who did not receive new vision correction prescriptions. Children who received new prescriptions were not more likely than others to have their headaches improve. Assessing the causes of the headaches and addressing the children’s long-term outcomes were beyond the scope of this study. 

“We hope our study will help reassure parents that in most cases their children’s headaches are not related to vision or eye problems, and that most headaches will clear up in time,” said Zachary Roth, MD, who led the research team. “The information should also be useful to family doctors and pediatricians in caring for children and parents who have this common health concern.” 

About 30 percent of the children in the study had eye conditions that went beyond the need for vision correction, including strabismus, amblyopia or other rarer, more serious conditions. Seventeen percent had a family history of migraine. Because this was a retrospective study, the researchers were unable to connect these factors with headache causes.

Soothing Sounds Ease Cataract Surgery Anxiety
The use of an audio therapy known as binaural beats can significantly reduce patients’ anxiety during cataract surgery, say authors of a recent study in Thailand. The 141-patient study is the first of its kind in cataract surgery. 

Binaural beat audio therapy consists of two tones that are each pitched at a specific, slightly different frequency, with each tone delivered to a separate ear via headphones. The technique evokes alpha-frequency brainwaves, a state that is linked to relaxation and reduced perception of fear and pain. In this study, the researchers combined binaural beats with soothing music and nature soundscapes that included ocean and forest sounds, to provide a pleasant, familiar experience for patients.

The study was conducted using three groups, each consisting of 47 patients, matched for age, gender, cataract type and other health factors. Patients who listened to a binaural beats-music mix before, during and after the procedure had less anxiety and slower heart rate, compared with the control group patients who did not receive the therapy. 

Systolic blood pressure was also significantly reduced in both the binaural beats-music mix patient group and a second patient group who listened to music only. Control group patients heard the usual sounds that occur in a surgical suite. All patients were assessed before and after surgery using the State-Trait Anxiety scale, a standard test used to diagnose anxiety. Their heart rate and blood pressure were also measured before and after surgery. 

The research team focused on cataract surgery because it is usually done under local anesthesia, with the patient awake and continuously exposed to unfamiliar, potentially upsetting sounds such as surgical machinery and conversations between the surgeon and staff. Although the procedure is highly effective and safe, patients may be worried about whether their vision and quality of life will be improved or reduced after the surgery. The results were consistent with the finding of previous research on the use of the therapy reducing anxiety in general surgery patients. 

“As populations in many parts of the world grow older, it’s increasingly important for ophthalmologists to explore new ways to improve patient care for seniors,” said Pornpattana Vichitvejpaisal, MD, of Chiang Mai University, Thailand, who led the research. “Our study shows significant emotional and physiological benefits from adding binaural beats to music therapy for cataract surgery patients. This provides a simple, inexpensive way to improve patients’ health outcomes and satisfaction with their care.”

Dr. Vichitvejpaisal referenced one of his study participants who reported that during her first cataract surgery, she was afraid from the moment she entered the surgical suite. Though she’d been told it wouldn’t take long, the surgery seemed to drag on endlessly. Receiving sound therapy during her second surgery dramatically changed her experience from start to finish. She said that she felt very little anxiety, and that the surgery was over before she knew it.  REVIEW