Eyeworld

EW IN OTHER NEWS November 2011 65 R etired Army Master Sergeant Gordon Ewell believes if there's one thing preventing him from going completely blind, it's the research of Glenn Cockerham, M.D. Since 2006, Dr. Cockerham, chief of ophthalmology, Veterans Affairs (VA) Palo Alto Health Care System, Calif., and colleagues have studied closed-eye ocular injuries among Iraq and Afghanistan war veterans with blast- induced traumatic brain injury (TBI). MSgt. Ewell is one of them. Be- tween December 2005 and Decem- ber 2006, he was deployed in Iraq to coordinate Convoy Route Clearance and Route Clearance Observation missions. "I was a bomb hunter, basi- cally," he said. "My job was to be embedded with all the teams that had the mission of doing route clearance. I was a vehicle to rapidly share information with all the teams, so every one of the teams knew the latest tricks the enemy was using to hide the bombs." According to MSgt. Ewell, he has many service-related injuries in- cluding TBI; permanent loss of hear- ing, leaving him legally deaf; anatomical loss of his right eye; and vision loss in his left eye, leaving him legally blind. He also sustained a loss of balance that causes him to fall down often, which he believes has affected his vision. "With every fall, my visual field has decreased," he explained. "I see an area about the size of a dinner plate." It's this dinner-plate range of sight MSgt. Ewell hopes Dr. Cockerham can save with his re- search on silent eye injuries, the re- sults of which were published in the New England Journal of Medicine in June. Between 2006 and 2009, Dr. Cockerham and colleagues evaluated 49 combat veteran inpatients—43 men and six women—with docu- mented TBI from blast exposure. According to the Defense & Vet- erans Brain Injury Center (DVBIC), 212,742 service men and women have suffered a TBI, which is defined as a traumatically induced structural injury or physiological disruption of brain function as a result of an exter- nal force to the head, between the year 2000 and May 16, 2011. "We're probably seeing more [TBI] in this conflict than we did in other wars because the weapon of choice these days is the close-in high explosives," said Col. Robert Mazzoli, M.D. (retired), director of Education, Training, Simulation & Readiness, Department of Defense/ VA Vision Center of Excellence. Diagnosing TBI can be challeng- ing for providers because in many cases, such as those with a mild TBI commonly called a concussion, it can hinge on the patient's recollec- tion of events, which may be fuzzy, said Michael Wilmore, M.P.A.S., P.A.- C., director, Division of Clinical Affairs, DVBIC. "I personally feel [that] doing a good screening for TBI and concus- sion is dependent upon the art of the clinical interview and taking the time to allow a service member to describe the [entire] injury event; look for gaps in memory or clouded recollection of what happened," he said. "[It's essential that] you iden- tify whether there was an alteration in consciousness or loss of con- sciousness." TBI and its symptoms range in severity from mild, moderate, severe, to penetrating. For example, a mild TBI or concussion is characterized by a normal MRI or CT scan, a confused or disoriented state lasting less than 24 hours, loss consciousness for up to 30 minutes, and memory loss lasting less than 24 hours. In con- trast, a severe TBI is characterized by a confused or disoriented state last- ing more than 24 hours, a loss of consciousness for more than 24 hours, memory loss for more than 7 days, and structural brain imaging yielding normal or abnormal results. Thanks to advances in body armor, medical care, and equipment, more soldiers are surviving devastat- ing blast injuries, including those to the eyes. Use of polycarbonate eye protection has reduced the number of open-globe eye wounds service members sustain, but this eye pro- tection does not guard against the effect of blast waves. "We don't know what the effect of the blast wave is to the eye," said Dr. Mazzoli. "We don't know what the mechanics of that are. We don't know blast physics of the actual blast wave, the different pressures, and how they affect the different structures of the eye. If we don't know that, it's hard to design some- thing to protect against it." Despite the eye protection, many service members have obvious eye injuries that are diagnosed and cared for in theatre. But it's the less obvious internal eye injuries that may go undetected without the comprehensive examination that Dr. Cockerham is focusing on. "[Soldiers] have a helmet on, they have a thick skull, they have spinal fluid that acts as a cushion around the brain, and nevertheless the brain is getting injured," said Dr. Cockerham. "It may not affect vi- sion, but there are injuries that can lead to retinal detachment. They can have glaucoma or other things that we're not aware of. Initially, they're on a lot of medications and have other problems going on, so even if it would be noticeable to them oth- erwise they aren't going to notice it in that situation." Jason Poole, a former Marine Corporal, is one of Dr. Cockerham's patients with complex injuries be- yond the eyes. While on patrol in Iraq in 2004, Cpl. Poole, two Iraqi soldiers, and an interpreter were hit with an IED. Cpl. Poole was the only survivor and gravely injured. It was his third tour of duty. He was just 10 days from returning home. Cpl. Poole's injuries were exten- sive and primarily to his left side. "In my left eye, I'm completely blind," he said. "It's actually sunken in. I have a prosthetic eye. I have to turn my head all the way around to see." He spent 2 months in a coma and is deaf in his left ear. He has a TBI, and the left side of his brain, which controls reading, writing, spelling, and talking, is damaged. His right eye has internal injuries from shrapnel. "I don't really have a tear duct, so I cry all the time," he explained. "I could be laughing, but I shed a tear." According to Dr. Cockerham's study, 43% of patients had closed- eye injuries across three anatomical zones. Zone 1 included injuries to the conjunctiva and external cornea. Zone 2 encompassed the irido- corneal angle, iris, and lens. Zone 3 contained the vitreous, retina, choroid, macular, and optic nerve. Ten patients had injuries in a single zone, four in two zones, and six in all three. For example, 22% of the patients with closed-eye injuries had by Faith A. Hayden EyeWorld Staff Writer Uncovering hidden eye injuries in wounded warriors Glenn Cockerham, M.D., and Jason Poole, a former Marine Corporal Source: Kerri Childress Cpl. Jason Poole was injured while on patrol in Iraq in 2004 Source: Cpl. Jason Poole continued on page 66 64-68 ION_EW November 2011-DL-3_Layout 1 11/4/11 1:48 PM Page 65

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