[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]




 
                     TRAUMATIC BRAIN INJURY RELATED
                             VISION ISSUES

=======================================================================

                                HEARING

                               before the

                     SUBCOMMITTEE ON OVERSIGHT AND
                             INVESTIGATIONS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 2, 2008

                               __________

                           Serial No. 110-79

                               __________

       Printed for the use of the Committee on Veterans' Affairs



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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois                  GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania       MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada              BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado            DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas             GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana                VERN BUCHANAN, Florida
JERRY McNERNEY, California           VACANT
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                  HARRY E. MITCHELL, Arizona, Chairman

ZACHARY T. SPACE, Ohio               GINNY BROWN-WAITE, Florida, 
TIMOTHY J. WALZ, Minnesota           Ranking
CIRO D. RODRIGUEZ, Texas             CLIFF STEARNS, Florida
                                     BRIAN P. BILBRAY, California

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             April 2, 2008

                                                                   Page
Traumatic Brain Injury Related Vision Issues.....................     1

                           OPENING STATEMENTS

Chairman Harry E. Mitchell.......................................     1
    Prepared statement of Chairman Mitchell......................    43
Hon. Ginny Brown-Waite, Ranking Republican Member................     2
    Prepared statement of Congresswoman Brown-Waite..............    43
Hon. Zachary T. Space............................................     3
Hon. Eric Cantor.................................................     4
Hon. David L. Hobson.............................................     4
Hon. Corrine Brown...............................................    20
    Prepared statement of Congresswoman Brown....................    44
.................................................................

                               WITNESSES

U.S. Department of Veterans Affairs:
    James Orcutt, M.D., Chief of Ophthalmology, Office of Patient 
      Care Services, Veterans Health Administration..............    27
        GPrepared statement of Dr. Orcutt........................    64
    Glenn Cockerham, M.D., Chief of Ophthalmology, Veterans 
      Affairs Palo Alto Health Care System, Veterans Health 
      Administration, U.S. Department of Veterans Affairs........    29
        GPrepared statement of Dr. Cockerham.....................    67
U.S. Department of Defense:
    Colonel (P) Loree K. Sutton, M.D., USA, Special Assistant to 
      the Assistant Secretary of Defense (Health Affairs), 
      Psychological Health and Traumatic Brain Injury, and 
      Director, Department of Defense Center of Excellence for 
      Psychological Health and Traumatic Brain Injury, Department 
      of the Army................................................    30
        GPrepared statement of Colonel Sutton, M.D...............    69
    Major General Gale S. Pollock, Deputy Surgeon General for 
      Force Management, and Chief, United States Army Nurse 
      Corps, Department of the Army..............................    32

                                 ______

Blinded Veterans Association, Thomas Zampieri, Ph.D., Director of 
  Government Relations...........................................     9
    Prepared statement of Dr. Zampieri...........................    50
Minney, Petty Officer Glenn, USN (Ret.), Frankfort, OH...........     7
    Prepared statement of Petty Officer Minney...................    48
Neuro Vision Technology Pty. Ltd., Torrensville, Australia, Gayle 
  Clarke, Chief Executive Officer................................    22
    Prepared statement of Ms. Clark..............................    59
NovaVision, Inc., Randolph S. Marshall, M.D., M.S., Associate 
  Professor of Clinical Neurology, and Chief, Division of 
  Cerebrovascular Diseases, and Program Director, Vascular 
  Neurology Fellowship Training Program, The Neurological 
  Institute, Columbia-Presbyterian Medical Center, New York, NY..    21
    Prepared statement of Dr. Marshall...........................    55
Pearce, Staff Sergeant Brian K., USA (Ret.), and Angela M. 
  Pearce, Mechanicsville, VA.....................................     5
    Prepared statement of Staff Sergeant Pearce..................    45
Performance Enterprises and Dynavision 2000, Ontario, Canada, 
  Mary Warren, M.S., OTR/L, SCLV, FAOTA, Associate Professor of 
  Occupational Therapy, and, Director, Graduate Certification in 
  Low Vision Rehabilitation Program, University of Alabama at 
  Birmingham, School of Health Professions.......................    22
    Prepared statement of Ms. Warren.............................    56


                     TRAUMATIC BRAIN INJURY RELATED
                             VISION ISSUES

                              ----------                              


                        WEDNESDAY, APRIL 2, 2008

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
              Subcommittee on Oversight and Investigations,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:07 a.m., in 
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell 
[Chairman of the Subcommittee] presiding.

    Present: Representatives Mitchell, Space, Walz, and Brown-
Waite.
    Also Present: Representatives Brown of Florida and Boozman.

             OPENING STATEMENT OF CHAIRMAN MITCHELL

    Mr. Mitchell. Good morning and welcome to the Subcommittee 
on Oversight and Investigations. This is a hearing on traumatic 
brain injury (TBI) related vision issues. This hearing will 
come to order.
    We are here today to hear from veterans and the U.S. 
Department of Veterans Affairs (VA) about a very serious 
problem in the care of wounded servicemembers that has been 
overlooked for too long. Traumatic brain injury, TBI, is one of 
the signature issues of the wars in Iraq and Afghanistan. I am 
afraid that vision problems are becoming the unrecognized 
result of that injury.
    Research being conducted by physicians, psychologists, and 
blind rehabilitation specialists at the VA Palo Alto Polytrauma 
Rehabilitation Center and the VA Western Blind Rehabilitation 
Center shows that TBI causes serious vision disturbances in a 
large number of cases even when the veteran retains 20/20 
vision, and without any obvious injury to the eye. We will be 
hearing today from Staff Sergeant Brian Pearce and Petty 
Officer Glenn Minney, Iraq veterans who are legally blind as a 
result of TBI.
    Staff Sergeant Pearce and Petty Officer Minney do not have 
happy stories to tell us about their experiences after they 
were injured. We owe these two a great deal of debt for their 
service. Both of their TBI-related vision issues went 
unrecognized and untreated for a long time.
    The wars in Iraq and Afghanistan have forced us to deal 
with unexpected and often unpleasant realities. But we know now 
that military and VA healthcare providers must be especially 
alert to vision defects resulting from TBI--even when there is 
no obvious physical injury to the eye.
    This is not only critical so that these vision deficits can 
be addressed, but also because undiagnosed vision problems can 
seriously interfere with TBI rehabilitation and also 
rehabilitation for other injuries that often occur along with 
TBI.
    Following our first panel, we will be hearing from several 
companies that are working with the VA to provide innovative 
treatment for TBI-related vision deficits. Our third panel 
consists of witnesses that are from the U.S. Department of 
Defense (DoD) and the VA.
    Two of the researchers from the Palo Alto VA are leading 
efforts to better identify and diagnose vision deficits in TBI 
patients. They are to be commended for their cutting edge work. 
In the 2008 National Defense Authorization Act, Congress 
directed DoD and VA to create a cooperative program 
specifically to address TBI-related vision issues. We are 
looking forward to hearing exactly what it is that the 
Departments are doing, how they are directing funds for their 
efforts, and when they expect to have a fully functional 
program.
    I am also very interested to see whether DoD and VA are 
currently doing all they can to identify and track these 
patients, not just at Palo Alto but everywhere. Because the 
seriousness and the extent of vision problems resulting from 
TBI are just now becoming better known, we would like to hear 
from the Departments what they are doing to identify and 
contact TBI patients whose vision issues may have been 
overlooked.
    Our veterans served honorably to protect our Nation. We 
have a responsibility to take care of them when they come back 
home.
    [The prepared statement of Chairman Mitchell appears on p. 
43.]
    Mr. Mitchell. Before I recognize the Ranking Republican 
Member for her remarks, I would like to swear in our witnesses. 
I would ask that all witnesses please stand and rise from all 
three panels.
    [Witnesses sworn.]
    Thank you.
    Next I ask unanimous consent that Ms. Brown and Mr. Boozman 
be invited to sit at the dais at the Subcommittee hearing 
today.
    Hearing no objection, so ordered.
    I now recognize Ms. Brown-Waite for her opening remarks.

          OPENING STATEMENT OF HON. GINNY BROWN-WAITE

    Ms. Brown-Waite. Good morning and I certainly thank the 
Chairman for recognizing me.
    I appreciate your calling this hearing to allow us to 
review how the Department of Veterans Affairs and the 
Department of Defense are evaluating and treating vision 
problems encountered by Operation Iraqi Freedom/Operation 
Enduring Freedom (OIF/OEF) soldiers and veterans returning home 
with traumatic brain injuries.
    As we know, this was is different in many ways from those 
of the past. Soldiers who sustain injuries that would have 
resulted in death in previous conflicts now have a much greater 
survival rate. However, survival does not necessarily mean 
returning home to a normal way of life.
    Improvised Explosive Devices, IEDs, and now Explosive 
Forced Projectiles, EFPs, cause some of the most serious 
injuries among OIF/OEF soldiers. Because of these types of 
attacks, many of our most severely injured veterans experience 
traumatic brain injury and require treatment at one of the four 
Polytrauma Centers around the country.
    The Polytrauma Rehabilitation Center (PRC) nearest my 
district is at James A. Haley Medical Center in Tampa. Where I 
visit there frequently, I see firsthand the tremendous strides 
that wounded soldiers make.
    I am also very pleased that the VA has made a commitment to 
expand the PRC Network to include a facility in San Antonio, 
Texas.
    Treating these severely wounded servicemembers has been a 
learning process. As our physicians treat the various and 
previously unseen injuries from IEDs/EFP blasts, we learn more 
about the resulting co-morbid conditions, such as visual 
impairments suffered by our servicemembers. From information 
that I have obtained over 44,000 veterans have utilized the 
services of VHA's blind rehabilitation program.
    We here on the Committee need to be assured that these 
veterans are receiving the care and services that they desire 
and are deserving of. I look forward to hearing the opinions of 
our first panel as to the evaluation, treatment, and care they 
received while moving from the battlefield through to the VA.
    I have read the testimony, and again the transitions you 
made going from the Department of Defense to VA have not been 
an easy road to follow. I would like to ask the administration 
officials sitting behind you to listen very closely to your 
testimonies. The situations you have encountered along your 
path to recovery need to be resolved by both departments so 
that others do not face similar problems in the future. We 
appreciate you coming forth with the individual stories that 
you have and experiences that you had.
    I also look forward to hearing from officials from the Palo 
Alto VAMC on the research they are doing with respect to vision 
issues related to a Polytrauma. I would hope that they are 
sharing their experiences, methodologies and treatment plans 
with the other PRCs.
    As I have stated in the past, all medical centers need to 
be sharing their best practices with one another so that our 
veterans and servicemembers receive the very best possible 
care. This is particularly critical in the area of TBI where 
treatments are often on the cutting edge.
    I would like to commend the work of the BVA, the Blinded 
Veterans Association, for their efforts. I look forward to 
hearing what they and their members have encountered when 
helping veterans navigate the system.
    Thank you again, Mr. Chairman, for calling this hearing and 
at this point I yield back the balance of my time.
    [The prepared statement of Congresswoman Brown-Waite 
appears on p. 43.]
    Mr. Mitchell. Thank you. Mr. Space.

           OPENING STATEMENT OF HON. ZACHARY T. SPACE

    Mr. Space. Thank you, Mr. Chairman. I am pleased to welcome 
Glenn Minney from my region, along with my colleague Dave 
Hobson whose district abuts my district in Ohio, and of course 
Mr. Zampieri as well. We are happy to have him here today to 
testify regarding the somewhat unseen results of this war. And 
I use that word with a tone of irony.
    Mr. Minney is here to tell us about his experiences in 
Iraq. I was honored to have him in my office last night with 
Mr. Zampieri to talk very candidly about both the problems 
associated with the transition from DoD to the VA, as well as 
the problems associated with those coming back from this war 
with traumatic brain injury, which in many cases leads to 
attendant eye injury. We are again honored to have Mr. Minney 
here. I know it took an act of courage to come and testify 
today and I would like to thank him for that. Welcome.
    Mr. Mitchell. I ask unanimous consent that all Members have 
5 legislative days to submit a statement for the record. 
Hearing no objection, so ordered.
    At this time I would like to recognize Congressman Eric 
Cantor of Virginia, who is here to introduce his constituent, 
Staff Sergeant Brian Pearce, and his wife Angela.
    Congressman Cantor.

             OPENING STATEMENT OF HON. ERIC CANTOR

    Mr. Cantor. Thank you, Mr. Chairman. Chairman Mitchell, and 
Ranking Member Brown-Waite, I want to thank you very much for 
having this hearing and thank you for having me here this 
morning.
    It is my privilege to introduce Sergeant Brian Pearce, a 
resident of my district who is a combat veteran of the U.S. 
Army and an honorable patriot.
    He and his wife Angie came up yesterday from 
Mechanicsville, Virginia, to lend their story to the 
proceedings here this morning.
    Sergeant Pearce was injured in 2006 while serving with the 
Army near Baghdad. The vision loss, which occurred from his 
injuries is unique in that his eyes are fine. It is his brain 
which sustained the injury and which caused the optic nerve 
within the brain to stop working. While his eyes see 20/20 his 
brain cannot receive and process those images in full. In his 
words, he sees as if he is looking through a drinking straw. 
His recovery and transition back to civilian life has not been 
easy. His service to our country is admirable. His courage 
amidst new challenges is inspirational. I have no doubt that 
his testimony will help us understand how we can better serve 
the needs of our returning soldiers from the hospital bed and 
beyond as they recover from the loss of vision due to brain 
related injuries. I would also like to thank again, his wife, 
Angie, who has been a tireless advocate for his care throughout 
this arduous process and I thank you again and yield back.
    Mr. Mitchell. Thank you. Next I would like to recognize 
Congressman Dave Hobson of Ohio who is here to introduce his 
constituent Petty Officer Glenn Minney.
    Congressman Hobson.

           OPENING STATEMENT OF HON. DAVID L. HOBSON

    Mr. Hobson. Thank you Mr. Chairman and Members of the 
Subcommittee. I appreciate the opportunity to introduce a 
constituent of mine who is appearing before you today. As 
mentioned his name is Glenn Minney and he is a retired Navy 
medic who served in Lima Company, a Marine reserve unit of the 
3rd Battalion, 25th Regiment, based in my district. I just 
missed him when I was in Iraq with Mr. Murtha at the Haditha 
Dam, and he pointed out to me that the mortar hole in the dam 
was the one that caused his injury. Lima Company was assigned 
to Haditha, Iraq, and while he worked to treat the medical 
needs of his unit he himself was injured by a mortar blast, as 
I talked about.
    It is that blast had caused a traumatic brain injury and a 
severe visual problems that he is here to talk about today. And 
while Glenn is appearing today as an Iraqi combat veteran, he 
is also a patient advocate for the VA Medical Center in 
Chillicothe, Ohio, in my district and I think it is a county 
that Mr. Space and I both share there.
    I met with Glenn in my office yesterday and I asked him if 
there was anything that he wanted me say. He said that he was 
just a man who was trying to make a difference for other 
soldiers who have suffered from traumatic brain injuries that 
have left them with severe visual problems.
    During our conversation, I learned that there is a problem 
with the Department of Defense and maybe a certain official 
there in moving forward with the Military Eye Trauma Center of 
Excellence and Eye Trauma Registry. I am glad that this problem 
was brought to my attention. I am having my staff check this 
out from the funding side, as I am a Member of the Defense 
Appropriations Committee and working with Dr. Tom Zampieri from 
the Blinded Veterans Association on this issue, I assure you 
that I'm going to bring it to my Chairman's attention and my 
Ranking Member's attention on the Defense Appropriations 
Committee.
    I'm sorry I can't stay for this hearing because I'm 
supposed to be the Ranking Member at the Energy and Water 
hearing that is going on right now on nuclear weapons. So I 
need to get there. But I hope this is an issue that we can 
bring to a successful conclusion because these people are our 
heroes and we need to take care of them.
    Thank you, Mr. Chairman.
    Mr. Mitchell. Thank you. At this time I would like to 
recognize in this order, Sergeant Pearce, Petty Officer Minney 
and Dr. Zampieri for 5 minutes each.

STATEMENTS OF STAFF SERGEANT BRIAN K. PEARCE, USA (RET.) (U.S. 
ARMY COMBAT VETERAN), AND ANGELA M. PEARCE, MECHANICSVILLE, VA; 
  PETTY OFFICER GLENN MINNEY, USN (RET.), FRANKFORT, OH (U.S. 
 NAVY COMBAT VETERAN); AND THOMAS ZAMPIERI, PH.D., DIRECTOR OF 
       GOVERNMENT RELATIONS, BLINDED VETERANS ASSOCIATION

          STATEMENT OF STAFF SERGEANT BRIAN K. PEARCE

    Staff Sergeant Pearce. Chairman Mitchell, Members of the 
Subcommittee, thank you for the opportunity to speak to you 
today regarding our experiences following my injuries in Iraq 
and during my medical care to date.
    I joined the Army in June 1992 and served until March of 
2000, joining the West Virginia Army Reserve and National 
Guard. After a 3-year service break, I returned to active duty 
in January of 2004. Joining my new duty station in Alaska, 
which was the 172nd Stryker Brigade Combat Team from of Ft. 
Wainwright. I was then assigned to 4-11th Field Artillery as 
the brigade's Survey/Targeting Acquisition Chief. After an 
intense training period we deployed in July of 2005. My brigade 
combat team spent August of 2005 through August 2006 operating 
in the Mosul area of Iraq.
    As the brigade prepared to re-deploy home to Ft. Wainwright 
in July we were extended for 120 days. I had already been 
returned to Alaska in June to prepare for the brigade's 
homecoming. Then I was called back to Iraq in August of 2006, 
in our new area of responsibility in the Sunni Triangle.
    On October 20, 2006, I was severely injured by an IED blast 
that caused shrapnel to penetrate the right occipital lobe of 
my skull. Once the blast zone had been secured and I was air 
evacuated to the field hospital in Balad, there I underwent an 
emergency craniotomy to the right occipital lobe and posterior 
fossa with duraplasty. I also retained foreign body and was 
considered to have cortical blindness. Later we learned it was 
the cause of more complex visual impairments such as post 
traumatic stress disorder (PTSD), hearing loss, pulmonary 
embolism, seizures and rapid eye movement sleep and seizure 
disorders.
    During this time my wife was contacted in Alaska and told 
that I had been involved in an IED blast and was in stable 
condition complaining of neck injuries. Roughly 3 hours later 
she was contacted by my commander who was in Iraq with me and 
he then told her that I had come through the brain surgery 
fine, and was listed in very critical condition and--excuse me, 
I lost my place and my wife has to help me here.
    Ms. Angela Pearce. He was listed in critical condition and 
at that time we didn't realize that there was any blindness 
until his PA's wife came over to the house to talk to me to see 
how I was and bring dinner. At that time she informed me that 
my husband had no vision and of course I didn't know what was 
going on.
    So I initially got back in contact with the doctor in 
Balad. On 21 October, he informed me that my husband was 
diagnosed with cordial blindness and that we did not know 
whether his eyesight would come back or not. That was all that 
was said.
    Then they evacuated him to Landstuhl, Germany, on the 21st. 
He had to go through another surgery there to clean out--where 
he had a bleed out. And so, he was there until they transferred 
him to Bethesda, Maryland, to the hospital first. He had to 
have an angiogram done there and then on to Walter Reed.
    So from 25 October until December 5, 2006, he was in an ICU 
unit at Walter Reed.
    All this time I was asking about his vision, I kept being 
told, his vision does not matter at this time, we need to take 
care of his traumatic brain injury. And so he was transferred 
to Richmond at that point. I made that decision to transfer him 
to Richmond McGuire's VA at that time. So then he continued to 
go on with his care.
    They did have a BROS there and they did work with him, but 
the BROS got frustrated with all the bureaucracy and he left.
    So we went from--he left in June of 2007, and so Brian went 
from 2007 of June until October when he went to West Haven, 
Connecticut, to the Blind Rehab Center before he had any more 
care. And so there was a big lapse there. And we kept being 
told that, you know, his vision is the last thing that needs to 
be worried about at this time. So we had no idea what was going 
on with his vision.
    Once he got to Connecticut, we found out that his vision 
was a lot more extensive than what we were told.
    So, therefore, my big question is, had we been given the 
appropriate information from the very get go, would I have 
gotten better care for him elsewhere and would he have strived 
better in other therapies along with getting visual therapy. 
And there is no--as far as I know it is not being documented 
anywhere how many visual impairments that there are. And I 
would ask you here; do any of you know how many are coming out 
of the combat zone that have visual impairments and if you do 
not, I challenge you to find out and start with getting 
documentation for this to get care for these soldiers. There 
has to be something documented somewhere. And not to take away 
from the amputees or any other signature wound, but we need to 
get stuff for traumatic brain injury with visual impairments.
    Most people do not understand that the vision and the brain 
go hand-in-hand. And with my husband's injury it is not from 
his eyes, it is from his brain injury. His brain will not allow 
his eyes to function to see. He can see straight ahead of him 
about eight degrees, no more. There is nothing on either side 
of him.
    So I really strongly encourage that this panel makes 
something happen and it starts getting documented and money is 
out there to take care of these guys.
    And again, I thank you for your time.
    [The prepared statement of Staff Sergeant Pearce appears on
p. 45.]
    Mr. Mitchell. Thank you.
    Petty Officer Minney.

            STATEMENT OF PETTY OFFICER GLENN MINNEY

    Petty Officer Minney. Once again I would like to thank you, 
Mr. Mitchell and the rest of the panel for allowing me to speak 
today. It is easier to see this way.
    I first joined the Navy on September 4, 1985, where I 
attended Basic Training and Naval Hospital Corps School in 
Great Lakes, Illinois. After doing a tour of active duty, I 
came back to Ohio and I joined the Reserves in Columbus, Ohio. 
At that point I was attached to Lima Company 3rd Battalion, 
25th Marines.
    On January 3rd of 2005, 3rd Battalion, 25th Marines was 
called to active duty to serve in Iraq. After spending 2 months 
at Twentynine Palms, California, doing a train up, we left for 
Iraq.
    The 3/25 was assigned to Haditha, Iraq, and also to Hit. 
The majority of the battalion was assigned to Haditha Dam. A 
10-story hydroelectric dam that was used as a firm base.
    We had to make makeshift chow halls, sleeping quarters 
inside engine rooms, and a Battalion Aid Station in a 
electrical elevator room.
    On April 18, 2005, at approximately 16:30, I was on the 
10th story of the dam. While I was out trying to obtain medical 
supplies from a Conex Box, a mortar round hit the dam. At that 
point I was propelled backward and thrown up against the 
railing. Thank goodness there was a railing there, or I would 
have plummeted 10 stories down. But I hit the rail. The next 
thing I remember, I was running toward the Battalion Aid 
Station. I remember a flash of light and that is it. I went 
back to the Battalion Aid Station ready to assist in taking 
casualties.
    Well the next day, I noticed my eyes were a little scratchy 
and a little red. I went to the Bttalion Aid Station and they 
told me, you have pinkeye. So they treated me for pinkeye. It 
continued on. A few months later I went back with the same 
symptoms. You have pinkeye. I logged this into the sick call 
log. I was given Motrin and Erythromycin. But the primitive 
equipment that we had at the Battalion Aid Station, just an 
ophthalmoscope, was not really able to detect what was going on 
in the back of my eye.
    At that point I noticed that I was becoming more of a 
liability than an asset because I would go out on patrols and I 
could not see well enough to fire my weapon.
    I went to my battalion surgeon and I told him, I am losing 
my sight. He then notified Al Asad. I was medivaced to Al Asad 
in August. From Al Asad to Balad to Homburg or to Landstuhl, 
Germany. Then from Landstuhl they sent me to the German 
hospital at Homburg, Germany, where I underwent two eye 
surgeries on the 16th and 17th of August.
    You have to excuse me for a moment.
    After having my surgeries I was then sent home to Bethesda, 
Bethesda Naval Medical Center. From Bethesda they said I am 
still in the healing process, you have to go back to Ohio, and 
from there I was put on convalescent leave.
    The second day I was home my eyes reattached. I lost my 
vision. I went to Grant Medical Center. They preformed another 
surgery that evening on me to help save my sight. From there I 
went back home and I had to lay face down for almost a month. I 
was not able to do anything. At that point no one knew who I 
belonged to. What unit does he belong to, because I am on 
convalescent leave and now I am past my 30 days convalescent 
leave. No one wanted to take care of who I was so I was in 
limbo.
    All this time I was at home. I went back to my VA to ask 
for care. I was told, you are active duty. You cannot get care 
here. You have TRICARE. Well, from that point I got upset and 
went to the associate director, who at that point said, you get 
all the care you need here in Chillicothe VA.
    I am instrumental for the Chillicothe VA for the simple 
fact they done something. They recommended I get an MRI of my 
head. But before they could do that I was sent back to Camp 
Lejeune to the Wounded Warrior Barracks for therapy and then 
that is where I had an magnetic resonance imaging (MRI).
    Ladies and gentlemen, Homburg, Germany, Landstuhl, 
Bethesda, Grant, none of these major medical facilities 
bothered to look inside my head. The VA did in there and that 
is when they were able to discover that I had a traumatic brain 
injury. I had lost a portion of my parietal and occipital lobe 
which works my eyes. They could not figure out, you have had 
three surgeries, how come your eyes are not getting any better. 
because you never bothered to look outside the box and look at 
my brain. Maybe that is where the problem was and that is why I 
am here today with Mr. Zampieri and Sergeant Pearce. We need to 
start looking, you know, look outside the box. There are other 
injuries that cause traumatic brain injuries.
    And I would like to say this, at no time while I was in 
Iraq did I ever go on patrol nor any of my marines and we said 
it is too costly to go down that alley, or go on this patrol 
because it is too risky or it is too costly.
    Well now how come DoD and the VA can come back and say, 
well we cannot provide this care or that care because it is too 
costly. I never said it was ever too costly so why should these 
agencies say the same to me.
    Thank you.
    [The prepared statement of Petty Officer Minney appears on
p. 48.]
    Mr. Mitchell. Thank you. Finally Dr. Zampieri is the 
Director of Government Affairs for the Blinded Veterans 
Association (BVA) and is here to discuss the nationwide 
implication of TBI related vision problems. Thank you.

              STATEMENT OF THOMAS ZAMPIERI, PH.D.

    Dr. Zampieri. Thank you, Mr. Chairman and Ranking Member 
and other Members of the Subcommittee for having this hearing 
today.
    The Blinded Veterans Association has been in existence for 
63 years. Since the end of World War II and we're trying to 
dedicate ourselves to helping all of our Nation's blinded 
veterans and their families.
    It is an honor for me to be here today with these two 
witnesses who served their country and did a great job. And it 
is sad though that in preparing for this hearing when I was 
asked how many witnesses do you have possibly to come and 
speak, there is at least 12 others with similar stories. And 
that should be very disturbing to the Members in this room.
    These are not a couple, quote, accidents that fell through 
the cracks. And there are other cases out there that are very 
similar to this. And so hopefully, at the conclusion of this 
hearing today, there will be some major steps taken toward 
fixing this in regards to administratively and clinically 
better coordination between the Department of Defense and the 
VA in regards to all of the eye injured casualties returning.
    The numbers seem to be a moving target here. When I first 
started this job 3 years ago, I was just asking people how many 
eye injured have come from either Iraq or Afghanistan? No one 
seemed to be able to tell me. And if you go back and look at 
some of my earlier testimonies from a couple of years ago, they 
were drastically lower. And in reality, if people had really 
started to look at this issue earlier, they would have realized 
from looking at the International Classification of Diseases 
(ICD)-9 codes that the VA had, and also DoD, that the numbers 
were growing rapidly as early as in 2005. Here we are in 2008, 
the most recent numbers that I can come up with is close to 
1,400 combat-eye injured, battle-injured eyes. And there is 
another component, which is the reason for this hearing is the 
traumatic brain injuries and the visual impairments associated 
with TBI.
    So individuals who can have the penetrating eye injuries 
from battle-related injuries, they are obvious. But the ones 
that come back who have had repeated head concussions and have 
suffered from a traumatic brain injury like with Glenn Minney 
and Sergeant Pearce, their injury is in the back of the brain 
are effecting their vision. And with their other emphasis on 
other types of manifestations neurologically of these TBIs, I 
think what happens is a lot of times the initial assessment is, 
well, your eyes appear normal. And both of these gentlemen have 
been told by people who have come up to them and said, well 
your eyes look okay there must not be anything else wrong.
    The neurological pathways in the brain--I put a lot in my 
testimony, not to overwhelm anybody, but I think it is 
important that people understand one critical thing here today. 
That vision is 70 percent of our awareness of our environment. 
The other senses that you learned about in school as far as 
hearing, touch, smell, taste, we are visual animals. And so if 
you have a traumatic brain injury and any of these different 
pathways are disrupted as in my written testimony, it can cause 
a huge number of different types of visual problems. Anywhere 
from color blindness to loss of peripheral field vision, depth 
perception and all of these various neurological complications 
from TBI that effect vision will effect everything else. 
Rehabilitation, vocational training, it is certainly going to 
have a negative impact on employment. And so we worked with 
Congress last year to get the Military Eye Trauma Center of 
Excellence included in the National Defense Authorization Bill 
as part of the Wounded Warrior legislation and I appreciate and 
thank the Members in this room who helped get that passed.
    I think it was everybody's intent that the DoD would 
establish a TBI Center of Excellence, a PTSD Center of 
Excellence and a Military Eye Trauma Center of Excellence. And 
that these centers would collaborate, work jointly, provide 
follow-up, best practices, look at what is going on in regards 
to the specific types of neurological research, both in eye and 
vision research, but also in other areas. They would be 
educators of the different practitioners that are dealing with 
these types of injured casualties coming into the VA and the 
DoD facilities. And importantly, also work with the families. 
One of the things that has bothered me the most about this is 
when I meet with a lot of these servicemembers families who 
have had eye injuries they are rarely given much information 
about what is low vision. You know, what would happen if Glenn 
Minney or Sergeant Pearce is--if they are transferred into the 
blind rehabilitative centers.
    You know, the good news is, there is always--I try any way 
to balance bad news with good news. The VA--and I thank former 
Secretary Nicholson, and Dr. Kussman. The VA started planning a 
couple of years ago for the full continuum of care for low 
vision and blind veterans. And they have implemented and 
started to open a large number of outpatient specialized 
clinics with ophthalmologists and optometrists and with blind 
rehabilitative specialist and vision specialists and they are 
in the process of hiring these people. There are about 54 
different VA Medical Centers that have been identified to have 
these new types of programs and so they are ideal for not only 
the aging population of veterans that they were created for 
with degenerative eye diseases, but for this generation who 
have different types of visual impairments that need care and 
services.
    Again, you ask though, does DoD know where these sites are, 
are they working collaboratively, are they providing accurate 
numbers to the VA people. I doubt it. And so my experience has 
been that the moving numbers here are amazing.
    Basically, I included a lot of recommendations and 
hopefully you'll look at those and consider them. I do want to 
stress again that my interaction with the VA and DoD 
ophthalmologist and optometrist is, I am amazed and impressed 
at their abilities. And if you go back historically and look at 
the results of eye trauma from World War II, most of those 
soldiers just lost their eyes. They were surgically removed. 
And today due to advanced skills of the ophthalmologist serving 
in Iraq and in Landstuhl, Germany, and the surgeons at Walter 
Reed and Bethesda, I have the greatest respect for what they 
are doing. It is just simply amazing.
    So this is not a hearing about a healthcare problem in the 
sense of are they not doing something medically that they 
should be doing. And I just wanted to stress that. This is 
about the age old problems of two bureaucracies talking to each 
other facilitating the implementation of this Military Eye 
Trauma Center of Excellence as Congressman Boozman and I had 
hoped, and make this work. And so again, I appreciate this 
opportunity to testify today and will be willing to answer any 
questions and thank you all again for having this hearing.
    [The prepared statement of Dr. Zampieri, appears on p. 50.]
    Mr. Mitchell. Thank you. I have a question of Mr. Pearce. 
Is there any care that you are currently receiving that you 
need? Let me put it this way. Is there any care that you are 
not currently receiving but need, or could it be better?
    Ms. Angela Pearce. I would like to answer that if you do 
not mind. The care that we received--that Brian has received 
from the VA has been excellent. I was left with the decision of 
where do I take my husband after he comes out of the ICU Unit. 
He spent 47 days being in the ICU Unit and 1 day on the floor 
at Walter Reed. We didn't have a good experience at Walter 
Reed.
    So, you know, and I had heard all these horror stories 
about VA. So then it was left up to me to make a decision where 
do I take my husband now. And so I chose Richmond. The only 
reason I had chose Richmond is I had had a friend there 
previously. I had to go off and leave my 7- and 8-year-old, at 
the time, in Alaska to come be by his bedside. So we are 
originally from Ohio. We were going to send the kids to Ohio 
with family. Okay, Richmond is the closest place for me to be 
able to get with my kids if I need to. I am glad that I made 
the decision to take him to Richmond. He has received wonderful 
care there. And I did take him there knowing that they did not 
have a full-blown blind rehab center. But again, you have to 
remember, I was told, do not worry about his vision, that is 
the last thing we need to worry about. Had I been told more, I 
would have probably chose somewhere different to take him and 
that is the question I have to ask, and I will continue to ask. 
Had I known ahead of time more about his visual impairment 
would I have chose Richmond? Probably not. He got good care 
there, but not for his vision.
    So that makes me wonder, did we--was he able to get and 
gain all the therapy that he really needed? If I would have 
taken him to Palo Alto would he have gained more from there and 
be further along now?
    So as far as your question, we received great care there. 
And we still continue to receive great care there. Brian.
    Staff Sergeant Pearce. The only thing I will add is that, 
and it is kind of--it goes away from your question a little 
bit, but it goes back to the same thing with the eyes and the 
vision and not knowing. When we left Walter Reed and we went to 
Richmond the answer was or their statement was, do not worry 
about the vision, the main problem is the TBI. That is the main 
thing we kept hearing all the time. Do not worry about your 
vision, worry about your TBI. Do not worry about your vision, 
worry about the TBI.
    Well I spent 16 years in the Army, and learned from day one 
to know that bad news does not get any better with time. You 
are not going to wake up on the 5th day and all of a sudden it 
is good news. It is not going to happen.
    Telling me at day one, son, you are blind. I got it. Okay, 
let me move on and live with it. And they did not do that. They 
need to start being up front about what is there, and what you 
have to live with. I have a whole new norm now I have to deal 
with and an 8- and a 9-year-old and--well they are now 9 and 
10--a 9- and a 10-year-old and a wife that I have to try and 
figure out how I am going live a new norm for a lifetime with.
    Mr. Mitchell. Thank you. Mr. Minney can you give us some 
suggestions that could improve the VA outreach to veterans who 
have been injured with TBI that later are experiencing vision 
problems?
    Petty Officer Minney. The one thing that I can see is there 
needs to be more of a communication between DoD and VA. When an 
individual is in the military they have a health record jacket. 
I had mine, so the VA was able to go back and look at that. But 
there are guys that come in to the VA system that do not have a 
health record so when they start their process, their 
transition from DoD to the VA, there is no health record. So 
the VA has to start from ground zero and this servicemember has 
to go through every physical exam, every bit of treatment that 
he went through DoD once again through the VA. If those records 
were just taken from DoD--if DoD would just share them 
completely with the VA there would be a better seamless 
transition there. That is one thing that I can see that could 
help with the visually impaired. Because every eye exam, which 
some of them are painful, that I have had to go through, I had 
to go through three and four times, because the VA said well we 
do not have copies of your military health record we have to do 
it all over again. Well it just so happens being a good 
corpsman, I kept copies so I didn't have to go through every 
eye exam. But there are guys out there that do. They have to go 
through every physical evaluation all over again.
    Mr. Mitchell. Thank you. We have heard that same story 
since we have been having these hearings.
    Ms. Brown-Waite.
    Ms. Brown-Waite. Thank you, Mr. Chairman. Dr. Zampieri when 
I look through your testimony there were different estimates in 
there of the number of blinded veterans as a result of serving 
in Iraq and Afghanistan. What is the final number, I mean, as 
of maybe the beginning of this year even? Because there seems 
to be conflicting percentages and numbers and is--and in your 
testimony, I think, you mentioned that there was an official 
report. What was that number and is it an official report? I 
think it said ``estimated to be.''
    Dr. Zampieri. Yes, thank you. The numbers, I think, are 
like trying to get the accurate numbers on traumatic brain 
injuries at large and unfortunately, you know, I have been told 
recently that the number last September was this number that I 
put in there of 1,162 as of September 17, 2007. Now these are 
not all blind and I am glad you asked that question. The VA is 
aware of approximately 100 to 104 OIF/OEF veterans who are 
legally blind, which is 2200 or less or 20 degrees of 
peripheral vision loss or less.
    So the actual number who are blind is a small percentage, 
really of the total number though have suffered major eye 
injuries. And what one of our biggest fears is that the ones 
that had initially successful surgeries the other 1,100, are at 
risk if they get lost between the systems and do not get follow 
up of complications. And there is three common complications, 
to make a short answer long, that most ophthalmologists are 
very concerned with this population of veterans and that is 
traumatic cataracts, glaucoma and detached retinas that can 
occur seemingly almost at anytime after somebody has sustained 
a traumatic injury. And these are types of things that normally 
in the private sector ophthalmologists or optometrists would 
see in a very old population of individuals.
    We think of glaucoma as something that our parents get. We 
think of cataracts as something a 70-year-old gets. But I met a 
24-year-old Army sergeant with cataracts. I met a 28-year-old 
Army lieutenant who was blinded in his right eye. His right eye 
was enucleated in Iraq, and surgically removed. His left eye 
was, quote, normal but they found at Walter Reed fortunately 
when they tested him just before he was to be discharged he had 
glaucoma with pressures equivalent to what a 65-year-old might 
have.
    So the actual number of blinded individuals that are 
enrolled in the VA Visual Impairment Service Team Program is 
about 104, but there is these other 1,100 or 1,200 out there 
that have sustained major eye injuries. And then the experts 
who will testify later may tell you that there are neuro-
ophthalmologists who believe looking at the TBI data and 
private research numbers that as many as 7,000 TBI patients 
probably, which is in my testimony, have some type of visual 
TBI impairment. And when you look at hearing loss and vision 
loss combined, I would say that this is sort of like the silent 
epidemic from the war that most people have not really started 
to add up and look at. So thank you.
    Ms. Brown-Waite. Thank you very much. The conditions you 
described, the cataract condition, the glaucoma, and detached 
retina, when you have those technically that is where you are 
considered legally blind. In most States that would be the 
definition of legally blind, am I correct?
    Dr. Zampieri. Yes. They can result in blindness especially 
the detached retinas and the glaucoma.
    Ms. Brown-Waite. Right.
    Dr. Zampieri. In fact, there was recently a survey. The 
National Eye Institute did a survey of Americans and they asked 
them, you know, like do you recognize information or do you 
know about glaucoma. And only 8 percent of the Americans that 
they surveyed said that they had any idea that glaucoma does 
not cause any symptoms. There is no pain. There is initially no 
problems that the person is going to be aware of. And then 
suddenly the pressures--if they last long enough on the optic 
nerve they will go blind.
    Whereas cataracts can be operated on and removed and the 
vision will return. I guess one of the interesting things about 
cataracts though is when you do cataract surgery in a 70-year-
old, most ophthalmologist are well aware of, you know, 10 years 
later what might happen. I do not think many people have a lot 
of experience with 24-year-old who have had cataract surgery 
what will happen to them when they are 45 years old or 60 years 
old.
    So there is a great need here for a lot of long-term 
longitudinal research on all of these types eye injured 
casualties. And those are great questions.
    Ms. Brown-Waite. Thank you very much doctor. I yield back 
the balance of my time.
    Mr. Mitchell. Thank you. Mr. Space.
    Mr. Space. I thank you, Mr. Chairman. Mr. Minney, how much 
time expired between the date of your injury and the date that 
you were diagnosed with traumatic brain injury?
    Petty Officer Minney. My injury was in April of 2005 and I 
want to say I was diagnosed with a traumatic brain injury in 
February of 2006.
    Mr. Space. So roughly 10 months?
    Petty Officer Minney. Yes.
    Mr. Space. And that would have been after the magnetic 
resonance imaging (MRI)?
    Petty Officer Minney. No, the MRI is what discovered the 
brain injury.
    Mr. Space. Right. But you were not diagnosed until you had 
the MRI done?
    Petty Officer Minney. Right.
    Mr. Space. I understand that was recommended by a VA 
facility.
    Petty Officer Minney. Yes, they had recommended it but I 
was at Camp Lejeune so----
    Mr. Space. It was within the jurisdiction of the Department 
of Defense. And you had been in a number of medical providers 
prior to that under the ambit of the DoD and not once had 
anyone recommended an MRI until the VA recommended it?
    Petty Officer Minney. No MRI, no CAT scan, no X-ray. No one 
even bothered looking at my head. Everyone was focused on my 
eyes.
    Mr. Space. And they were obviously aware that you had been 
subjected to a blast and were having vision problems throughout 
that entire period. A deteriorating condition, no less, 
correct?
    Petty Officer Minney. Yes.
    Mr. Space. Do you have any idea as to why no one thought of 
doing an MRI prior to 2006?
    Petty Officer Minney. No, I do not. I just think that they 
were just focused on the eyes and they did not want to think 
outside the box and think that maybe there was a brain injury 
that was related to the eyes. They did not put two and two 
together.
    Mr. Space. Alright. Do you think cost might have been a 
factor?
    Petty Officer Minney. I do not know.
    Mr. Space. Okay. Had the Department of Defense diagnosed 
TBI, let us say within 6 weeks or a month or a week after your 
injury, would that have had an affect on your condition or made 
a difference in your prognosis for recovery?
    Petty Officer Minney. It may have made a difference in my 
recovery. I could have started my speech therapy sooner. I 
could have started my cognitive therapy sooner.
    Mr. Space. So you were delayed essentially for 10 or 11 
months in all that?
    Petty Officer Minney. Yes.
    Mr. Space. Apart from the eye conditions that you suffer 
from, did the brain injury manifest itself in any other ways?
    Petty Officer Minney. Yes. I have cognitive thinking 
disorder. I have short-term memory loss. There are things that 
happened before my injury in my life that I do not remember 
now. And I have some associative disorders that I have to go 
through speech therapy with. I can be speaking and sometimes 
forget the next word. So I am going through therapy to help me 
learn to speak and basically to think all over again in a 
different way.
    Mr. Space. I thank you again, Mr. Minney for your 
testimony.
    Dr. Zampieri, I have one or two brief questions for you. 
What can the VA do better, or the Department of Defense for 
that matter, in tracking or effectively screening and/or 
diagnosing TBI and/or ophthalmological conditions that might 
not otherwise be readily apparent from a visual inspection?
    Dr. Zampieri. Thank you. I guess sort of the gold standard 
that I have really been impressed with is what is going on at 
Palo Alto. They are just doing some exceptionally great 
screening out there. And, you know, I guess if I were to wave 
the magic wand and be up in a high enough level in DoD of VA I 
would say, okay, we need to replicate the types of optometry/
ophthalmology/blind rehabilitative specialist that are at Palo 
Alto that are working and screening all these TBI patients at 
least initially through all of the VA Polytrauma Centers.
    Mr. Space. Would the implementation of the Military Eye 
Trauma Center of Excellence that you referred to in your 
testimony be of assistance in that regard?
    Dr. Zampieri. Yes, it would be huge.
    Mr. Space. Okay.
    Dr. Zampieri. Because, you know, I think most people 
envision that the Eye Trauma Center of Excellence would be sort 
of the lead coordinator of this and make sure that people like 
Angie and Glenn Minney's wife, Gretchen, that they get 
information. Again families need to have information about 
where in the VA they can get help and assistance. The Eye 
Trauma Center of Excellence should not be viewed though is like 
all patients with eye injuries are going to go to one place.
    Mr. Space. Right.
    Dr. Zampieri. But it should be, you know, I mean, they are 
setting up the TBI Center of Excellence and the PTSD Centers of 
Excellence to facilitate and coordinate those injuries and 
someone telling me, well we will send them to the eye clinic 
for the eye part. No.
    Mr. Space. Right. And I have exceeded my time, but I just, 
with the consent of the Chairman, would like to ask one 
additional question?
    Thank you, Mr. Chairman. Is there, in your opinion, one 
specific factor that you can point to that represents a barrier 
to the establishment or the implementation of that Center of 
Excellence?
    Dr. Zampieri. I hate to say this, you know, because you 
fund the VA a huge amount and you funded DoD a large amount but 
I have been sort of told that well the $5 million wasn't 
included to cover the Military Eye Trauma Center of Excellence, 
therefore, we are going to set up a computer registry which is 
an important part of this. And there are actually DoD and VA 
ophthalmologists and optometrists that are working from a 
clinical standpoint to develop the computer registry. But that 
is not the end of this. I mean, these guys will tell you, I am 
not a number in the computer registry with a diagnoses and 
peripheral field measurements and a surgical op note, you know 
or whatever other various things that are in that registry 
which is important. But these other things. The research and 
the best practices and the continuing education of the other 
providers.
    So I am just stunned when I am told, well Congress did not 
include the $5 million so, therefore, we are not going to 
implement this but we will set up the computer part. No. And I 
am embarrassed to have to ask, well could you guys put the $5 
million in somewhere. I just cannot believe I am even saying 
that in front of you. It is terrible.
    Mr. Space. I appreciate your candor. Thank you Doctor, 
thank you Mr. Minney and Sergeant Pearce.
    Mr. Mitchell. I thank you. Mr. Boozman.
    Mr. Boozman. Thank you, Mr. Chairman. I am an optometrist, 
an eye doctor, and I have dealt with low-vision patients, 
people that had impaired vision for a long time. I actually set 
up the low-vision clinic at the Blind School in Arkansas. The 
very first one, so I really do have a lot of experience in that 
regard.
    I can say that what you all went through early on, being 
somebody that treats folks in that--I am not a surgeon, but 
again being in a position of trying to figure out what is going 
on. I think with the literature that was available there, our 
experience that is available you could almost look at your care 
and understand what was going on. Now, there is a difference 
because of the fact that we do now understand exactly what we 
did not understand exactly then. But we understand that there 
is a mechanism associated with TBI that very much effects 
vision and because of the prevalence of TBI this is something 
that, you know, we have to pursue. As a result, we were able to 
work with most of the Committee and several others. Dr. 
Zampieri has been wonderful in helping us establish the 
Department of Defense Excellence--the Center, you know, what we 
have been talking about. The problem again is funding. And so 
the law is in place. I really, you know, I appreciate your 
testimony.
    Sergeant Pearce, your six things that we need to do, you 
know, this does that. Okay. Exactly, and a lot of other things. 
You know, we need to follow up and get you guys fixed up. I am 
not real upset that what happened to you happened in the way it 
did in the sense that, you know, generally recognized things 
were practiced. Where I am going to be very upset is the guys 
that this happened to since this law has passed. And as Dr. 
Zampieri referred to, it has not been funded and is not being 
done then that is where we are going to get upset. There is no 
excuse now. Again, based on what we have learned from you guys 
there is no excuse now not to follow up on that. And this 
particular law actually came from the ophthalmologists and 
optometrists that are out there fighting the battle. They came 
to us and said, look, we need to do this. And so I really do 
appreciate your testimony. Hopefully at this point, you know, 
we will go forward and make sure that individuals that have run 
through the same problem because of the fact that we have 
identified the problems that you have had now that we can 
forward and then also continue to get the treatment that you 
need.
    Let me ask one thing and you might address this Dr. 
Zampieri. There is a little bit--in the testimony we learned 
that there is a discrepancy in the different Polytrauma Centers 
as far as what they have available to treat eye injuries. Can 
you address that? Is that acceptable in the sense that we are 
better off kind of clustering folks that need the intensive 
low-vision treatments or this or that or do we need to have the 
same care at every center? Does that make sense? In other 
words, Richmond did not offer one thing. Should all of these be 
offering the same thing or are we better off having this 
specialized at some centers versus the others?
    Dr. Zampieri. Yes. I guess again the model--and to be fair 
Palo Alto had the infrastructure because they had the Blind 
Center there. So they did have additional staff that the other 
three VA Polytrauma Centers would not normally have. And they 
were able to draw upon some of that expertise from their Blind 
Center staff and this TBI screening program. But I think that 
the important take home message for some folks is that the--
when you look at the Wounded Warrior legislation, in fact, it 
was almost like they had a list of all the occupations that are 
vital for the TBI Polytrauma Centers, and then the--I remember 
looking at the Senate legislation and I was astounded because 
down at the bottom it says, the Polytrauma directors, I am 
paraphrasing here, can assign other occupations as needed and 
they mentioned ophthalmology and optometry and I forget who 
else. But up at the top of the list of the major people who 
have to be involved they got recreation therapy, of course the 
physical therapy and the occupational therapy and those were--
everybody is important. Ha. But excuse me, if 70 percent of my 
sensory awareness is from my vision, and you are supposed to be 
the centers of excellence for Polytrauma and TBI, the first 
person I want making rounds everyday on the team, is an 
ophthalmologist and an optometrist with low-vision credentials. 
And to be told again, well, they are a part of the team but 
they are over there. Well, I got news, I can get real mad 
today. There are neurology clinics, too. I worked in the VA for 
19 years. That is why I think I irritate people because I have 
healthcare experience too. And sure, there are physical therapy 
clinics in every VA hospital, so why do you have to have them 
inside the polytrauma team. There are dietitians in every 
hospital. So do not--no. That game stops today. Either it is a 
multi-disciplinary team approach or it is not. And you do not 
put others as assigned. Not for this. Both of these gentlemen 
can tell you that when you lose 98 percent of your vision, your 
life is changed forever.
    The employment figures and this is not an employment 
hearing, but nationally the employment rate for blind 
individuals is 32 percent and that has not changed in 10 years. 
And that should be an astounding thing to consider what these 
individuals are up against. And if nothing else from that 
perspective alone, we have a long way to go and so I appreciate 
it. I am sorry I get angry.
    Mr. Boozman. No, that is okay. Thank you very much. I think 
that is very, very well said.
    Mr. Mitchell. Thank you. Mr. Walz.
    Mr. Walz. Well thank you, Mr. Chairman and thank you to our 
witnesses, Staff Sergeant Pearce and Mr. Minney. First of all 
thank you for serving this Nation and doing it with great 
dignity. As representatives of the American people our job is 
to make sure we serve you with that same dignity and 
professionalism, and I can tell you my constituents want us to 
get this right. So I thank you for being there.
    Ms. Pearce, I will not for a minute allow anyone to forget 
that our warriors do not fight alone. Their families fight with 
them and your care now is going to forever change your life. It 
is going to change your career trajectory. It is going to 
change a lot of those things and the realization that needs to 
come out of Congress, and it needs to come out that the 
American people want to make sure that you are fully cared for 
too and that you are made as whole as possible. Doing these 
things is not winning the lottery. There is a moral 
responsibility that this Nation has to provide and it also 
sends a message to future generations who wish to serve this 
Nation that when you come back you are not going to fight us 
and have to come here. So Dr. Zampieri, I totally agree with 
you. The idea that you would come here and bring these warriors 
with you, and have to beg for money to fund this. The 
juxtaposition against yesterday having oil company executives 
here and them telling us the $18.6 billion we gave them needs 
to continue on and you not getting your $5 million. If that 
escapes anyone in this country, shame on them.
    Just a couple of things that I would like to say. I can 
say, Chairman Mitchell and this Subcommittee and having Dr. 
Boozman on here as an expert is critically important and I am 
very appreciative of that. This understanding, and I think you 
have all hit this very clearly, and I think it is a sense of 
optimism but also a frustration on this issue of 
communications, electronic medical records, and the ability to 
disseminate that across DoD into the VA.
    We went to Iraq and Afghanistan in January with the 
specific purpose of taking a look at trying to break the 
stovepipes down and get them to communicate. One thing I have 
been expressing in my district and I want to thank BVA for 
bringing this forward. It was the BVA, I think, that turned us 
on to the traumatic brain injury and I think Ms. Pearce and 
others have talked about this. We need to be careful about a 
signature injury. Every injury is an injury to a warrior and is 
equally important to service. And if we lose track of that 
understanding we are going to rob Peter to pay Paul without 
making our military and our warriors whole. So we went there 
looking at this issue and one of the things I am deeply 
concerned about and I am glad that you brought this up is, I 
can anticipate already now we have an Agent Orange scenario on 
our hands. I have talked to warriors over there who have gotten 
blown up five times. They say, yeah, I got blown up five times. 
I got up and dusted myself off. They are going to come in 5 
years, maybe 10, maybe shorter, maybe longer and they are going 
to go to the VA and they are going complain of vision. And they 
are going to complain of memory lapses and all that. And then 
they are going to be asked, ``what happened to you?'' Well, I 
was blown up near Baghdad. ``Prove it.'' And we have the 
electronic medical record to be able to record these and with 
the work that has been done on this, the serial injuries, 
especially--it seems like an oxymoron, but the mild traumatic 
brain injuries that are happening are leading to this and I do 
not know why we are not taking--I think we are moving forward 
on that, we are trying to take the initiative. We have the 
technology. We have the ability to do this. Now we need the 
political will and the expertise to put that into play.
    So a couple of things I would ask on this. Mr. Minney, was 
your blast recorded on your record or was it going in to be 
seen about the eye? I mean, did your medical record the blast 
as being significant in this?
    Petty Officer Minney. Yes.
    Mr. Walz. Okay. So it was on there?
    Petty Officer Minney. Yes.
    Mr. Walz. Okay. But thank goodness you had it and you 
carried it through.
    Petty Officer Minney. Yes.
    Mr. Walz. So we had it there. All right. Very good. The 
other thing, and I guess that this is one that I would go back 
to--well no I will leave it at that. I'm with Dr. Zampieri, I 
do not want to get angry about this one because I understand 
and I can tell you--the only thing I guess I would tell you on 
this is that the commitment is here, the will of the electorate 
who put me here is here to do this right, the expertise is out 
there to be able to this, the council is there, and yet here 
you are today asking for us to try and improve this. So I would 
first of all applaud you for coming here. This is critically 
important that you do that. We are not going to forget for a 
minute. Your suggestions are based upon personal experience, 
but they are also based on when researchers are looking on this 
they come to the same conclusion right where you are at.
    So it is aligning there. I am optimistic that we have 
started to move toward as Dr. Boozman alluded to. There were 
things that are going right but there is more that needs to be 
done and our commitment needs to be with you. So again thank 
you for that and thanks for your service. I yield back.
    Mr. Mitchell. Thank you. Ms. Brown.
    Ms. Brown of Florida. Mr. Chairman, I don't have any 
questions, I just want to thank the men and the wife, the 
spouse, for their service to the country, and you can rest 
assured that I will be supporting the Subcommittee in whatever 
they recommend. I think it is just crucial that we do not 
forget the people that we sent forth, whether we supported the 
war or not, it is our duty to make sure that the men and women 
have what they need and when they come back that they are taken 
care of.
    So you have my commitment on that. Thank you.
    Mr. Mitchell. And thank you very much for your service and 
your testimony has been terrific and we hope as a result of 
this you will see some changes. Thank you very much.
    If the second panel would come forward. We are scheduled to 
have votes fairly soon but each of the three people here 
representing the next panel will have 2 minutes apiece to make 
their presentations.
    The first person that I want to recognize is Congresswoman 
Corinne Brown who is here to introduce her constituents 
NovaVision.
    As soon as all three take their place we will begin. And 
again please keep your remarks to 2 minutes.

            OPENING STATEMENT OF HON. CORRINE BROWN

    Ms. Brown of Florida. Thank you, Mr. Chairman. And you know 
we know how to do 1 minutes in the House of Representatives.
    [Laughter.]
    Mr. Chairman and Members of the Subcommittee, I am pleased 
to introduce NovaVision today for their testimony regarding TBI 
and vision.
    NovaVision, which is headquartered in Florida, develop and 
provide innovative medical devices and a wide range of 
solutions to restore the vision of patients. They have 
developed a therapeutic base on the brain's ability to adopt 
and form new connections to compensate for injuries.
    Dr. Marshal will elaborate further on this therapy. Dr. 
Randolph S. Marshall is Professor of Clinical Neurology at 
Columbia University and the Director of the Stroke and Critical 
Care Division in the Department of Neurology.
    He obtained his undergraduate degree from Harvard 
University and his medical degree from the University of 
California.
    His clinical work focuses on the treatment and prevention 
of stroke and related disorders. He has a research program that 
investigates stroke recovery. He is accompanied by Mr. Mehta.
    Mr. Mehta has 15 years of experience in managing technology 
companies. He cofounded NovaVision in 2002, guiding the company 
through the Food and Drug Administration clearance of his 
vision restoration therapy. He is also a certified public 
accountant in the State of New York. I yield back the balance 
of my time.
    [The prepared statement of Congresswoman Brown appears on 
p. 44.]
    Mr. Mitchell. Thank you. Mary Warren is here on behalf of 
Performance Enterprises and Dynavision 2000. And Gayle Clarke 
is the Chief Executive Officer of Neuro Vision. All of these 
companies are currently working to improve rehabilitation 
services for blinded veterans as a result of TBI and are here 
to discuss the use of treatment methodologies.
    First Dr. Marshall and then Ms. Warren and Ms. Clarke will 
have 2 minutes apiece. Thank you.

   STATEMENTS OF RANDOLPH S. MARSHALL, M.D., M.S., ASSOCIATE 
    PROFESSOR OF CLINICAL NEUROLOGY, AND CHIEF, DIVISION OF 
   CEREBROVASCULAR DISEASES, AND PROGRAM DIRECTOR, VASCULAR 
    NEUROLOGY FELLOWSHIP TRAINING PROGRAM, THE NEUROLOGICAL 
INSTITUTE, COLUMBIA-PRESBYTERIAN MEDICAL CENTER, NEW YORK, NY, 
ON BEHALF OF NOVAVISION, INC.; ACCOMPANIED BY NAVROZE S. MEHTA, 
 PRESIDENT AND CHIEF EXECUTIVE OFFICER, NOVAVISION, INC., BOCA 
  RATON, FL; MARY WARREN, M.S., OTR/L, SCLV, FAOTA, ASSOCIATE 
  PROFESSOR OF OCCUPATIONAL THERAPY, AND, DIRECTOR, GRADUATE 
CERTIFICATION IN LOW VISION REHABILITATION PROGRAM, UNIVERSITY 
  OF ALABAMA AT BIRMINGHAM, SCHOOL OF HEALTH PROFESSIONS, ON 
BEHALF OF PERFORMANCE ENTERPRISES AND DYNAVISION 2000, ONTARIO, 
CANADA; AND GAYLE CLARKE, CHIEF EXECUTIVE OFFICER, NEURO VISION 
         TECHNOLOGY PTY. LTD., TORRENSVILLE, AUSTRALIA

         STATEMENT OF RANDOLPH S. MARSHALL, M.D., M.S.

    Dr. Marshall. Ranking Member Brown-Waite and other Members 
of the Subcommittee.
    I commend the Subcommittee for holding a hearing on this 
incredibly important topic and commend Representative Brown for 
showing tremendous leadership in this and other issues 
effecting the veterans. Thank you very much for allowing me to 
testify.
    As mentioned, I am a Professor of Neurology and Chief of 
the Stroke Division at Columbia University in New York. I 
conduct research in the area of recovery after brain injury and 
see patients in that capacity as well. The science of brain 
reorganization and neuroplasticity is one the hottest fields in 
medicine right now.
    One of the most interesting components of this field is the 
training and rehabilitation of partial visual loss. Since 2003, 
the NovaVision Company has been offering an exciting new option 
for treating partial visual loss after brain injury. It is 
known as visual restoration therapy or VRT.
    There are now over 40 centers across the U.S. offering the 
therapy, including clinics in Scottsdale, Arizona, Clearwater, 
Florida, Cincinnati Eye Institute, and Sharp Memorial Hospital 
in San Diego, California.
    Columbia, where I practice was the fourth site to begin 
treating brain injured patients using VRT. One of the most 
memorable patients for me was Bart Goldstein, who was featured 
in a recent NBC Nightly News story.
    Bart was a 19-year-old young man who had suffered a 
devastating motor vehicle accident 3 years before. He underwent 
VRT and not only regained some of his lost vision, but improved 
his attentional capacity as well. He was able to leave home and 
live independently and begin a school program.
    Bart is similar to the wounded soldiers we heard from in 
having a closed head injury. As we heard in previous testimony, 
both visual loss and additional neurological deficits, such as 
attention, are common in this condition.
    Mr. Chairman, finally with respect to the veteran 
population, NovaVision has donated five devices to treat 
veterans in the Tampa VA Polytrauma Center. The first of these 
veterans are now being treated.
    I am confident that VRT will be a very important adjunct to 
the rehabilitation treatment that we can offer these veterans. 
Thank you, very much.
    [The prepared statement of Dr. Marshall appears on p. 55.]
    Mr. Mitchell. Thank you. Ms. Warren.

        STATEMENT OF MARY WARREN, MS, OTR/L, SCLV, FAOTA

    Ms. Warren. I thank you for allowing me to provide this 
testimony in favor of the Dynavision.
    I am an Associate Professor at the University of Alabama at 
Birmingham and an occupational therapist. I have worked for 30 
years in clinical practice with persons who have traumatic 
brain injuries with their visual issues and I'm very glad to 
see this Committee addressing those issues. Twenty years of 
that time I have used the Dynavision as an apparatus to help 
individuals learn to use their remaining vision more 
efficiently. It is a very dynamic piece of equipment. It is 
very versatile and flexible and allows us to do a lot of 
different programs for our clients. It is a piece of athletic 
equipment that we have modified and used for persons with brain 
injuries and because of that it is a very competitive device 
and works particularly well with young men who have a 
competitive nature, who want to do an athletic activity and it 
is a very good device in drawing out their ability to use their 
remaining vision more efficiently.
    I guess I can be very brief.
    [The prepared statement of Ms. Warren appears on p. 56.]
    Mr. Mitchell. Very good, thank you. Ms. Clarke.

                   STATEMENT OF GAYLE CLARKE

    Ms. Clarke. Chairman Mitchell, Ranking Member Brown-Waite, 
and Members of Subcommittee Neuro Vision Technology would like 
to thank you sincerely for being asked to present today. There 
is a few brief points that I would to make which Dr. Zampieri 
has already mentioned.
    Historically worldwide traumatic brain injury 
rehabilitation programs include, physiotherapy, occupation 
therapy, and speech therapy. About the incidents of speech 
deficits in traumatic brain injury is the same as that as 
vision deficit. So why is vision therapy not part of the 
interdisciplinary rehabilitation program that is applied in 
acute settings and rehabilitation settings. There is a definite 
need for early intervention and I was distressed to hear that 
patients and your veterans here today were being told that 
vision is not important in their early intervention.
    In Australia for 20 years, we have been working with 
patients from day two following trauma and implementing vision 
therapy programs. It is awful to hear that there is a real 
issue and research has stated that 50 percent of people that 
already have been admitted to hospital go undiagnosed with 
vision-related deficits. These people can be 5 years, 10 years 
out and still be undiagnosed with vision deficit problems that 
are occurring. And this should not happen to your veterans.
    Blind Rehabilitation Centers are designed to provide 
veterans with programs that are for ocular disorders such as 
glaucoma, macular degeneration. Most staff have minimal 
understanding of additional cognitive and physical deficits 
associated to traumatic brain injury. The complexities of 
injuries, in addition to vision loss, make these cases very 
challenging for vision rehabilitation programs. Staff need to 
understand the difference and be trained in the different 
programs for neurological vision impairment intervention.
    Vision therapy is totally different for this group of 
veterans. They have to think brain and not eyeball. And that is 
again what we have heard today.
    Validation in the form of clinical research trials are 
essential and time and money needs to be allocated. However 
there is an existing need now. These veterans do not deserve to 
wait for 3 and 5 years for research to come out.
    Research programs should be conducted but in conjunction 
with implementing of proven therapy programs. Neuro Vision 
Rehabilitation System that we provide at NVT is not just a 
device but a staff training and therapy intervention program 
that actively transfers skills into functional tasks such as 
mobility and ADL. It is based on assessment and training 
programs which have been successfully implemented in Australia 
since the early 1980s.
    I spent 25 years of my life, sir, as a clinician. My key 
motivator is improving patient quality of life. And as such I 
believe----
    Mr. Mitchell. Could you wrap it up, please?
    Ms. Clarke [continuing]. And as such I believe passionately 
that comprehensive commitment to vision therapy programs such 
as NovaVision, Dynavision and NVT needs to be provided.
    I thank you sincerely for the opportunity to present today.
    [The prepared statement of Ms. Clarke appears on p. 59.]
    Mr. Mitchell. Thank you. I have one question for all of you 
and that is, the technologies that you represent, can they help 
identify servicemembers that are suffering with vision issues 
or do they only help servicemembers once they have been 
identified as having vision problems?
    Ms. Clarke. The NVT Program is an assessment and training 
program. We assess for vision loss. We assess for visual 
processing, visual spatial, and for visual orientation.
    So for patients who have difficulty in understanding the 
spatial concepts around them, we can work with them from day 
one.
    Ms. Warren. The Dynavision is primarily a training tool, 
but in the hands of good clinician, often times we uncover 
visual processing deficits that were not seen by our referring 
physicians. So the answer is primarily, no, but there is some 
evaluation component to it.
    Dr. Marshall. The NovaVision technology is specifically 
designed to begin with an assessment of the visual field loss 
that then leads to a targeted therapy.
    The first step is a mapping of the visual fields. There is 
both a comprehensive map that is done by a clinician when there 
is a problem known, but the NovaVision Company also has a 
screening module that is a more rapid assessment.
    Mr. Mitchell. Ms. Brown-Waite.
    Ms. Brown-Waite. Thank you very much, Mr. Chairman. I 
certainly want to thank you for the donation to the Tampa 
Hospital, the TBI Unit. They do a great job there. Dr. Scott 
is, I think, one of my heroes and every time I go there I 
pretty much hear the same thing from the servicemen who are 
there and their families.
    Ms. Warren, what is the typical process that an individual 
goes through when they are referred to your services?
    Ms. Warren. Well they are referred generally by a another 
physician, so we have an identified diagnosis. And our real 
responsibility is to ensure that they can engage in whatever 
activity they would like to engage in again. So it can be work, 
leisure, homemaking activities, whatever they need to do. We 
use the Dynavision to increase the efficiency of their vision 
so that they can use their remaining vision more effectively 
those activities.
    Ms. Brown-Waite. And how extensively do you work with the 
VA in rehabilitating servicemembers?
    Ms. Warren. I do not work with the VA. I am not an employee 
of the VA, nor have I worked with them. I have worked in 
clinical practice in various facilities and now I am at the 
university and in a clinical practice there, so I do not have 
experience with the VA but I have a lot of experience working 
with persons with brain injury.
    Ms. Brown-Waite. So is some of the research that you are 
doing being shared out there?
    Ms. Warren. All of the research that has been done on the 
Dynavision has been in publication for quite a while now since 
the device has been around for so long. So it is available to 
whoever uses it. I do a lot of training of occupational 
therapist including therapist who work for the VA in order to 
help them understand how to provide visual rehab for persons 
with brain injuries.
    Ms. Brown-Waite. Thank you very much, Mr. Chairman. As you 
can tell by the buzzer we are being called for a vote, so I'll 
yield back the balance of my time.
    Mr. Mitchell. Thank you. Let me just ask. Are there any 
questions that any of the rest of the Members would like to ask 
our panelists here before we dismiss them and then we will come 
back?
    Mr. Space. I would like to ask one question.
    Mr. Mitchell. Okay. Go ahead.
    Mr. Space. Thank you, Mr. Chairman. This is for Mr. 
Marshall. I am curious as to the effect of delayed diagnosis 
and, for example, the case of one of the gentlemen that 
testified today, there was a 10-month lapse of time before a 
diagnosis of TBI had been made. Up to that point, they 
suspected pinkeye which to me is somewhat inconceivable given 
that there are other manifestations of the injury. Is a 
prolonged period prior to diagnosis something that can affect a 
patient's prognosis for recovery and are there other effects of 
failure to properly and promptly diagnosis?
    Dr. Marshall. That is a very interesting question. I will 
leave aside the question of the misdiagnosis. But as far as 
treatment goes most of the patients treated with VRT have been 
treated in the chronic phase after 3 to 6 months after injury 
because of the fact that there are some spontaneous improvement 
and we wanted to make sure, at least in the early going that we 
were making an effect that was independent of spontaneous 
improvement. That being said there is a lot of interesting 
information coming out in other areas of brain recovery in 
other modalities. Motor recovery, language and so on that 
suggests that there is an early time period in which the brain 
may be actually more amenable to rehabilitation, retraining and 
that there is an early time period that may actually be more 
effective. Actually there is a study being purposed at the 
moment to try more acute therapy and it is something that we 
have been very interested in.
    Mr. Space. And would you be willing to provide us with 
copies of the results of that study upon completion?
    Dr. Marshall. Of course.
    Mr. Space. Thank you, Doctor.
    Mr. Mitchell. Thank you.
    Ms. Brown-Waite. Mr. Chairman, depending on how long the 
votes go, I may or may not be able to be back for the third 
panel, so I would ask if Mr. Art Wu could be in my place if 
there is not another Member here?
    Mr. Mitchell. So ordered. Yes.
    Ms. Brown-Waite. Thank you.
    Mr. Mitchell. Mr. Boozman.
    Mr. Boozman. Thank you. Very quickly. You said that the 
device had been around for a long time, do you have a 
controlled peer review study that compares this method of 
treatment with other methods in relation to TBI?
    Ms. Warren. What was the question?
    Dr. Marshall. I'm sorry, who are you addressing?
    Mr. Boozman. I do not care, whoever knows the answer.
    Mr. Mehta. Yeah, the NovaVision study and Dr. Marshall 
could add to this has been peer reviewed and there have been 
many double-blind placebo controlled studies.
    Mr. Boozman. In regard to TBI?
    Mr. Mehta. And with regards to both traumatic brain injury 
and TBI.
    Mr. Boozman. And the studies say that this is much more 
effective or the same? What do the studies say that have been--
--
    Dr. Marshall. The seminal study that was done for the VRT 
technology was published in the Nature Neuroscience in 1998 and 
compared a fixation training with this VRT technique. It has 
not been, as far as I know, specifically tested against other 
types, for example psychotic training and others. However most 
likely, the best results are going to result from a combination 
of therapies. The one VRT addresses a restorative 
neuroplasticity based treatment. And as was mentioned here, 
some of the others address a compensatory mechanism for 
overcoming the deficits that are in existence.
    Mr. Boozman. Okay. Do any of you all have financial 
interest in the company?
    Ms. Warren. No.
    Dr. Marshall. I have none.
    Ms. Clarke. I do.
    Mr. Mehta. I do.
    Mr. Boozman. Okay. And how long have you two, Ms. Warren 
and Dr. Marshall, how long have you all used the equipment and 
are familiar with it?
    Ms. Warren. I have used the Dynavision for 20 years. I was 
actually the first occupational therapist to see a Dynavision. 
Because it is a part of sports training I saw it and realized 
that it was an apparatus that I could use with my clients who 
had vision problems, particularly those who had hemianopsia and 
in attention. So I brought it into rehab and over the years a 
lot of other therapist have adopted it is use as well because 
we find it to be a useful tool in our arsenal when we are 
trying to assist a person to use their vision more effectively.
    So it is not the only--we talk about the fact that we use a 
variety of different therapies to achieve our goals and this is 
just one tool that helps us.
    Mr. Boozman. Good. And that's the other reason that going 
ahead with funding of our Vision of Excellence Center. These 
are the kinds of questions that we need to be asking and need 
to be answered based on good studies and things. And certainly 
a 1998 study is one thing, but now we are into 2008 and a lot 
has happened, intervened in that in regard to TBI and our 
knowledge of it and what we are doing now compared to then so, 
thank you very much.
    Mr. Mitchell. Thank you. And I want to dismiss the second 
panel and not adjourn, but to recess this hearing for the third 
panel until right after the votes. It should be, maybe, 15 or 
20 minutes and we will continue with that panel at that time. 
Thank you.
    [Recess.]
    Mr. Mitchell. Thank you. The hearing will reconvene and I 
want to welcome panel three to our witness table.
    Dr. James Orcutt, and Dr. Barbara Sigford are here to 
testify on behalf of the Veterans Health Administration. Dr. 
Cockerham and Dr. Goodrich are here to discuss the new research 
they are conducting at the VA's Western Blind Rehabilitation 
Center in Palo Alto. And Colonel Loree Sutton is the Director 
of DoD's Center for Excellence for Psychological Health and 
Traumatic Brain Injury.
    At this time we would like to recognize Dr. Orcutt, and 
then Dr. Cockerham and then Colonel Sutton for 5 minutes each.

   STATEMENTS OF JAMES ORCUTT, M.D., CHIEF OF OPHTHALMOLOGY, 
       OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
 ACCOMPANIED BY BARBARA SIGFORD, M.D., PH.D., NATIONAL PROGRAM 
  DIRECTOR FOR PHYSICAL MEDICINE AND REHABILITATION, VETERANS 
  HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
GLENN COCKERHAM, M.D., CHIEF OF OPHTHALMOLOGY, VETERANS AFFAIRS 
 PALO ALTO HEALTH CARE SYSTEM, VETERANS HEALTH ADMINISTRATION, 
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY GREGORY L. 
    GOODRICH, PH.D., SUPERVISORY RESEARCH PSYCHOLOGIST AND 
 COORDINATOR, OPTOMETRY RESEARCH FELLOWSHIP PROGRAM, VETERANS 
     AFFAIRS PALO ALTO HEALTH CARE SYSTEM, VETERANS HEALTH 
 ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; COLONEL 
   (P) LOREE K. SUTTON, M.D., USA, SPECIAL ASSISTANT TO THE 
ASSISTANT SECRETARY OF DEFENSE (HEALTH AFFAIRS), PSYCHOLOGICAL 
HEALTH AND TRAUMATIC BRAIN INJURY, AND DIRECTOR, DEPARTMENT OF 
   DEFENSE CENTER OF EXCELLENCE FOR PSYCHOLOGICAL HEALTH AND 
TRAUMATIC BRAIN INJURY, DEPARTMENT OF THE ARMY, U.S. DEPARTMENT 
 OF DEFENSE; AND MAJOR GENERAL GALE S. POLLOCK, DEPUTY SURGEON 
  GENERAL FOR FORCE MANAGEMENT, AND CHIEF, UNITED STATES ARMY 
NURSE CORPS, DEPARTMENT OF THE ARMY, U.S. DEPARTMENT OF DEFENSE

                STATEMENT OF JAMES ORCUTT, M.D.

    Dr. Orcutt. Good morning Mr. Chairman and Subcommittee 
Members. I also wanted to acknowledge the testimony of the 
veterans previously and I also wanted to praise their service 
to our country, after all that is really why we are here is to 
provide the highest quality and safest care to our veterans.
    I also want to thank you for the opportunity to discuss the 
Department of Veterans Affairs provision of care for veterans 
needing support for visual impairment and traumatic brain 
injury.
    I am joined by Dr. Barbara Sigford, and I will be doing the 
oral presentation for the both of us. She is the National 
Program Director for Physical Medicine and Rehabilitation and I 
would also request that a written statement be placed into the 
record.
    The Veterans Health Administration has developed one of the 
most extensive rehabilitation programs and systems in the 
country for visual impairment, and our work in treating TBI, 
dating back to the creation of four National TBI centers in 
1992, is unmatched. Our Polytrauma System of Care is uniquely 
positioned to address the complex needs of veterans and 
servicemembers exhibiting these two conditions, and others, 
simultaneously. My testimony today will provide an overview of 
the continuum of care VA provides veterans and servicemembers 
to ensure they receive the right care, in the right way, at the 
right time, to further their goals of rehabilitation and 
reintegration.
    I would like to begin by noting that VA is aware of the 
preliminary work being done in Palo Alto. And we are interested 
in all efforts to expand our understanding of TBI related 
visual impairment.
    We must stress, however, that this data is from a small 
select population. Sampling in a larger cohort with scientific 
scrutiny must demonstrate the same results before a system wide 
changes would occur.
    Future research would include pre-injury data on visual 
functioning and longitudinal analysis to determine if 
conditions improve naturally over time. We want to be certain 
that any changes in our care are to the benefit of our veterans 
and reflect the best scientific evidence available.
    The VA continually reviews and improves our care for these 
wounded and injured warriors. In the area of visual impairment 
the VA hosted a conference in December of 2007 with the 
Department of Defense on the visual consequences of traumatic 
brain injury. This conference was attended by members of the 
visual team for each Polytrauma Rehabilitation Center as well 
as blind rehabilitation specialists, optometrists, and 
ophthalmologists from both departments and provided an 
opportunity to initiate a consensus validation process.
    This validation process will identify and disseminate the 
most effective strategies for treatment when they are known or 
to determine where our additional research is needed.
    The VA has also assembled teams of specialist to develop 
questions for determining evidence based treatments. We 
anticipate this process will be complete in the summer.
    The VA holds an annual conference, portions of which are 
jointly conducted with the Blinded Americans of America who are 
experts and BVA representatives can discuss new treatment 
methods and further areas of cooperation.
    The VA has developed several initiatives to facilitate the 
ease of transfer for veterans and servicemembers transitioning 
from the military service in Operation Enduring Freedom and 
Operation Iraqi Freedom.
    For example blind rehabilitation service involvement often 
begins when the injured servicemember is still a patient at a 
military treatment facility. The patient is transferred to a VA 
Blind Rehabilitation Center as soon as it is medically 
indicated, and at the patient's request. There is no waiting 
time for these OEF or OIF patients in Blind Rehabilitation.
    VA's four regional Polytrauma Rehabilitation Centers 
provide the most intensive specialized care and comprehensive 
rehab available for combat injured patients transferred from 
military treatment facilities. As veterans recover and 
transition closer to their homes the polytrauma system of care 
provides a continuum of integrated care to 21 polytrauma 
network sites and 76 polytrauma support clinic teams. Any OEF/
OIF veterans seen at a VA medical facility is automatically 
screened for TBI with a 22-item checklist. Veterans for whom 
the screen is positive are referred for a full, in-depth 
evaluation. The evaluation process includes a standardized 
evaluation template for common problems following brain injury. 
This template includes checks for visual impairment. Our visual 
treatment specialists conduct comprehensive visual examinations 
for findings associated for blast injuries, including but not 
limited to, visual acuity, visual field testing, pressures 
within the eye, imaging of both the retina and the cornea to 
assess damage to these structures and abnormalities of eye 
movements.
    Currently, 164 Visual Impairment Service Team coordinators 
provide lifetime case management for all legally blind 
veterans, and all OEF/OIF patients with visual impairments. 
Additionally, 38 Blind Rehabilitation Outpatient Specialists 
provide blind rehabilitation training to patients who are 
unable to travel to a blind center.
    Each Polytrauma Rehab Center and Polytrauma Network site 
has dedicated funding for a Blind Rehabilitation Outpatient 
Specialist on the Polytrauma team.
    I want to thank you again for the opportunity to meet with 
you today and that ends my remarks and I would be happy to 
answer questions at the appropriate time.
    [The prepared statement of Dr. Orcutt appears on p. 64.]
    Mr. Mitchell. Thank you very much.
    Dr. Cockerham.

               STATEMENT OF GLENN COCKERHAM, M.D.

    Dr. Cockerham. Chairman Mitchell, Ranking Member Brown-
Waite, and Members of the Subcommittee, thank you for this 
opportunity to testify. I am accompanied today by my colleague, 
Dr. Gregory Goodrich, Research Psychologist and Coordinator of 
the Optometry Research Fellowship Program at the Western Blind 
Rehabilitation Center in Palo Alto California.
    We are here today to discuss our research on vision issues 
and traumatic brain injury. This research was conducted at the 
Palo Alto Polytrauma Rehabilitation Center and Polytrauma 
Network Site on samples of just over 100 patients, including 
both veterans and active duty servicemembers. A common injury 
of Operation Enduring Freedom/Operation Iraqi Freedom veterans 
with polytrauma is traumatic brain injury caused by explosive 
devices. The precise incidence of eye injuries and visual 
disability occurring in operation OIF and OEF is currently 
unknown.
    The VA's Polytrauma Rehabilitation Centers recognize the 
importance of early intervention for visual impairment and 
structured interdisciplinary teams to include blind 
rehabilitation specialists. In addition neuro-ophthalmology was 
identified as a key consultative service.
    All Polytrauma Rehabilitation Centers conduct eye 
examinations on their patients as needed. Dr. Goodrich and I 
began studying this area after noticing abnormalities in visual 
function as well as ocular injuries despite normal or near 
normal visual acuity. Our research seeks to determine if this 
patient population is typical of other veterans and 
servicemembers with polytrauma.
    Before continuing I must note that this is preliminary 
research and much more work needs to be done to determine 
conclusively the risks for this population.
    Our research is focused on two groups. First, veterans and 
servicemembers receiving inpatient care at the Palo Alto 
Polytrauma Rehabilitation who have sustained visual impairments 
associated with life threatening polytrauma injuries. And 
second, outpatients receiving care at the Palo Alto PNS who 
have visual dysfunctions associated with mild traumatic brain 
injury. While the inpatient and outpatient groups may seem far 
apart in terms of the severity of their injuries, they do share 
two common factors: the most common cause of injury in both 
groups is a blast event, and both groups have sustained a 
traumatic brain injury, of varying levels of severity. Our 
preliminary research suggests both groups may have increased 
rates of visual impairment or dysfunction.
    Among the Palo Alto polytrauma patients with moderate to 
severe traumatic brain injuries studied, those with injuries 
stemming from a blast event were about twice as likely to have 
a severe vision impairment, including blindness, as were those 
whose injuries were caused by all other events.
    In my research looking specifically at veterans in the 
Polytrauma Rehabilitation Center with traumatic brain injury 
caused by combat blast, abnormalities in visual field and 
contrast sensitivity were discovered in some patients despite 
normal or near normal visual acuity by conventional testing. 
Eye examinations by ophthalmologists and neuro-ophthalmologists 
detected damage to vital eye structures including cornea, 
retina, and optic nerve that could result in visual loss in the 
future.
    In other patients in this population, problems such as 
double vision, inability to track moving objects effectively or 
to focus normally were present. The long-term significance of 
these findings is not known.
    In conclusion, I wish to emphasize that our testimony is 
based upon findings from early studies with relatively small 
and selected population samples. This data is not definitive 
and conclusions should not be drawn from it. The need for 
additional study is recognized. Our preliminary data has 
allowed us to obtain funding from VA to enlarge our study 
group, to develop a comparison group, and to determine the 
natural history of our findings over time.
    Understanding these visual injuries and developing an 
evidence base for treatment has involved a collaborative effort 
utilizing the expertise and resources of many disciplines. VA's 
experience with vision related injury and impairment supports 
the claim that many of these patients can be effectively 
treated.
    Thank you again, Mr. Chairman, for inviting us today. That 
concludes my oral testimony.
    [The prepared statement of Dr. Cockerham appears on p. 67.]
    Mr. Mitchell. Thank you.
    Colonel Sutton.

      STATEMENT OF COLONEL (P) LOREE K. SUTTON, M.D., USA

    Colonel Sutton. Good morning Mr. Chairman and distinguished 
Members of the Committee, thank you so much for inviting us 
today to offer insights on the Department's progress in 
establishing a Center of Excellence for Visual Impairment and 
Ocular Injuries.
    I am accompanied today by Major General Gale Pollock who is 
the Deputy Surgeon General for Force Management and also the 
Chief of the Army Nurse Corps.
    Most importantly for our purposes today General Pollock has 
been absolutely a pioneer in this effort, this campaign to 
improve care and research and treatment for our warriors who 
are suffering from visual impairment related to any cause 
including combat injury.
    As the Director for the Center of Excellence (DCoE) for 
Psychological Health and Traumatic Brain Injury, I have a deep 
and abiding commitment to the development of this new center as 
vision impairment often results from traumatic brain injuries.
    Visual experts in both the military and Veterans Health 
Affairs' Systems have recognized the importance of the 
continuum of ocular care and have initiated essential 
coordination and collaboration efforts. As you know, 
revolutionary lifesaving care results in sharply increased 
survival rates. That in turn means that profoundly injured 
patients reach facilities in the United States where they 
require extensive care and rehabilitation. We have amputee care 
centers and we continue the process of establishing the 
psychological health and traumatic brain injury centers to 
focus more specifically on the breadth of care required by our 
warriors suffering these injuries.
    As we examine the many injuries suffered by our warriors, 
we find that a significant number have sustained visual 
impairments such as those suffered by Staff Sergeant Pearce and 
Petty Officer Minney today.
    I would just like to take a moment to thank those two 
individuals as well as Ms. Angie Pearce for coming forward and 
exercising the courage to tell their stories that we together 
can learn from them and do better. We owe them our best.
    In addition to visual deficits caused by direct injuries to 
the eye, visual problems also may present in individuals 
suffering traumatic brain injury. This may include injury due 
to repeated mild concussion as well as other more severe 
traumatic brain injuries. TBI can disrupt the visual process 
interfering with the flow and processing of information. Visual 
problems resulting from TBI can be overlooked during initial 
diagnosis and treatment of the injury. Frequently these visual 
problems are subtle and when neglected they can lengthen and 
even impair rehabilitation.
    To meet the needs of wounded warriors who require 
definitive treatment and rehabilitation for visual impairment 
the Department is currently reviewing a comprehensive concept 
for the Congressionally directed Center of Excellence for 
Vision.
    This proposal depicts the Center as a central hub for 
coordinating a program or network of excellence with multiple 
sites located throughout Departments of Defense and Veterans 
Affairs to ensure a holistic spectrum of rehabilitation, 
technology, education, research, and compassionate care. This 
new visual program will provide our visually impaired wounded 
warriors with individualized treatment and rehabilitation 
tailored to traumatic injury to the eye and visual nervous 
system.
    Clinical activities of this center as in the other centers 
will be bolstered by an active research capability having 
strong ties to leading academic, private and international eye 
injury research centers.
    This research capability will allow the latest advances in 
care, technology and rehabilitation to be rapidly integrated 
into the center's programs, best practices and guidelines. The 
Department proposes expansion of its current network of 
research partners with an increased investment in technologies 
focused on preventing, diagnosing and restoring visual function 
lost due to trauma.
    The role of the center with its collaborative networks 
within the military and the veterans systems and the private 
sector, its research programs, its development of best 
practices, and clinical guidelines, its training for 
caregivers, its outreach to families for inclusion in patient 
rehabilitation plans and importantly its advancement for 
prevention, care, treatment and rehabilitation will underscore 
its value as a national asset.
    In closing, Mr. Chairman, eye injuries resulting from 
combat do demand an integrated and holistic response for 
prevention, treatment, education, surveillance and research. 
The Department's concept for this state-of-the-art, full 
spectrum, world class program of care with programs and 
research aimed at both near and long term improvements will 
meet that demand. Success is generated by integration of 
research, treatment and rehabilitation capabilities pioneered 
through this concept. It can transition throughout the military 
in veterans health systems and to the private sector where 
these improvement will benefit our Nation as a whole.
    Thank you, Mr. Chairman and distinguished Committee 
Members, for your strong interest and dedicated concern for the 
health and well-being of our warriors and for providing the 
resources needed to help us help them return to productive 
lives.
    We are reminded that no condition or disease is rare for 
the individual who suffers from it. I think you will agree with 
me that it is time for a little less talk and a lot more 
action. Together we will keep after it, our warriors deserve 
our best. At this time, Mr. Chairman, I would be happy to 
answer your questions.
    [The prepared statement of Colonel Sutton appears on p. 
69.]
    Mr. Mitchell. Thank you very much. I would also like to ask 
General Pollock if she would like to make any statements.

           STATEMENT OF MAJOR GENERAL GALE S. POLLOCK

    General Pollack. Thank you. I'd like to thank the Committee 
for being willing to look at what has traditionally been an 
area that has been left and pushed aside in healthcare because 
vision rehabilitation has been so difficult.
    So I'm delighted that all of you are interested in that. 
And I'm also very pleased that our servicemembers and their 
families were willing to come here and share their stories and 
continue to support one another. The buddy care that they 
continue to do is truly amazing.
    I have been delighted in the last couple of weeks--months 
to be officially, as of last week, designated as the Conceptual 
Director of the Center of Excellence for Vision. And I have 
some good news that I would like to report over that, because 
although there is no policy, although there has been no over 
guiding direction from either one of the departments, the 
people that do patient care everyday have been very engaged 
with one another.
    Starting last summer, they began working together and in 
September there was a combined DoD/VA Visual Professional 
seminar out in Seattle. And then in December there was the VA/
DoD Visual Consequences of Traumatic Brain Injury, that was 
attended by over 500 people from the militaries, from the VA, 
from other government agencies and there were international 
participants as well as we tried to draw together all of the 
people who had information that could help us move forward.
    The Army has been engaged in some of this because of the 
blast injury research that has been ongoing and that work up at 
Medical Research and Materiel Command (MRMC) is going to be 
instrumental in our future because we have to look at the 
mitigation of these injuries whenever that is possible.
    The other piece that I think is very good news is we have 
identified the different data sources that might have 
information about any of these servicemembers who are suffering 
from visual challenges. And we are now running them together to 
say, okay, have we missed anyone. Are there people that are 
falling through the gaps.
    So the clinicians are very, very engaged. We have the IT 
people engaged and I think that you will be pleased with the 
progress that we will be able to make over the next few months.
    Thank you.
    Mr. Mitchell. Thank you. I have a couple quick questions. 
First to those of you from the Palo Alto, do you recommend 
testing and follow-up for all patients that have had TBI, blast 
induced TBI?
    Dr. Cockerham. I can only speak for the population, Mr. 
Chairman, that we are currently working with and it is our 
practice to do that at Palo Alto and it is certainly our 
practice as part of the study that we see everyone that is an 
inpatient. I am restricting myself to the inpatients and 
perhaps Dr. Goodrich can.
    Mr. Mitchell. Kind of a follow up to that. Do you know if 
there are any other polytrauma centers doing the same thing or 
is it just Palo Alto?
    Dr. Cockerham. I am not--I cannot speak to that, I can only 
speak to Palo Alto. The other PRCs have ophthalmology and 
neuro-ophthalmology and optometry staff. But as to their 
current practice I cannot speak.
    Mr. Mitchell. So all the research that is being done is 
being done in Palo Alto?
    Dr. Cockerham. That is the only one that I am aware of in 
this particular population, yes, sir.
    Mr. Mitchell. Thank you. Colonel Sutton or General Pollock, 
either one, in the 2008 National Defense Authorization Act, it 
directed the VA and the DoD to develop a cooperative program 
for servicemembers and veterans with TBI for ``vision screening 
diagnostics, rehabilitating management and research.'' Now the 
question is, why would you want to separate the vision center 
from the TBI Center for Excellence?
    General Pollack. Sir, I believe there were two different 
issues. There definitely needs to be attention directed at the 
visual consequences of traumatic brain injury and that must 
work in very, very close collaboration with the Center of 
Excellence for TBI but there are other injuries that are not 
the result of TBI that also require care. And collectively 
across the VA and DoD we felt that all of those patients who 
have visual injuries should be addressed in that Center of 
Excellence.
    Mr. Mitchell. You know earlier we heard two servicemen who 
fell through the cracks because they had nothing that 
physically looked like they had an eye injury. How are you 
going to address these kinds of issues if you separate and say 
well we assume that those people who do not have any physical 
impairment with their eyes then they will go to traumatic brain 
injury, the center for excellence there. How would you ever 
check?
    General Pollack. Sir, I believe that the clinical 
guidelines and the evidence based practice parameters that we 
are looking at now will require that everyone be screened 
rather than waiting for people to make a complaint to say, gee, 
I think that something has changed. And that is where the 
research that is being done now is really going to help us 
because we will understand what changes we should expect; 
therefore, what are the most appropriate screening tests to be 
done. But I think that it is not going to be just those who are 
blast injured. We have a significant number of men and women in 
the services who are very actively engaged in sports. We have 
head injuries as a result of sports. Motor vehicle accidents. I 
think some of the second and third order effects of the work 
that these clinicians and researchers are doing, is going to 
demonstrate other gaps in our healthcare system that we need to 
address so that we can ensure after people are injured for any 
reason, we can return them to their maximum level of 
functioning.
    Mr. Mitchell. Will you be testing all blast induced TBIs 
for vision care?
    General Pollack. I pause simply because I want to really 
look at the research, because one of the pieces that we look at 
is how are you exposed to the blast. If you were in a vehicle 
in a convoy and one of the vehicles was affected by a blast, 
how do we define your exposure to blast. And we have not 
defined that well yet. You know, how close do you have to be? 
What kind of physical changes do you manifest as a result of 
the blast? It is not just the psychological exposure of, I was 
in a convoy that had IEDs go off. And I don't think that we 
have done a complete analysis yet of what that space needs to 
be. That is certainly why we are putting the little manometers 
on helmets now, to help determine, what is the intensity of a 
blast so we can then look to see, gee, what does the data show 
us. Unfortunately we do not have answers to a lot of these 
questions and that is why it is so important that we do the 
research and truly make it evidence based so that we are doing 
the best that we can for the men and women that are serving.
    Mr. Mitchell. One thing that I heard from the testimony 
earlier was that there was a 10-month gap from the time the 
person was injured until they finally recognized that he needed 
to go to have some screening. And this occurred outside, it was 
not inside a vehicle. From what I understood the blast occurred 
and he ran up against a rail. And we also heard that it was 
important that the quicker people get therapy, the quicker they 
can be healed. So if we are spending an awful lot of time 
trying to find out what kind of blast, how was the blast, where 
were they, we could be losing valuable time. And as I heard 
earlier, 70 percent of our senses are sight. This is pretty 
dramatic.
    Colonel Sutton. Mr. Chairman I would certainly share your 
concern as well as your urgency. The research is absolutely 
essential but we are not waiting to get the results back from 
the research. We have already launched the MACE Test, which is 
the Military Acute Concessive Evaluation Scale which is being 
implemented throughout theater. What that does then is when a 
unit comes back or a squad comes back from patrol, if they have 
been exposed to a blast, their leader then will have them fill 
out that concessive evaluation. That is entered then to become 
part of their medical record. And then at any other point where 
they receive medical care or when they go through the variety 
of screening mechanisms that we have in place now which do 
include the pre-deployment health assessment, and post 
deployment health assessment. Also, we realized back in 2005 
that a number of our soldiers coming back from deployment, 
waited between the assessments and seeing their families and 
going on block leave after a year in combat. They were not 
eager to spend a lot of time going through surveys and hearing 
briefings. So the post deployment health reassessment program 
has been another really important opportunity, between that 90- 
to 180-day window, to again, address issues related to the 
kinds of problems they are having, headaches, blurred vision, 
dizziness. It is a chance for every solider to sit down with a 
healthcare professional and review their health status.
    The yearly now periodic health evaluation is another time 
that we address the health status with our warriors and their 
unit leaders. So there are a variety of opportunities along the 
way as well as, of course, any warrior can go to sick call on a 
daily basis to access healthcare if they are having an acute 
problem.
    So we are absolutely focusing our efforts at this point to 
educate our providers so that they know to be sensitized to the 
connection between traumatic brain injury and visual impairment 
and ocular injuries. We are also developing that system with 
the MACE that I described for you that will allow us to have 
documentation in the medical record at the time of the blast 
that this servicemember has been exposed.
    Mr. Mitchell. Two very quick ones. One, is DoD doing any 
research or is it just the VA doing research on this?
    Colonel Sutton. No, the DoD absolutely is doing research on 
this and in fact we had a number of studies that were funded in 
this last year's Broad Agency Announcement which was just 
completed. In fact I have the records here, sir, which I will 
be glad to submit for the record that shows all of the DoD 
funding.
    Here is our challenge though. In the past, much of that 
funding has been for visual impairment due to illness as 
opposed to blasts. And so we are now looking, starting with 
this year's program, to expand that focus and then as we 
develop the Broad Agency Announcement for this coming year, we 
will likewise expand our focus to make sure that this essential 
area of knowledge becomes part of our research program to a 
greater extent than ever before.
    Mr. Mitchell. And one last comment. We heard this morning 
and we have heard at every one of these hearings the lack of 
continuity of records flowing from DoD to the VA and the 
corpsman carried his own. He knew better.
    That is something that we have to continually improve on 
because no one can get the full medical care they need unless 
the physician has all of the records. And so that is something 
that has to be improved upon between the two departments.
    Colonel Sutton. Thank you.
    Mr. Mitchell. Mr. Wu.
    Mr. Wu. Thank you, Chairman Mitchell, for extending Ms. 
Brown-Waite's request and the courtesy of counsel being able to 
ask questions. But with your permission I would defer my line 
of questioning until after Dr. Boozman since he has the degree 
and the specialty in the area.
    Mr. Boozman. Thank you very much. First of all I want to 
thank all of you. I know how hard you work to take care of our 
soldiers and really are doing a good job and it is a very 
challenging job especially as we start to see things that we 
have never seen before. And I know in visiting with our 
optometrists and ophthalmologists, you know, the way we got 
involved in this is that they were concerned that they were 
seeing a class of patients that outwardly everything seemed to 
be normal and yet they could not concentrate. They could not 
scan the way they were before. You can imagine if you are a 
National Guardsman and you were an accountant or a top English 
or really whatever your profession was and all of a sudden you 
came home and you could not concentrate or whatever and then 
that becomes very frustrating and it can cause all kinds of 
problems.
    So I think that is why--you know, you alluded to a lot of 
different things. I think that is why the registry is so 
important. You know, that we can link certain entities. You 
know, certain symptoms with what is going on. And so I hope 
that we are proceeding on. You made the statement, you know, a 
lot less talk and a lot more action and I think that really is 
the key. What I want, as I alluded to earlier, is that if an 
individual--I was in Iraq last weekend, and what I want is if 
one of those guys goes through any sort of injury, eye injury 
or whatever, but we are talking about eye injuries today, that 
they will get treatment based on what we know now. Because we 
do know a lot more about this and hopefully we are 
disseminating that information so that when these guys come 
back with these injuries, we will be able to treat them better 
and then also be able to rehabilitate them better. And then the 
other part of that is to prevent them better. If we can figure 
out exactly how to link whatever. So I am really excited about 
this. And again the things I want to know I think the concept 
is great. The question is, though that we have to get it done. 
Not getting it done in a fairly short timeframe really is 
inexcusable.
    How are we with funding and stuff? Do we have the money? 
Are you going to come to us next year and say well we wanted to 
do this but we could not because we did not have any money?
    Colonel Sutton. Sir, I will need to take that one for the 
record. As you know we support the President's Budget, but we 
would certainly be glad as we develop this concept and get it 
approved in the very near future which is certainly the plan. 
In fact I would say, and I'll let General Pollock comment on 
that, but within just the very near future this concept will be 
presented to the Assistant Secretary of Defense for Health 
Affairs, Dr. Cassells. And upon approval of the final plan then 
certainly we will figure out the kinds of funding and support 
that will be required to execute it.
    I can assure you sir that it is not our intent to come back 
next year without any action this year.
    [The following information from DoD was subsequently 
received:]

        Preliminary estimates for the Department of Defense Ocular 
        Center of Excellence initiative are $3 million for Fiscal Year 
        2009 and funds are available within the Defense Health Program.

    Mr. Boozman. I guess my answer to that is that you do send 
these guys in harm's way, and this is something that--I mean, 
we pass supplementals, we do this and that. We provide body 
armor, we do the whole bit as we're asked to do. But there is 
no excuse for not taking care of them once we know that this 
problem is there. I mean that makes no sense to me at all and 
it is indefensible. I cannot defend that. So like I say, I know 
that you are working hard but again if we do not do this 
knowing that it is out there. If we are not able--knowing the 
testimony that we had earlier and then again--and those were 
pretty blatant cases. The ones that are really hard the 
questionable symptoms, you know, where this and that, that are 
much--that are a little bit harder sometimes to figure out 
although that can be equally as troublesome in the performing 
of their job and whatever. But like I say, we need to get this 
done and I know I am committed. The Committee is committed. 
This is a VA Committee and I know that you are DoD, but again 
it is just something that we have to get done. So have you got 
a time line for us?
    General Pollack. The expectation is that I will be 
presenting the next steps in how we would move forward on the 
17th of April to combine DoD and VA panel. The same group that 
met together about, just about a month ago, asking me to put 
that together. And then they will be identifying the lead for 
that to be able to take that forward.
    Mr. Boozman. So, will you be in charge of that, General 
Pollock, or is that your deal?
    General Pollack. I will be coordinating it for the next few 
weeks. I go to a retirement position effective the third of 
July.
    Mr. Boozman. So who is taking your place?
    Colonel Sutton. No one can take Major General Pollock's 
place, sir.
    General Pollack. There has not been anyone identified at 
this time, sir. We will be talking about that on the 17th when 
we get together.
    Mr. Boozman. So Dr. Sutton and you will be----
    General Pollack. She will be at that meeting as well.
    Colonel Sutton. There is no question the interaction, the 
collaboration, the support, not only within DoD, surrounding 
these issues, but of course as you have heard today with our 
partners in the VA system and within the civilian sector at 
large, it is absolutely essential whether the concern is 
traumatic brain injury in general, visual disturbances as a 
result of TBI, psychological health, whatever is ailing our 
wounded veterans and of course their families, we are there 
sir.
    Mr. Mitchell. Okay, so I guess the other questions then is, 
very quickly, you are happy with the structure of the law, the 
structure of the concept, as far as the Eye Center of 
Excellence. I mean we are all in agreement with the things that 
need to get done. Is that right? And we are in agreement with 
the collaboration between VA and DoD helping out?
    Dr. Orcutt. I can comment on that too, I am very happy with 
it. In fact, I was the VA representative to the February 28th 
meeting. Met with the DoD several times and they strongly 
encourage that ongoing collaboration. It was not something I 
had to force on them to be in there. It is an open and free 
meeting. We started on this project between my compatriot in 
the Army last summer because we recognized we needed this 
registry. We needed to move forward. So we started with all the 
meetings that we have already mentioned. We are having ongoing 
conference calls twice a week with DoD people. We are moving 
very rapidly in order to work toward the registry and also in 
great cooperation with the DoD. And I could not, frankly, be 
happier than what I have seen in terms of the willingness and 
ability to work hand-in-hand with the DoD folks that are in 
charge of this. So, I am very pleased.
    Mr. Boozman. Good. Thank you very much. The only other 
thing is hopefully in the not too distant future, you can have 
us out, Dr. Sutton, and kind of show us what is going on. And 
we will go from there.
    Colonel Sutton. Sir, thank you so much. I would be 
delighted to have you folks out. And as you mentioned and just 
been affirmed by the VA, we are all in this together. There is 
no daylight between DoD and VA on this issue. We are absolutely 
committed to providing the very best for our warriors and their 
families.
    And of course, sir, as you well know, today's best is just 
that. It is not good enough. We have to keep making it better 
and better. Thank you so much.
    Mr. Boozman. Thank you very much. Thank you, Mr. Chairman.
    Mr. Mitchell. Thank you and thank you very much. I 
appreciate that. One thing that I was struck with that I think 
is important, was when I was in Iraq in January, we were told 
by a commander that in this day of voluntary military service, 
they do not just recruit a soldier anymore, they recruit a 
family. And that is so important because the family is an 
important part of the whole healing process. And to hear what 
went on this morning, the couple that have a 10- and 9-year-
old. And they are up in Alaska. We really need to treat the 
family just as we do the individual soldier. They are an 
important part--they are in this together. And I appreciate 
that. And I appreciate all of you and the research you are 
doing and the work you are doing and I thank you and that 
concludes the hearing.
    Mr. Boozman. Can I just----
    Mr. Mitchell. Sure.
    Mr. Boozman. Dr. Sutton and General Pollock alluded to a 
meeting that you are going to have. Could you follow-up with us 
in writing about how that went----
    General Pollack. Certainly.
    [The information from DoD follows:]

        The purpose of the meeting referenced by Mr. Boozman was to 
        determine who would replace Major General Pollock as the lead 
        for the Vision Center of Excellence. The scheduled meeting 
        between Major General Pollock and Brigadier General Sutton did 
        not occur. The Assistant Secretary of Defense for Health 
        Affairs initiated a nomination process to select a leader for 
        the Center who would report directly to the Director, TRICARE 
        Management Activity. Colonel (Dr.) Donald Gagliano was selected 
        as the Director, Vision Center of Excellence and Dr. Claude L. 
        Cowan was selected as Deputy Director.

    Mr. Boozman. Okay. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Mitchell. I am sorry.
    Mr. Wu. Thank you, Chairman Mitchell.
    A couple of things in conjunction. You got your question, 
Dr. Boozman?
    Mr. Boozman. Yes.
    Mr. Wu. Dr. Cockerham, Dr. Goodrich, good to see you again 
from Palo Alto.
    I see in the testimony you had here, specifically in the 
work done by Dr. Cockerham, looking specifically at a small 
sample population, the PRC with TBI. TBI caused combat blast, 
that there were significant abnormalities and visual function 
were found despite normal or near normal visual acuity by 
conventional testing.
    I think that when the staff, Geoff Bestor and I were there, 
the question came up, if that is documented in your population 
and is replicated in a larger sample, the question came up 
should there be redeployment of those soldiers, the 
servicemembers that are going to be redeployed after being 
subjected to IED and perhaps MTBI and whether they should be 
redeployed or not.
    Would you like to comment on that?
    Dr. Cockerham. I think it is a little outside of my sphere. 
I can speak specifically about the problems we are finding in 
the small sample we have looked at so far if that would be 
helpful. But the ramifications of that to the larger system, I 
do not know that I can shed much light on that.
    Mr. Wu. Colonel Sutton.
    Colonel Sutton. Sir, I would definitely agree that we need 
to expand the research that has been started at Palo Alto. I 
think we need to expand it to both populations that are in the 
other polytrauma centers as well as at places, oh, say, Fort 
Lewis or Fort Hood, places where you have a large power 
projection platform and where you can see in a more general 
population of warriors who are coming back who have not been as 
severely wounded, but we need to better understand the entire 
spectrum of and continuum of care as well as depth----
    Mr. Wu. Right. I understand that.
    Colonel Sutton [continuing]. Of the injury.
    Mr. Wu. The question I have is, if, in fact, you have 
documented TBI----
    Colonel Sutton. Yes.
    Mr. Wu [continuing]. On a servicemember that has been in 
theater and there might be documentation or it looks like the 
possibility that there is some abnormality that has manifested, 
should they be redeployed without some more intensive and 
conclusive testing, whether it be optometric or 
ophthalmological, before they are redeployed?
    I think on Chairman Mitchell's CODEL in January, we came 
across servicemembers that had been exposed to multiple IEDs 
and were on their second and third deployment.
    Colonel Sutton. Yes, sir. I would absolutely agree for 
those soldiers for whom we know that they have been exposed to 
repetitive blasts or even a single blast with a sufficient 
magnitude to cause serious injury, there is no question but 
what further evaluation would be in order. And that is why we 
have the pre-deployment checks that are in place as well as the 
post-deployment. And we will continue to learn as we go from 
the research, but we are not waiting for the research results. 
We are moving forward in that effort.
    Mr. Wu. Can we ask then when a servicemember comes back 
from theater or in theater that is subject to an IED or EFP, 
are they then seen by an ophthalmologist or an optometrist or 
are they just going through the assessment form, self-
assessment form?
    Colonel Sutton. When they come back and go through the 
post-deployment health assessment, if they are having any 
health problems, they are evaluated. They are actually 
evaluated by a primary care provider. They are going through 
the screening process. And any difficulties that they identify, 
if they require specialty referral, then they certainly get 
that specialty referral.
    Now, the case that you mentioned, sir, which certainly 
concerns all of us, might be that warrior who is coming back 
and perhaps does not at that point realize that they have some 
sort of visual impairment or processing impairment perhaps 
related to a traumatic brain injury, and that is where we are 
really focusing our efforts right now to increase our knowledge 
so that we can determine best how to identify and meet the 
needs of those individuals.
    But certainly for anyone who is experiencing symptoms, 
whether that be headache, blurred vision, dizziness, et cetera, 
they are absolutely evaluated at that time and referred as 
needed.
    Mr. Wu. All right. I failed to mentioned we had earlier 
brought to the attention of Ms. Brown-Waite that you are 
promotable. When do you pin your star on?
    Colonel Sutton. Sir, I feel way humbled and way blessed to 
become a Brigadier General on Friday, the 9th of May.
    Mr. Wu. That is great. Congratulations.
    Colonel Sutton. Thank you so much, sir.
    Mr. Wu. Dr. Orcutt, you know, I heard you say that there is 
a lot of collaboration and Kumbaya between you and DoD. I have 
been here for 14 years. I am looking at DoD/VA collaboration. 
That is the most positive thing I have heard in 14 years.
    I mean, besides----
    Dr. Orcutt. Okay.
    Mr. Wu. Besides collaborating on the registry, what goes 
beyond that in this collaboration? I think you need to do more 
than a registry. I mean, that is my personal and professional 
opinion.
    Dr. Orcutt. Well, absolutely. I think that the cooperation 
we have had with the DoD and working with the VA input into 
what should be components of the Eye Center of Excellence 
within the DoD, there are all the types of things that General 
Pollock has already talked about, the increased research, the 
increased education, dissemination of information, best 
practices, dissemination.
    But I think that is what I feel is going to be so positive 
about this center is that with both sides being involved, we 
are going to have this information and research developed on 
both sides distributed on both sides.
    The other great thing is on the eye care registry side is 
the notion of this being a bidirectional information flow. It 
does not start in the DoD and end in the VA. It starts wherever 
a patient is first identified and flows both ways.
    And so the DoD can do a lot more of their preventative 
research based upon some of the longitudinal long-term outcomes 
of their veterans that they cannot do now because of shorter-
term follow-up.
    There are so many advantages to the registry that it is 
just almost impossible to list them all, not the least of which 
is professional----
    Mr. Wu. The other question I have is, Colonel Sutton 
mentioned there was some research being done on the DoD side. 
You said that there is research being done on the VA side with 
Dr. Cockerham and his fellow practitioners.
    Can you identify any of this research that is 
collaborative?
    Dr. Sigford. I think we should take that for the record. We 
have specific research departments in the VA and in DoD. And I 
would like to request that we search those databases to look 
for this and take that question for the record.
    [The following was subsequently received from VA:]

        Question: Are VA and DoD cooperating on any research projects 
        on TBI-related vision issues?

        Answer: While the Department of Veterans Affairs (VA) and the 
        Department of Defense are independently funding a number of 
        research projects, VA is unaware of any jointly funded efforts 
        concerning TBI-related vision issues. Joint work could be 
        ongoing at a local level or through independent support.

    Mr. Wu. That is fine, Dr. Sigford, but there is nothing 
that comes to your mind immediately?
    Dr. Sigford. Not directly, no.
    Mr. Wu. Dr. Cockerham.
    Dr. Cockerham. No, sir, not at this time.
    Mr. Wu. Would it be safe to say that there is probably no 
collaborative research at this time to the best of your memory 
and experience? Anyone on the panel?
    Colonel Sutton. Sir, I think we can improve our efforts in 
this area. Certainly with the supplemental funding that came 
out last year for the broad agency announcement encompassing 
both traumatic brain injury as well as psychological health 
issues, I can assure you that we will ensure that there are 
collaborative efforts this next year involving both VA and DoD.
    As Dr. Sigford said, there may well be some already. I am a 
psychiatrist, not an ophthalmologist, but I will certainly look 
into this to figure out what we can do.
    General Pollack. I do know that there is work going on with 
the VA center that is in Seattle and Madigan Army Medical 
Center. Their optometrists, their ophthalmologists are working 
at both facilities dealing with patients and following them 
across. I would expect that there are initiatives up there at 
least.
    One of our challenges, I think, is that we are not always 
collocated with one of the VA polytrauma centers, so it makes 
it more difficult to do some of the immediate research. But 
since so often our staff are also doing training at the VA 
facilities, I would expect that there are levels of research 
that are being done now that are simply not visible at our 
levels. But we can get back to you.
    Mr. Wu. That is great. I just would hate to see you all 
plowing the same north 40.
    Dr. Sigford. Right. And I would like to also make one 
comment in that in the VA, we have what is called the 
Polytrauma and Blast-Related Injury Query which is a quality 
enhancement research initiative.
    We have on our executive panel members of the DoD. And this 
is really one of our programs which allows us to develop this 
cross-collaborative research and discuss the needs for this. So 
that is another piece that I know we have in place currently.
    Mr. Mitchell. Thank you. And thank you all for being here. 
And we are all working for the same end. Thank you.
    [Whereupon, at 12:22 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Harry E. Mitchell,
         Chairman, Subcommittee on Oversight and Investigations

    We are here today to hear from veterans and the Department of 
Veterans Affairs about a very serious problem for the care of wounded 
servicemembers that has been overlooked for too long. Traumatic brain 
injury (TBI) is one of the signature injuries of the wars in Iraq and 
Afghanistan. I am afraid that vision problems are becoming the 
unrecognized result of that injury.
    Research being conducted by physicians, psychologists, and blind 
rehabilitation specialists at the VA Palo Alto Polytrauma 
Rehabilitation Center and the VA Western Blind Rehabilitation Center 
shows that TBI causes serious vision disturbances in a large number of 
cases even when the veteran retains 20/20 vision and without any 
obvious injury to the eye. We will be hearing today from Staff Sergeant 
Brian Pearce and Petty Officer Glenn Minney, Iraq veterans who are 
legally blind as a result of TBI.
    Staff Sergeant Pearce and Petty Officer Minney do not have happy 
stories to tell us about their experience after they were injured. We 
owe these two a great debt for their service. Both of their TBI-related 
vision issues went unrecognized and untreated for a long time.
    The wars in Iraq and Afghanistan have forced us to deal with 
unexpected and often unpleasant realities. But we now know that 
military and VA healthcare providers must be especially alert to vision 
deficits resulting from TBI--even when there is no obvious physical 
injury to the eye.
    This is not only critical so that these vision deficits can be 
addressed, but also because undiagnosed vision problems can seriously 
interfere with TBI rehabilitation and also rehabilitation for other 
injuries that often occur along with TBI.
    Following our first panel, we will be hearing from several 
companies that are working with the VA to provide innovative treatment 
for TBI-related vision deficits. Our third panel consists of witnesses 
from both DoD and VA.
    Two of the researchers from the Palo Alto VA are leading efforts to 
better identify and diagnose vision deficits in TBI patients. They are 
to be commended for their cutting edge work. In the 2008 National 
Defense Authorization Act, Congress directed DoD and VA to create a 
cooperative program specifically to address TBI-related vision issues. 
We are looking forward to hear exactly what it is that the Departments 
are doing, how they are directing funds for their efforts, and when 
they expect to have a fully functioning program.
    I am also very interested to see whether DoD and VA are currently 
doing all they can to identify and track these patients, not just at 
Palo Alto but everywhere. Because the seriousness and extent of vision 
problems resulting from TBI are just now becoming better known, we 
would like to hear from the Departments what they are doing to identify 
and contact TBI patients whose vision issues may have been overlooked.
    Our veterans served honorably to protect our Nation. We have a 
responsibility to take care of them when they come back home.

                                 
    Prepared Statement of Hon. Ginny Brown-Waite, Ranking Republican
          Member, Subcommittee on Oversight and Investigations

    Thank you for yielding, Mr. Chairman.
    Mr. Chairman, I appreciate you calling this hearing to allow us to 
review how the Department of Veterans Affairs and the Department of 
Defense are evaluating and treating vision problems encountered by OEF/
OIF soldiers and veterans returning home with traumatic brain injury.
    As we know, this war is different in many ways from those of the 
past. Soldiers who sustain injuries that would have resulted in death 
in previous conflicts now have a much greater survival rate. However, 
survival does not necessarily mean returning home to a normal way of 
life.
    Improvised Explosive Devices (IEDs) and now Explosive Formed 
Projectiles (EFPs), cause some of the most serious injuries among OEF/
OIF soldiers. Because of these types of attacks, many of our most 
severely injured veterans experience traumatic brain injury, and 
require treatment at one of the four Polytrauma Rehabilitation Centers 
(PRC) across the country.
    The Polytrauma Rehabilitation Center nearest my district is at the 
James A. Haley VA Medical Center in Tampa, where I am a frequent 
visitor, and see first hand the tremendous strides wounded soldiers 
make. I am also pleased that the VA has made a commitment to expand the 
PRC network to include a facility in the San Antonio, Texas area.
    Treating these severely wounded servicemembers has been a learning 
process. As our physicians treat the various and previously unseen 
injuries from IED/EFP blasts, we learn more about resulting co-morbid 
conditions, such as visual impairments suffered by our servicemembers.
    From information that I have obtained, over 44,000 veterans have 
utilized the services of VHA's Blind Rehabilitation Program. We here on 
the Committee need to be assured that these veterans are receiving the 
care and services they deserve.
    I look forward to hearing the opinions of our first panel as to the 
evaluation, treatment, and care they received while moving from the 
battlefield through to the VA. I have read your testimony, and again, 
the transitions you made going from the Department of Defense to the 
Department of Veterans Affairs have not been an easy road to follow.
    I would like to ask the Administration officials sitting behind you 
to listen closely to your testimony. The situations you have 
encountered along your path to recovery need to be resolved by both 
departments so that others do not face similar problems in the future.
    I also look forward to hearing from officials from the Palo Alto 
VAMC on the research they are doing with respect to vision issues 
related to traumatic brain injury. I would hope they are sharing their 
experiences, methodologies and treatment plans with the other PRCs.
    As I have said in the past, all medical centers need to be sharing 
their best practices with one another, so that our veterans and 
servicemembers receive the best care possible. This is particularly 
critical in the area of traumatic brain injuries, where treatments are 
often on the cutting edge.
    I would like to commend the work of the Blinded Veterans 
Association (BVA) for their efforts. I look forward to hearing what 
they have encountered when helping veterans navigate the system.
    Again, thank you Mr. Chairman for calling this hearing, and I yield 
back the balance of my time.
                                 
               Prepared Statement of Hon. Corrine Brown,
         a Representative in Congress From the State of Florida

    Mr. Chairman and Members of the Subcommittee, I am pleased to 
introduce NovaVision today for their testimony regarding TBI and 
vision.
    NovaVision, Inc., headquartered in Boca Raton, Fla., develops and 
provides scientifically based, innovative medical devices and 
comprehensive solutions to restore the vision of patients with 
neurological visual impairments. NovaVision's FDA-cleared NovaVision 
Vision Restoration Therapy TM; (VRT) is based on neuroplas-
ticity--the brain's ability to adapt and form new connections to 
compensate for injury. NovaVision diagnostic testing maps areas where 
vision may be improved, and therapy targets and stimulates regions 
within the brain's vision-processing areas.
    VRT is based on more than 10 years of research with clinical 
studies published in leading journals including Nature Medicine, 
Neurology, and The Journal of Cognitive Neuroscience. Data from a 
recent retrospective study identified that more than 70 percent of U.S. 
patients who underwent VRT for an initial 6-month treatment period 
showed significant improvements in their vision.
    More than 1,000 patients have been treated with VRT and clinical 
results are positive. VRT is currently offered at leading neurological, 
eye and rehabilitation centers nationwide.
    Dr. Marshall will elaborate further on this therapy.
    Dr. Randolph S. Marshall is Professor of Clinical Neurology at 
Columbia University and Director of the Stroke Division in the 
Department of Neurology. Dr. Marshall obtained his undergraduate degree 
from Harvard College in 1982 and his medical degree from the University 
of California in 1988, including an MD degree from UC San Francisco and 
a Master's degree from UC Berkeley. He completed his neurology 
residency in 1992 at Columbia and subsequently trained as a clinical 
and research fellow in cerebrovascular diseases at Columbia-
Presbyterian Medical Center.
    His clinical work focuses on the treatment and prevention of stroke 
and related cerebrovascular disorders. He has a research program that 
investigates the hemodynamic and physiological mechanisms of stroke 
recovery, with emphasis on the functional neuroimaging correlates of 
brain plasticity and recovery after injury.
    Current NIH grants include an fMRI project in acute stroke patients 
to identify patterns of brain activity that predict subsequent recovery 
of function, and a multi-center clinical trial to assess the effects of 
extracranial-intracranial bypass surgery on cognition in patients with 
hemispheral hemodynamic impairment from symptomatic carotid artery 
occlusion. He has also been involved in restorative treatment 
modalities after brain injury.
    He is accompanied by Navroze S. Mehta, President and Chief 
Executive Officer, NovaVision.
    Mr. Navroze Mehta brings 15 years of experience managing technology 
companies to his post at NovaVision. Mehta co-founded NovaVision in 
2002 guiding the company through the FDA clearance of its Vision 
Restoration Therapy (VRT), the accumulation of 50 Partner Centers and 
three rounds of financing.
    Mr. Mehta received an MBA from Syracuse University and a Bachelor 
of Commerce degree from Sydenham College at the University of Bombay, 
India. He is a Certified Public Accountant (CPA) in the State of New 
York, a member of the Young Presidents Organization (YPO) and past 
chairman of America's Gateway Chapter in Miami.
    Thank you Mr. Chairman.
                                 
   Prepared Statement of Staff Sergeant Brian K. Pearce, USA (Ret.),
  (U.S. Army Combat Veteran), and Angela M. Pearce, Mechanicsville, VA

    Chairman Mitchell, Members of the Subcommittee, thank you for the 
opportunity to speak to you today regarding our experiences following 
my injuries in Iraq and during my medical care to date.
    I joined the U.S. Army in June 1992 and served until March of 2000, 
joining the WVARNG. After a 3-year service break I returned to Active 
Duty in January of 2004. My new duty stationed was the 172nd Stryker 
Brigade Combat Team out of Ft. Wainwright, Alaska. There I was assigned 
to 4-11th FA as the Brigade's Survey/Targeting Acquisition Chief. After 
an intense training period, we deployed in July of 2005. My SBCT spent 
August 2005 through August 2006 the first year of our deployment 
operating in the Mosul area. As the Brigade prepared to re-deploy home 
to Ft. Wainwright in July we were extended for 120 days. I had already 
returned to Alaska in June to prepare for our Brigade's homecoming. 
Then I was called back in August 2006 to our new area of responsibility 
in the Sunni Triangle.
    On October 20, 2006, I was severely injured by an IED blast that 
caused shrapnel to penetrate the right occipital lobe of the skull. 
Once the blast zone had been secured I was air evacuated to the field 
hospital in Ballad, Iraq. There I underwent an emergency craniotomy of 
the right occipital and posterior fossa with duraplasty retaining 
foreign body, and a ventriculostomy. This blast in turn caused me to 
suffer from a severe TBI and cortical blindness. Later we learned it 
was the cause for more complex visual impairments, PTSD, hearing loss, 
pulmonary embolism, seizure and REM sleep disorders.
    During this time, my wife was contacted in Alaska and was told that 
I had been involved in IED blast and was in stable condition 
complaining only of neck injury. Roughly 3 hours later she was 
contacted by my commander who was with me in Iraq. He then told her 
that I had come through the brain surgery fine and was listed as very 
critical and once they could get me stable enough I would be air lifted 
to Landstuhl, Germany. She was not told of any problem with my sight at 
that time. Then that evening, my PA's wife came over to check on her 
and bring dinner. The PA's wife then asks how my sight was. Of course 
my wife had no idea what she was talking about. Once she was able to 
talk to my doctor at Ballad, this was the first question she asked him 
about. My wife was told at that time my diagnosis was cordial blindness 
and a severe TBI.
    Sometime on 21 October, I was air evacuated to Landstuhl, Germany. 
There I underwent a re-exploration surgery before being transported 
onto the U.S. mainland. Upon my arrival in the States on 24 October, I 
was admitted to Bethesda Naval Hospital first to have a cerebral 
angiogram done. Late on the evening of 25 October I was transferred to 
WRAMC's ICU. There I remained in a coma-like state for 47 days. During 
this time my wife kept asking for someone to tell her something about 
my visual problems but was told that the TBI needed more attention than 
the vision. During the entire time I was a patient at WRAMC there was 
not much done for my visual problems. The only thing that my wife was 
told is that an ophthalmologist came to look at my eyes and dilate 
them. However, before they could complete an exam they received an 
emergency in the OR.
    Once I had somewhat regained my consciousness my wife was forced 
with the decision of what VA treatment facility I was going to be 
transferred to. Walter Reed had determined there was nothing more they 
could do for me. She chose Richmond and their PRC, knowing they did not 
have a low vision center there. The main reason for this decision was 
due to the fact that my wife had to leave our 7- and 8-year-olds in 
Alaska with a friend. Then they would be coming to stay with family in 
Ohio and this would be the closest PRC for us to see the kids. However, 
she was assured by officials at WRAMC that the vision problems again 
needed to take a back seat to the TBI and its severity. They did tell 
her however to discuss further treatment options with the staff at 
Richmond. If need be I could be transferred from there to another 
facility to deal with my vision impairments. The day that I was 
transferred to Richmond there BROS was awaiting my arrival to begin 
making an assessment on my vision. In the VA hospital there was little 
additional information as far as the vision was concerned. This left us 
to wonder how this type of injury could be taken so lightly. 
Especially, with your sight being a vital part of your day-to-day 
activities. How we stacked up against others that had been treated 
either by the VA or the DoD. It was at Richmond where I was diagnosed 
with a left sided homonymous hemianopsia on December 11, 2006.
    In January of 2007, I was discharged from inpatient care at 
Richmond where I had spent approximately 1 month. My inpatient care 
consisted of KT, PT, RT, OT, mental health, speech, and vision 
sessions. After my discharge I began outpatient therapies in February 
consisting of KT, PT, RT, OT, speech, vision and mental health. I 
should have returned to WRMAC to await my medical board. However, my 
wife had been told from several people to include my case manager at 
WRMAC that they could not offer the service I needed for my vision 
impairments. So we decided to get authorization to stay at Richmond to 
continue my care while waiting for my medical board.
    My medical board was started in March 2007. Everything went pretty 
smooth with this except for portion of the exam on my eyes. After 
getting a hasty eye exam from the optometrist she told me ``I know 
what's wrong but it would require me getting out my text books and I 
don't have time, go to the VA.'' They should be able to assist you with 
this since you are getting most of your care there. We turned in all 
the paper work to the PEBLO around the 9th of March 2007. He told us 
that it would take a couple of weeks to get all of the narratives from 
the doctors to send to the MEB. However, by the end of April 2007 we 
had not heard anything regarding the MEB. My wife contacted my PEBLO to 
find out what the status was on my MEB. He started researching the 
matter to find out they couldn't find my physical exam information. 
Finally he was able to track it down and sent it on to the MEB the 
first part of June 2007. The middle of June we received a call from the 
PEBLO that the MEB needed more documentation on my vision impairments. 
My wife gathered all the medical records she had from the Richmond VA 
and priority mailed them to the PEBLO on June 19, 2007. A few weeks 
went by and when we hadn't heard from him on the status of the 
information that we mailed to him.
    My wife contacts him around the end of June leaving a message for 
him to contact us regarding this matter. Finally, he returned her call 
right after the 1st of July 2007 to tell us he had not received these 
documents that she sent him in June. My wife checked with the postal 
service to track the documents sent. She was able to track that the 
documents has been delivered to the address at WRAMC on June 22nd and 
signed for on the 23rd. The PEBLO went to the postal service on WRAMC 
to check if it was there to be told no. Finally on July 9th 2007 he 
signed for and picked up the documents needed to complete the MEB 
stage. The PEBLO found out that the documentation had been locked up in 
WRAMC post office safe since June 23, 2007. Keeping in mind this should 
have already been done during my eye exam for the MEB physical. I think 
around July 19, 2007 my PEBLO calls to let us know that the MEB needs a 
current Goldman Visual Field screening in order to finish their finds 
on my vision. So we had to try and jump through hoops to make this 
happen with being on a tight timeframe for the MEB. My MEB six month 
window was due to expire on September 7, 2007. If not sent on to the 
PEB by this date I would be required to start the process all over 
again. We were lucky enough to have a good Vist Coordinator who was 
able to make this happen. After having Goldman visual field test July 
23, 2007 I was diagnosed for the first time as being legally blind.
    In June of 2007, my BROS therapist who had been growing 
increasingly frustrated at the lack of cooperation between the 
polytrauma network and the increasing difficulties in navigating the 
bureaucracy of the VA. He decided to leave this position. This left me 
without a blind therapist and no low vision doctor either. However, 
there had not been a low vision doctor but he did have a doctor in the 
eye clinic he could work with. So I went from June until October 2007 
with no care for my vision. My wife and I made the decision to send me 
to the Eastern Blind Rehab Center in West Haven, Connecticut after 
coming back from the BVA's 62nd National Convention.
    Once I arrived at the Eastern Blind Rehab Center I was put through 
extensive and thorough eye exams. I spent approximately 6 weeks going 
through extensive care and therapy to help me cope with everyday living 
with visual impairments. I also found out how complex my visual 
impairments are. What most people to include my doctors and therapies 
don't understand is the fact that my vision actually has nothing to do 
with my eyes themselves. My visual impairments stems from my TBI. My 
eyes are actually very health and I have 20/20 vision. It is my brain 
that will not allow my eyes to function appropriately. I have been left 
with no peripheral vision and about 8 degrees centrally. My wife and I 
often wonder if we would have had more information early in my care if 
this would have changed the outcome of my vision or my abilities to 
function better with my vision impairments. However, we have talked to 
several specialists since going to Connecticut and have been told that 
this would have made no difference. One of my wife's biggest concern is 
could I have gained more out of my therapies if we had the appropriate 
diagnose from the get go? Since returning from Connecticut the Richmond 
VA has hired a part-time low vision doctor and full time BROS. They 
have a plan from the ophthalmologist from West Haven that they are 
following and continuing my visual therapy. One to two days a week I 
either see my BROS or the low vision doctor. They have given me a plan 
for eye exercises to do at home as well.
    Some recommendations that my wife and I would like to suggest for a 
better seamless transition are:

    1.  More education for doctors, therapist, case managers, and 
nurses about visional impairments relating to TBIs both on DoD and VA 
side of the house.
    2.  Teams set up at the PRCs and MTFs to deal specifically with TBI 
patients with visual impairments.
    3.  It is imperative that there is a database both from DoD and VA 
to keep track of statistics on vision impairment associated with TBI.
    4.  More awareness of these types of injuries coming out of Iraq 
and Afghanistan.
    5.  There needs to be better communication between the DoD and VA 
to better plan for transfer to the appropriate facility for treatment 
regarding TBI patients with vision impairments.
    6.  There needs to be easier way for the DoD and VA to share 
medical information pertaining to the injury and there also needs to be 
better communication between different VA centers to access medical 
information.

    In closing my wife and I would again like to thank you for taking 
the time to listen to our testimony. We hope that you gain some insight 
from this hearing and make great strides to resolve these issues. I 
know that we are not the only ones to come up against these issues. I 
hope no other veteran has to feel there is no one who cares about the 
sacrifices they have made for their country. I proudly served my 
country and would do it again if I could. However, with the injuries I 
sustained I can no longer do the jobs I love. In November 2007 I was 
found unfit for duty. I was then retired with almost 16 years on 
December 27, 2007. Please understand that we have no complaints about 
the care that I received from the Richmond VA. I received excellent 
medical care here far better than the WRAMC gave me. The common thing 
we heard then and still hear now is we are understaffed. Well I and 
countless other leaders on the ground in Iraq were understaffed but we 
made due and completed our missions. Now it's time to do the job and 
account for our care. I will leave you with this question. Does the VA, 
DoD or anyone on this panel have any idea how many TBIs with visual 
impairments that have come out of this war? If you answer no I 
challenged you to find out and start tracking this information so that 
veterans get the utmost of care they so deserve.
    Veterans such as me have sustained what has been identified as the 
signature injury for this war. We do not discount the importance of 
keeping track of those who have made the ultimate sacrifice, but there 
are solid numbers for them. We continue on a daily basis to increase 
our numbers and fall through the cracks. Where are the statistics for 
how many of us there has been? This is basic job performance that as a 
leader in the Army I was expected to do, what I expected my soldiers to 
do and yet the entire DoD and VA healthcare systems cannot perform what 
one single Private in the Army could do?

                                 
     Prepared Statement of Petty Officer Glenn Minney, USN (Ret.),
                Frankfort, OH (U.S. Navy Combat Veteran)

    The testimony provided before this Committee today as a combat 
Veteran from the war in Iraq, and not as a VA employee, and I do not 
represent the views of the Department of Veterans Affairs on these 
issues today in my testimony.
    I first joined the United States Navy on September 4, 1985, where I 
attended Basic Training as well as Naval Hospital Corps School all at 
Great Lakes, Illinois. After serving on Active Duty tour in the late 
'80s, I rejoined the Navy reserves in Columbus, Ohio. As a reservist, I 
was assigned to Lima Company, 3rd Bat, 25th MAR. As a civilian I was 
employed by the Department of Veterans Affairs as a Pharmacy 
Technician, and then as a police office, and then finally as a 
firefighter.
    On January 3, 2005, I was called to Active Duty to serve in Iraq. 
After spending 2 months at Twentynine Palms Marine Corps Base, 
California, the Battalion was on its way to Iraq.
    The 3/25 was assigned to Haditha, Iraq, and also to Hit, Iraq. The 
majority of the Battalion was assigned to Haditha Dam, Iraq, a 10-story 
hydro-electric dam we used as a firm base. We had a makeshift chow 
hall, sleeping quarters inside engine rooms, and a Battalion Aid 
Station in a elevator control room.
    On April 18 at approximately 1630 I was on the 10th story of the 
dam outside retrieving medical supplies from a con-ex container. 
Without warning I was lifted from the ground and a bright flash of 
light flashed before my eyes. The next few seconds were a blur. The 
next thing I remember was that I was up against the rail of the dam. I 
then began running toward the Battalion Aid Station. Once I arrived at 
the BAS, I checked myself for any injuries and then began getting ready 
to start taking in casualties. Luckily, there were no other casualties 
but I was informed there had been four other mortar rounds that hit the 
water around the dam. Those rounds I don't remember.
    The next day I noticed my eyes were a little scratchy and I had a 
headache. The headache I figured was from the blast, and the eyes I 
thought might have been sand from the blast. Later I went to a fellow 
corpsman and had him look into my eyes and look for debris or 
scratches. Nothing was found that time. A few days later I logged in to 
be seen in sick-call. I was examined using an ophthalmoscope and 
nothing was seen so I was treated for pinkeye, and as far as the 
headaches went, Motrin. A month or two went by and the redness in my 
eyes was not getting better, nor were the headaches. I covered much of 
the problem up because I wanted to stay with my unit. Then one day I 
had awoke and noticed a slight veil covering the corner of my eye. I 
ignored it and went on with the mission. Days later the veil was almost 
covering my entire eye. I knew then I had to go back to the BAS. Once 
there, I described my symptoms to the Battalion Surgeon, who again 
looked into my eyes. Once again, they gave me the same pinkeye 
medication. The next day I was blind in my right eye, so I went back to 
the BAS. The Battalion Surgeon made a few calls and sent a few emails, 
and the next day I was flown to Al Asad Air Base. From there I was 
flown to Balad, Iraq. This was a Friday and once I arrived at the 
Medical Cache I was informed the eye surgeon was off duty for the 
weekend. I was placed in a transit tent until Monday when the eye 
surgeon was back on duty. That Monday I was seen and told I would be 
flown to Germany immediately on the next flight out.
    Once I arrived in Germany, I was taken to Landstuhl Medical Center 
and placed in a room. I was advised I would be having my surgery in the 
German Eye University located in Hamburg, Germany. Within an hour on 
August 16 was in surgery and the next day I was back in surgery having 
my left eye operated on. I spent 10 days in the German hospital with 
both eyes bandaged. And I didn't speak German. After having the 
bandages removed, I was then taken back to Landstuhl Medical Center. 
There I was evaluated and told I would be on my way back to the States 
in three days. After the three days, I arrived in Washington, DC, and 
was taken to Bethesda Naval Medical Center. Once there, I was seen by 
an eye surgeon and was told I was in the healing process and that there 
was nothing he could do. I was told I was to go home on 30 days con-
leave.
    I arrived home on September 1 and on September 3 I awoke to being 
blind again. After controlling the panic, I called my medical liaison 
at my reserve unit and was advised to call the closest eye surgeon who 
took TRICARE and get seen now. With the assistance of my fiance, we 
discovered a local surgeon and he was willing to see me after hours. 
Once I was seen, we were told I would need surgery ASAP. Within hours, 
I was back in surgery having my right eye operated on. After the 
surgery I was informed that I would have to lay flat for one to three 
months face down. After that first month, I was called by Bethesda 
Naval Medical Center and was told I was to report at once. I didn't 
know what to do. I called my reserve center and advised them what was 
going on. I was told the Commanding Officer would take care of it. 
Within days, I was advised that I was now assigned to my parent command 
in Columbus and that I could call daily to check in.
    During recovery time, I continued to have some headaches and vision 
problems so I went to my local Veterans Affairs Medical Center where I 
worked as a civilian. After I arrived, I was told I could not be seen 
there because I was on Active Duty and that I had TRICARE. Also, 
because I didn't have a DD-214, I wasn't a veteran. After speaking with 
the Associate Director, I was seen without any problems. I was 
scheduled for an MRI of my head because the doctor I saw asked if I'd 
had any sort of imagining after the explosions or after the surgeries 
and I said no. In December 2005, I was called by BUMED and advised that 
I either had to report to Great Lakes and process off Active Duty or 
they would do it over the phone. I called my Commanding Officer and 
advised him of the situation. Within hours I was advised that I would 
be staying on Active Duty and assigned to the Wounded Warrior Barracks 
at Camp Lejeune, North Carolina.
    While at the WWB I once again felt that I was an asset to a unit. I 
was back to being a Navy Corpsman taking care of Marines. I performed 
dressing changes, stump wound care, wound irrigation, and medical 
administration issues such as getting the Marines to their appointments 
or to the VA to begin their paperwork. Also while there, I went through 
different types of therapy and I received my MRI. It was then and 
finally then that it was discovered I was suffering from a severe TBI. 
All the medical centers I described above and not one had performed any 
sort of MRI, CT scan, or even an X-Ray. The VA in Chillicothe, Ohio, 
thought outside the box and set it up, but I was transferred before 
they could do the MRI so I had it done while I was at Camp Lejeune. It 
was then they discovered I had a loss of brain tissue in the parietal 
lobe as well as the occipital lobe (which works the eyes). I went 
through several neuro-psych exams to determine the extent of my injury, 
and after several tests, it was determined that the TBI was also a 
major cause in my loss of sight. The eye healed from the surgeries, but 
it was also the optic nerve that was damaged as a result of the TBI 
that was now a concern.
    In September 2006, I was officially retired from the Navy, and I 
was rated at 100 percent disabled. While at Camp Lejeune I had already 
began my VA disability paperwork so, once I arrived in Ohio at my 
parent VA, I was one step ahead.
    I ran into a problem, however. I couldn't see, so how was I going 
to provide for my family as a firefighter? The Associate Director of 
the VA in Chillicothe offered me the position of Patient Advocate. As 
he put it, ``Who better to assist veterans than a veteran''?
    Since returning to the VA as an employee and veteran, I have had to 
overcome some other barriers. Once I was working, I had trouble reading 
and getting around. Months after returning to work, I met my VIST 
Coordinator. I had no idea there was such a person. We met for about 30 
minutes and he gave me a folder of papers and a hand-held magnifier. I 
hadn't seen him since until this last month. I understand that in Ohio 
the VIST Coordinator only comes to the VA once a week for a few hours 
at a time. He is a mobile VIST Coordinator. After my first visit with 
the VIST Coordinator I was placed in touch with Vision and Vocational 
Services from Columbus, Ohio, a nonprofit organization that helps those 
with visually inabilities and with total vision loss. Within weeks of 
meeting the people from this organization, I was evaluated and provided 
with several magnifiers, a large computer screen, a new desk, several 
computer programs, and new glasses. Whoa, VVS came through. After this 
had all happened, my VIST Coordinator called and advised me that I 
would be getting a CCTV, a monitor that enlarges print. I work everyday 
helping veterans in whatever way I can and now I have the equipment I 
need to complete these tasks.
    In conclusion, it is my impression that there is still not a 
seamless transition between VA and DoD. I see evidence of this everyday 
in the VA system. Fellow combat vets are trying to enter the VA for the 
first time, still not sure of what to expect. I also would like to see 
a fully staffed TBI/EYE trauma center built so that other veterans like 
myself won't have to go months or years not knowing that the reason 
they are the way they are is actually due to a TBI. Right now I am on a 
registry. I'm a number, which isn't helping me or any of us who really 
need the one-on-one treatment from an actual TBI/EYE trauma center. 
Research, education, vocational rehab, adult daily living skills--these 
are all items that can come from such a facility. Staff the facility 
with eye specialists, neurologists, physicians' assistants, nurses, and 
rehabilitation specialists. The discovery of a TBI is the first step in 
a new life for an injured servicemember. The number of TBIs is growing 
every day and only a fraction of those exposed to explosions actually 
know when something is wrong. Thinking patterns, cognitive issues, 
memory problems, anger, and also vision problems. These are all issues 
related to TBIs. Once again, thank you.

                                 
              Prepared Statement of Thomas Zampieri, Ph.D.
     Director of Government Relations, Blinded Veterans Association

INTRODUCTION
    Chairman Mitchell, Ranking Member Brown-Waite, and Members of the 
House Veterans' Affairs Subcommittee on Oversight and Investigations, 
on behalf of the Blinded Veterans Association (BVA), thank you for this 
opportunity to present our testimony on Traumatic Brain Injury (TBI) as 
it relates to vision. BVA is the only Congressionally chartered 
Veterans Service Organization exclusively dedicated to serving the 
needs of our Nation's blinded veterans and their families. The 
Association has been helping blinded veterans for more than 63 years.
    BVA appreciates the invitation you have extended to Operation Iraqi 
Freedom (OIF) blinded veterans to share their stories today. Like other 
visually injured servicemembers, they have had to work through a 
bureaucratic system that does not even attempt to track, report, and 
provide a Seamless Transition of care for them. For nearly three years, 
BVA has tried to bring this issue to the attention of the Armed 
Services Committees, the VA Committees, DoD, and VA itself.
    Of paramount concern are the growing numbers of those returning 
from battle with penetrating direct eye trauma as well as the increase 
in cases of TBI visual dysfunction. OIF and Operation Enduring Freedom 
(OEF) returnees trying to enter the VA healthcare and benefits system 
today should never have encountered such a difficult process. Quick 
administrative changes are now vital to correct this.
    BVA wishes to make clear that the clinical skills of the DoD 
professional eye care providers have been deemed excellent. In many 
cases, outstanding ophthalmology surgery on the battlefield and in 
military facilities has saved partial vision of soldiers and Marines, a 
feat that could not have been possible in any previous wars. The 
weakness is in the administrative systems within both DoD and VA that 
account for the combat eye wounded and the TBI patients that need 
specialized vision screening.

PREVALENCE AND INCIDENCE OF VISUAL IMPAIRMENTS
    As of February 26 of this year, there were 29,317 wounded in OIF/
OEF operations, of which 8,904 required air medical evacuation. Another 
8,273 military personnel injured in non-hostile action have also been 
evacuated from Iraq or Afghanistan. Between March 19, 2003 and 
September 17, 2007, 1,162 of those evacuated had sustained direct eye 
trauma. This means that 13 percent of all evacuated wounded had 
sustained direct eye trauma, the highest percentage of eye wounded in 
more than 160 years of American wars. Based on additional information 
that we have received during the aforementioned 4-year period, mostly 
anecdotal in nature, BVA believes that perhaps many more than 1,162 
servicemembers evacuated from Iraq or Afghanistan have experienced 
direct eye trauma.
    The top three contributors to combat eye injuries have been (1) 
Improvised Explosive Devices (IEDs), which caused 56.5 percent of the 
injuries, (2) Rocket-Propelled Grenades (RPGs), and (3) Mortars. The 
Landstuhl, Germany, Military Medical Center began a TBI screening 
program last May, reporting that 33 percent of all wounded were 
diagnosed with mild, moderate, or severe TBI. The Defense Veterans 
Brain Injury Center reports that from October 2001 through September 
2007, 4,471 were diagnosed with TBI-injuries. The number of 
servicemembers who have actually sustained moderate-to-severe TBI 
injuries, to the extent that they are experiencing neurosensory visual 
complications, is essentially a guessing game. This is because emerging 
articles and surveys on TBI complications reveal updated numbers almost 
every month.
    What most concerns BVA are studies revealing that 75 percent of 
those with TBI injuries also have complaints about vision problems. 
Approximately 60 percent of those injured have associated neurological 
visual disorders of diplopia, convergence disorder, photophobia, 
ocular-motor dysfunction, and an inability to interpret print. Some 
TBIs result in visual field defects with sufficient loss to meet legal 
blindness standards.
    One early VA research study (2005) of OIF and OEF servicemembers 
who had entered the VA system with an ICD-9 (diagnostic code) search 
found 7,842 with a traumatic injury of some kind. Consistent with 
recent media articles and VA reports, the most common traumatic injury 
diagnoses were hearing loss and tinnitus (63.5 percent). Nearly 70,000 
of the more than 1.3 million troops that have served in OIF and OEF are 
now service-connected for tinnitus while 58,000 are service-connected 
for hearing loss. A major cause of this epidemic of hearing loss (60 
percent of the cases) is exposure to IEDs. The second most common VA 
diagnostic code was for visual impairment (27.9 percent).
    During the past four years, and especially recently, BVA has 
attempted to find out just how many total OIF and OEF servicemembers 
have sustained a traumatic eye injury requiring evacuation. We have 
suspected that the number is greater than the reported 1,162 stated 
above. We have also tried to determine how many service personnel from 
each branch of the military have been diagnosed with a TBI visual 
dysfunction. The answer from DoD has been either that this information 
is unknown or that it cannot be shared. We have also been told ``off 
the record'' within the past two weeks that as of March 1, 2008, there 
have been 1,499 serious eye injuries requir- 
ing evacuation from Iraq. A total of 376 of the 1,499 are now legally bl
ind in one eye.
    Other retired military sources have indicated that another 3,000 
men and women with eye injuries have been returned to duty in Iraq 
after treatment of eye injuries. Some experts have projected that 
7,000-8,000 veterans who, if screened, would be diagnosed with some 
visual dysfunction. We submit to this Subcommittee that OIF eye 
injuries could well be classified a ``Silent Epidemic'' and that the 
dual sensory loss of hearing and vision complications from TBI are, 
respectively, the number one and two injuries from OIF and OEF.

NEUROLOGICAL IMPACT OF TBI DYSFUNCTION
    Perception plays a major role in an individual's ability to live 
life. Although all senses play a significant role in perception, the 
visual system is critical to perception, providing more than 70 percent 
of human sensory awareness. With hearing being another critical 
component, IED blast injuries can obviously impair markedly these two 
key sensory systems.
    Vision provides information about environmental properties. It 
allows individuals to act in relation to such properties. In other 
words, perceptions allow humans to experience their environment and 
live within it. Individuals perceive what is in their environment by a 
filtered process that occurs through a complex, neurological visual 
system. With various degrees of visual loss comes greater difficulty to 
clearly adjust and see the environment, resulting in increased risk of 
injuries, loss of functional ability, and unemployment. Impairments 
range from loss in the visual field, visual acuity changes, loss of 
color vision, light sensitivity (photophobia), and loss of the ability 
to read and recognize facial expressions.
    Although one can acquire visual deficits in numerous ways, one 
leading cause is injury to the brain. Damage to various parts of the 
brain can lead to specific visual deficits. Some cases have reported a 
spontaneous recovery but complete recovery is unlikely and early 
intervention is critical. Current complex neuro-visual research is 
being examined in an attempt to improve the likelihood of recovery. The 
re-training of certain areas and functions of the brain has improved 
vision deficits in some disorders. Nevertheless, the extent of the 
recovery is often limited and will usually require long-term follow-up 
with specialized adaptive devices and prescriptive equipment.
    The brain is the most intricate organ in the human body. The visual 
pathways within the brain are also complex, characterized by an 
estimated two million synaptic connections. About 30 percent of the 
neocortex is involved in processing vision. Due to the interconnections 
between the brain and the visual system, damage to the brain can bring 
about various cerebral visual disorders. The visual cortex has its own 
specialized organization, causing the likelihood of specific visual 
disorders if damaged. The occipitotemporal area of the brain is 
connected with the ``what'' pathway. Thus, injury to this ventral 
pathway leading to the temporal area of the brain is expected to affect 
the processing of shape and color. This can make perceiving and 
identifying objects difficult. The occipitoparietal area (posterior 
portion of the head), is relative to the ``where,'' or ``action'' 
pathway. Injury to this dorsal pathway leading to the parietal lobe 
will increase the likelihood of difficulties in position (depth 
perception) and/or spatial relationships. In cases of injury, one will 
find it hard to determine an object's location and may also discover 
impaired visual navigation.
    It is highly unlikely that a person with TBI will have only one 
visual deficit. A combination of such deficits usually exists due to 
the complexity of the organization between the visual pathway and the 
brain. The most common cerebral visual disorder after brain injury 
involves visual field loss. The loss of peripheral vision can be mild 
to severe and requires specific visual field testing to be correctly 
diagnosed. 
In turn, a number of prescribed devices are frequently necessary to adap
t to this loss.
    Accompanying such complex neurological effects on the patient is 
the overwhelming emotional impact of brain injury on the patient and 
his/her family. BVA would ask Members of this Subcommittee to seriously 
consider the ramifications of such injuries. Brain injuries are known 
for causing extreme distress on family members who must take on the 
role of caregivers. According to a New England Journal of Medicine 
report of January 30, 2008, TBI ``tripled the risk of PTSD, with 43.9 
percent of those diagnosed with TBI also afflicted with PTSD.''
    At present, the current system of screening, treatment, tracking, 
and follow-up care for TBI vision dysfunction is inadequate. Adding 
visual dysfunction to this complex mix, especially if undiagnosed, 
makes attempts at rehabilitation even more daunting and potentially 
disastrous unless there are significant improvements soon.

VA LOW VISION AND VA BLIND REHABILITATION PROGRAMS
    A positive note is that the challenges inherent in the growing 
number of returning OIF and OEF servicemembers needing screening, 
diagnosis, treatment, and coordinated Seamless Transition of services 
can be met, at least to some extent, by the existence of world-class VA 
Blind Rehabilitation Centers (BRCs). The programs provided at such 
centers now have a 60-year history.
    In the larger picture of VA programs for blind and visually 
impaired veterans, BVA began working more than four years ago to ensure 
that VA expand its current capacity as the aging population of veterans 
with degenerative eye diseases requiring such specialized services 
continues to increase. Our organization has been particularly 
supportive of recent plans for intermediate and advanced low-vision VA 
rehabilitation programs on an outpatient basis. Several such programs 
are now opening with veteran-centered, vision-specialized teams 
providing the full range of services. Accompanying this effort is an 
emphasis by VA on outcome measurements and research projects within the 
Veterans Health Administration (VHA).
    The VA approach of coordinated team methods for rehabilitation care 
has unlocked strategies for new treatment, providing the most updated 
adaptive technology for blinded veterans. VHA Prosthetics reports 
$200,674 spent during FY 2003-07 on OIF/OEF blinded veterans who have 
required equipment and aids. The following three sections describe 
programs within an already existing system that DoD should utilize and 
coordinate with VHA. Doing so will ensure that veterans and their 
families receive the best care.

THE VISUAL IMPAIRMENT SERVICES TEAM (VISTs) AND BLIND REHABILITATION 
        OUTPATIENT SPECIALISTS (BROS)
    The mission of each Visual Impairment Services Team (VIST) program 
is to provide blinded veterans with the highest quality of adjustment 
to vision loss services and blind rehabilitation training. To 
accomplish this mission, VISTs have established mechanisms to 
facilitate more completely the identification of blinded veterans and 
to offer a review of benefits and services for which they are eligible. 
The VIST concept was created in order to coordinate the delivery of 
comprehensive medical and rehabilitation services for blinded veterans. 
VIST Coordinators are in a unique position to provide comprehensive 
case management and Seamless Transition services to returning OIF/OEF 
service personnel for the remainder of their lives. They can assist not 
only newly blinded veterans but can also provide their families with 
timely and vital information leading to psychosocial adjustment.
    Seamless Transition from DoD to VHA is best achieved through the 
dedication of VIST and Blind Rehabilitation Outpatient Specialist 
(BROS) personnel. VIST Coordinators are now following the progress of 
102 blinded OIF/OEF veterans who are receiving services. The VIST 
system now employs 99 full-time Coordinators nationwide. There are also 
37 full-time BROS serving as the critical source of blind 
rehabilitation for OIF and OEF blinded veterans.
    The VIST/BROS teams provide improved local services when veterans 
needing continued services leave inpatient BRCs and return home. Such 
veterans require this additional training due to changes in adaptive 
equipment or technology advances. Because of recent legislation, VA 
Blind Rehabilitation Service will establish 20 new BROS positions 
during FY 2008 and another 10 the following year. The creation of these 
additional positions provides VA with an excellent opportunity to 
deliver more accessible, cost-effective, and top-quality outpatient 
blind rehabilitation services.

ADVANCED BLIND PROGRAMS: VISUAL IMPAIRMENT SERVICES OUTPATIENT 
        REHABILITATION (VISOR)
    In 2000, VA initiated a revolutionary program to deliver services: 
Pre-admission home assessments complemented by post-completion home 
follow-up known as Visual Impairment Services Outpatient Rehabilitation 
(VISOR). The program offers skills training, orientation and mobility, 
and low-vision therapy for veterans who need treatment with prescribed 
eye wear, magnification devices, and adaptive technology to enhance 
remaining vision. Veterans returning from BRCs, especially those 
requiring additional outpatient assistance, seem to benefit most from a 
VISOR experience. A VIST Coordinator with low-vision credentials 
manages the program. Other key staff consists of certified BROS 
Orientation and Mobility Specialists, Rehabilitation Teachers, Low-
Vision Therapists, and a part-time Low-Vision Ophthalmologist or 
Optometrist.
    According to VA Outcomes Project Research, patient satisfaction 
with the program is nearly 100 percent. VHA recommended and endorsed a 
plan for this delivery model within each VISN Network's Advanced or 
Intermediate Program. During a VISOR experience, medical, subspecialty 
surgery, psychiatry, neurology, rehabilitative medicine, pharmacy, 
physical therapy, and prosthetics services can all be consulted as 
needed within the VA Medical Center, effectively providing the full 
continuum of care. DoD and VA are now establishing the means by which 
clinical eye trauma information is shared through an exchange of 
electronic healthcare records.
    Private agencies that offer blind rehabilitation rarely have the 
full medical and surgical subspecialty staffing that VA has within a 
single facility, meaning that veterans and families taking advantage of 
such services would be required to travel additional distances to 
receive other VA care, incurring wait times to see other specialists/
consultants and delays in obtaining prescribed medications or new 
treatment plans. BVA also strongly recommends that private agencies 
utilized for services be accredited by the Commission on Accreditation 
of Rehabilitative Facilities (CARF) or the National Accreditation 
Council for Agencies (NAC) Serving People with Blindness or Visual 
Impairment, and that such agencies be required to utilize VA electronic 
healthcare records for clinical care. BVA asks further that agencies 
contracted for services meet specific outcome measurements.

INTERMEDIATE LOW VISION PROGRAMS: VISUAL IMPAIRMENT CENTER TO OPTIMIZE 
        REMAINING SIGHT (VICTORS)
    Another important model of service delivery that does not fall 
under VA BRS is the VICTORS program. The Visual Impairment Center to 
Optimize Remaining Sight is an innovative program operated by VA 
Optometry Service for more than 18 years. The program consists of 
specialized services to low-vision veterans who, though not legally 
blind, suffer from visual impairments. Veterans must generally have a 
visual acuity of 20/70 through 20/200 to be considered for this 
service. The program, entirely outpatient, typically lasts 3-5 days. 
Veterans undergo a comprehensive, low-vision optometric evaluation. 
They receive prescribed low-vision devices and are trained in the use 
of adaptive technology to optimize functional independence.
    The Low-Vision Optometrists employed in the Intermediate Low-Vision 
programs are ideal for the highly specialized skills necessary for the 
assessment, diagnosis, treatment, and coordination of services for Iraq 
and Afghanistan returnees with TBI visual symptoms. This is because 
such veterans will often require long-term follow-up services. The 
programs will also assist the aging population of veterans with 
degenerative eye diseases. Such programs often enable working 
individuals to maintain their employment and retain full independence 
in their lives. They also provide testing for and research into the 
effectiveness of adaptive low-vision technology aids that have recently 
become available. In conjunction with a wide network of VA eye care 
clinics existing in VA medical centers nationwide, combined VIST/BROS 
teams and Intermediate/Advanced Outpatient programs can provide a wide 
network of specialized services for veterans and their families.

CONCLUSIONS
    Serious combat eye trauma and visual dysfunction associated with 
TBI, and that affect OIF and OEF service personnel, have climbed to 
second in most common injuries from the two conflicts. If hearing loss 
and visual impairments (dual sensory injuries) are lumped together, 
they become the most common type of injury. We urge Members of this 
Subcommittee to request that DoD/VA provide for the full implementation 
of the ``Military Eye Trauma Center of Excellence (ETCoE) and Eye 
Trauma Registry.'' Congress expected the three Defense Centers of 
Excellence (DCoE) included in the Wounded Warrior Act to be co-located 
in the same place so that multiple injuries could be diagnosed and 
treated more effectively. The establishment of the Mental Health Center 
and TBI Centers of Excellence, along with ETCoE in the same location, 
will substantially improve multidisciplinary coordination, treatment, 
rehabilitation, and research into eye trauma cases across the DoD and 
VA universes.
    At present, BVA is aware that the new military TBI Center of 
Excellence and Mental Health Center of Excellence will be placed 
together at the National Naval Medical Center in Bethesda, Maryland. 
Groundbreaking has been scheduled, a director has been appointed, 
staffing has been approved for 127 full-time personnel, and funding has 
been set at $70 million--all in preparation for the establishment of 
these two Centers. In contrast, important decisions regarding ETCoE, 
including its location, are still being debated in a variety of arenas 
and on various levels. BVA is puzzled that two DCoEs are being fully 
implemented and funded while ETCoE seems left behind in the process.
    As an example of ``progress,'' working groups of DoD/VA 
ophthalmologists and optometrists are developing a ``computer 
registry'' with data fields. This should not be considered the end 
product of the Eye Center of Excellence. DoD cannot spend more time 
trying to decide whether it will devote the full resources needed for a 
comprehensive, administratively effective DoD/VA Center.
    Chairman Mitchell and Ranking Member Brown-Waite, BVA again 
expresses thanks to both of you for this opportunity to present our 
testimony. BVA believes that as we move beyond the 5-year mark of OIF, 
the government can do better than it has in the past for those who have 
returned home with life-altering sensory losses. The urgent need for 
DoD and VA to implement the Military ETCoE, in the manner Congress 
intended, is now. Veterans who have suffered combat direct eye 
injuries, as well as those with TBI visual dysfunction, are at risk for 
complications in the future. Glaucoma, cataracts, retinal detachments, 
and other associated complications are all potential problems that we 
can well expect. We again reiterate our concern for the dual sensory 
``hearing and vision loss veterans'' who are caught up in this system. 
We hope that such individuals will most assuredly be entered into the 
clinical and/or administrative tracking system designed in the future.
    Because the population of war wounded is widely dispersed 
geographically and long travel distances pose delays to follow-up care, 
BVA never intended that just one medical treatment facility be tasked 
with all eye wounded or TBI patients with visual dysfunction. We 
respectfully state that one ``treatment center'' is not sufficient. We 
request that House and Senate VA Committees require several Eye Centers 
of Excellence to coordinate the care and rehabilitation of our Nation's 
blinded veterans who have sacrificed so much.
    We would now be pleased to answer any questions that Members of 
this Subcommittee may raise.

RECOMMENDATIONS
    The Secretary of Defense and Secretary of Veterans Affairs must 
appoint an Eye Trauma Acting Administrative Program Director and 
dedicated DoD/VA clinical/administrative staff teams. The appropriate 
personnel must secure immediate financial resources now in order to 
begin the full implementation of the Eye Trauma Center's operations. 
They should then report back to this Subcommittee within 90 days. BVA 
strongly supports, within VHA, an Eye Trauma Program Assistant to work 
with the Office of the Chief of Ophthalmology and Optometry. Also 
appointed should be a designated clinical Eye Trauma Coordinator at all 
four Polytrauma Centers. A Physician Assistant similar to the TBI Team 
Coordinator at Walter Reed Army Medical Center could facilitate high-
quality clinical care management and participate in research data 
collection for the ETCoE. All VA Polytrauma Centers should screen for 
and report all eye injuries to VHA and review previous cases so they 
can be tracked and followed.
    The Military ETCoE must be patient- and family-centered, 
comprehensive, coordinated, and compassionate. It must provide genuine 
Seamless Transition, thus ensuring electronic bi-directional exchange 
of both inpatient and outpatient eye care clinical records that both 
DoD and VA eye care staff can update and share with the Veterans 
Benefits Administration. All DoD/VA case managers need updates on the 
various programs for TBI visual dysfunction, eye trauma, and family 
education and information regarding the locations of vision services 
within VA. VIST/BROS teams must be notified of all transfers of eye 
wounded and all TBI Centers must report data on these cases to VHA.
    ETCoE should develop standards of care. It should also direct 
educational resources and training programs to DoD/VA eye care 
personnel on subjects relating to best clinical practices. The Center 
must also coordinate much-needed research on eye trauma and TBI visual 
dysfunction with DoD, VA, and the National Institutes of Health. 
Additional investigation is needed into the consequences of TBI visual 
dysfunction since many aspects of the long-term consequences of mild-
to-moderate TBI in OIF/OEF veterans are still unknown. In addition, in 
order to ensure a smooth transition for veterans with visual injuries, 
VA should explore the means by which further assistance can be provided 
to immediate family members.
    BVA also strongly supports the National Association of Eye Vision 
Research (NAEVR) position that eye and vision research funding must be 
expanded in the DoD/Congressionally directed Peer Reviewed Medical 
Research Program (PRMRP). The Association requests an increase above 
the $50 million authorized this year. The request is being made due to 
the large numbers of combat eye-injured TBI veterans returning from 
Iraq and Afghanistan, many of whom already have been or will in the 
near future be diagnosed with visual dysfunction.

                                 
        Prepared Statement of Randolph S. Marshall, M.D., M.S.,
         Associate Professor of Clinical Neurology, and Chief,
      Division of Cerebrovascular Diseases, and Program Director,
            Vascular Neurology Fellowship Training Program,
   The Neurological Institute, Columbia-Presbyterian Medical Center,
               New York, NY, on behalf of NovaVision, Inc.

    Neurologically related visual field defects (VFDs) can occur as a 
consequence of stroke, traumatic brain injury, or complications of 
brain surgery. VFDs can occur in one eye (ocular injury) or both eyes 
(brain injury), and range from partial loss of vision field to complete 
blindness. So much of human perception, learning, cognition, and daily 
activities are mediated through vision that visual loss of any sort can 
be devastating to patients' lives. In one study of stroke patients, for 
example, the probability of reaching relative independence (as measured 
on a standard disability scale, the Barthel Index) was diminished by 
20% when a visual field defect is present, and the chances of walking 
>150 feet was reduced from 35% to 3%.\1\
---------------------------------------------------------------------------
    \1\ Reding MJ, Potes E. Rehabilitation outcome following initial 
unilateral hemispheric stroke. Life table analysis approach. Stroke. 
1988;19:1354-1358.
---------------------------------------------------------------------------
    Until recently, the only clinically available treatments to assist 
patients with visual field cuts were prism lenses and oculomotor (eye 
movement) training. These approaches are ``compensatory'' in nature, in 
that the training relies on the acquisition of strategies to compensate 
for the impairment, rather than attempt to treat the impairment itself. 
Many current rehabilitation strategies work on the compensatory 
principle--for example learning to use a wheelchair when gait is 
impaired, or being trained to use the non-dominant hand to write if the 
dominant hand is weak. Although these compensatory strategies have an 
important role in getting the patient back to performing some 
activities of daily living, they leave untreated the impairment itself. 
There is growing evidence in the neuroscience community, however, that 
actual restoration of function through treatment at the level of 
impairment is possible, and can be accomplished through targeted 
behavioral, pharmacological, and brain stimulation techniques. These 
newer, targeted therapies are thought to work through 
``neuroplasticity,'' which is the ability of the nervous system to 
modify its structural and functional organization in order to respond 
to changes in one's environment or recover from injury. By working to 
reverse the impairment, a better ultimate outcome may be expected. It 
is in the category of impairment-targeted treatment that visual 
restoration therapy (VRT) is thought to work. Some initial data have 
been published from our lab regarding the brain reorganization that 
occurs early in the course of VRT treatment.\2\
---------------------------------------------------------------------------
    \2\ Marshall RS, Ferrera JJ, Barnes A et al. Brain Activity 
Associated With Stimulation Therapy of the Visual Borderzone in 
Hemianopic Stroke Patients. Neurorehabil Neural Repair. 2008;22:136-
144.
---------------------------------------------------------------------------
    Visual restoration therapy is a home-based, computerized visual 
stimulation treatment that was developed in the late 1990s by a 
neuroscientist in Germany, and introduced clinically in the U.S. in 
2003. It is now being offered across an expanding number of academic 
institutions and clinics in this country. Columbia University Medical 
Center was among the first to offer the therapy in the U.S. Because of 
my lab's ongoing clinical research on mechanisms of stroke recovery, we 
were interested in participating in the VRT program from a clinical as 
well as scientific perspective. We have treated 67 patients to date, 
some of whom have participated in our research investigations.
    Tracking the results of our patients from a clinical perspective, 
we find that approximately 50% of patients have a significant expansion 
of their visual fields, ranging from 3% to 20% (average 8.2%) absolute 
increase in detection of stimuli in visual areas that were previously 
blind. Furthermore, approximately 61% report subjective improvement, 
including faster reading speed, better mobility (e.g. bumping into 
things less), a return to previous hobbies, and overall improved visual 
function. Our results with regard to the visual field improvement are 
slightly lower than previously reported results, 3-5 which 
were derived from NovaVision's automated visual field testing that 
patients perform at home at the end of each monthly module. The main 
reason for the discrepancy we have come to learn is that some patients 
acquire a compensatory strategy of briefly shifting their eyes toward 
the blind field in order to bring stimuli into their seeing fields. 
These rapid out-and-back eye movements (visual saccades) are often 
performed without conscious awareness on the part of the patient, and 
may be a consequence of the VRT training procedure itself. When these 
eye movements are controlled for using a specialized eye camera there 
still appears to be true visual field expansion, which is the primary 
goal of the therapy. It may turn out that a combination of visual field 
expansion and subconsciously trained saccades account for the 
improvements in visual function that patients experience.
---------------------------------------------------------------------------
    \3\ Kasten E, Bunzenthal U, Sabel BA. Visual field recovery after 
vision restoration therapy (VRT) is independent of eye movements: an 
eye tracker study. Behav Brain Res. 2006;175:18-26.
    \4\ Kasten E, Wust S, Behrens-Baumann W, Sabel BA. Computer-based 
training for the treatment of partial blindness. Nat Med. 1998;4:1083-
1087.
    \5\ Poggel DA, Kasten E, Sabel BA. Attentional cueing improves 
vision restoration therapy in patients with visual field defects. 
Neurology. 2004;63:2069-2076.
---------------------------------------------------------------------------
    In addition to visual field expansion, the VRT stimulation therapy 
appears to confer additional benefits in other realms of cognitive 
restoration, in particular sustained attention. One young man we 
treated, a 19-year-old who had suffered head trauma from a motor 
vehicle accident 3 years prior, gained attentional skills such that he 
went from a score of 8 of 9 measures on a test for attentional deficit 
disorder prior to starting VRT, to a score of 1 of 9 by the end of the 
therapy. Thus, improved global and directed attention, a common 
accompanying deficit in head injury, may be an important secondary 
benefit to VRT.
    I would conclude that VRT has significant merit in the treatment of 
visual field defects following brain injury, and may contribute to 
improved functioning, both at the level of the visual impairment, as 
well as improvement of disability and quality of life.

                                 
      Prepared Statement of Mary Warren, M.S., OTR/L, SCLV, FAOTA
            Associate Professor of Occupational Therapy, and

 Director, Graduate Certification in Low Vision Rehabilitation Program,
   University of Alabama at Birmingham, School of Health Professions,
       on behalf of Performance Enterprises and Dynavision 2000,
                            Ontario, Canada

Background Information
    Persons with acquired brain injuries often experience significant 
changes in vision and visual perceptual processing that affect the 
ability to take in and use visual information to complete daily 
activities.1-4 Visual search, defined as the ability to scan 
the environment to locate targets and information, is a critical 
component of visual processing that is often impaired even in mild 
brain injuries.1-4 Visual search can be disrupted by 
deficits in the visual field (hemianopsias and other field deficits), 
impairment of visual attention (neglect and hemi inattention), 
oculomotor impairment (double or blurry vision), or loss of vision in 
one eye (altering depth perception).4 Disruption of visual 
search creates asymmetry and gaps in the visual information the person 
gathers from the environment. The quality of the person's decision 
making decreases because the brain is not receiving complete visual 
information in an organized fashion and therefore is unable to 
effectively use this information to make appropriate decisions. Visual 
scanning speed also slows significantly, making it difficult for the 
person to acquire information from the environment in a timely 
fashion.1 Deficient visual search can affect all aspects of 
daily living, however, the impairment is greatest for activities 
completed in dynamic environments where the person must be able to 
rapidly process visual information from a variety of 
sources.4 As a result driving and participation in community 
environments for work, shopping, leisure or social participation are 
often most affected.
---------------------------------------------------------------------------
    \1\ Zihl J. Rehabilitation of visual disorders after brain injury. 
East Sussex, UK: Psychology Press, 2000.
    \2\ Zihl J, Hebel N. Patterns of oculomotor scanning in patients 
with unilateral posterior parietal or frontal lobe damage. 
Neuropsychologia, 1997;35:893-906.
    \3\ Mort DJ, Kennard C. Visual search and its disorders. Current 
Opinion Neuro 2003;16:51-57.
    \4\ Kerkhoff G. Neurovisual rehabilitation: recent developments and 
future directions. J Neurol Neurosurg Psychiatry 2000;68:691-706.
---------------------------------------------------------------------------
    Therapists, faced with the responsibility of rehabilitating clients 
with brain injuries so that they can drive and successfully engage in 
dynamic community activities, have looked for devices that will enable 
them to reestablish efficient and fast search strategies in their 
clients. The Dynavision, originally designed to improve the visuomotor 
skills of athletes, is one of the devices adopted and modified by 
rehabilitation specialists to provide that same training benefit to 
clients. Occupational therapists have used the device in rehabilitation 
since 1986 to address visual, cognitive and motor impairment in persons 
with acquired brain injuries. For persons with visual and visuomotor 
impairment the apparatus is used to train compensatory search 
strategies, increase visual search speed and efficiency, improve 
oculomotor skills such as localization, fixation, gaze shift, and 
tracking, increase peripheral visual awareness, visual attention and 
anticipation, and improve eye-hand coordination and visuomotor reaction 
time. For persons with motor impairment it is used to increase active 
upper extremity range of motion and coordination, muscular and physical 
endurance and motor planning. It has been successfully used to improve 
function in adults with limitations from stroke, head injury, 
amputation, spinal cord injury and orthopedic injury.5 
Currently there are over 300 Dynavision units in rehabilitation clinics 
in the United States and 16 units have been added to VA programs within 
the last two years.
---------------------------------------------------------------------------
    \5\ Klavora P, Warren M. Rehabilitation of visuomotor skills in 
poststroke patients using the dynavision apparatus. Percep & Motor 
Skills 1998;86:23-30.
---------------------------------------------------------------------------
Description of the Dynavision Apparatus
    The Dynavision (Figure 1) is an approximately 5 foot by 4 foot 
board containing 64 small red square target buttons arranged in five 
nested rings. Each button covers a single small light bulb that 
illuminates randomly when the device is in use. An LED (light emitting 
diode) display is situated just above the center of the training 
surface. The board is wall mounted and adjustable to accommodate users 
of different heights. A computerized display panel, printer, and 
membrane control panel are situated on the left side of the board. The 
control panel has 37 operating keys that control four modes, six light 
speeds, three working areas, four quadrants, 1-7 digits with displays 
of 1 to .1 second and run times of 30, 60 or 240 seconds.
    With these numerous options, a variety of training and testing 
tasks can be generated using either self-paced or apparatus-paced 
modes. In the self-paced training mode (mode A), a target button 
illuminates in a random location on the board. The user must locate the 
light and strike it with the hand as quickly as possible. When struck, 
the light beeps and extinguishes and another target light appears in a 
random location on the board. The user proceeds to strike the target 
lights for the duration of the exercise. The numbers of light ``hits'' 
are recorded and displayed at the end of the run. In the apparatus-
paced mode, the light is illuminated for a pre-selected period of time 
of 5, 3, 2, 1, .75 or .5 seconds. The user must strike the target 
within the pre-selected time to score a ``hit.'' Apparatus-paced 
exercises are more challenging than self-paced exercises.
    The therapist selects different options to accompany the two modes 
depending on the needs of the user. Exercises can be pre-selected to 
run 30, 60, or 240 seconds. Longer durations are useful for working on 
maintaining sustained attention; shorter durations for exercises 
requiring high intensity performance. The board can be programmed so 
that lights appear within only one quadrant to challenge the user who 
may have difficulty scanning or reaching in a certain direction. The 
training surface can also be adjusted between use of the full board 
(lights in all five rings illuminate) the middle board (the inner four 
rings of the board illuminate) or the inner board (the central three 
rings illuminate). The middle and inner board surfaces are suitable for 
persons with limited upper extremity range of motion or strength. When 
the flash option mode is used, the LED display in the center of the 
board can be programmed to display from one to seven digits 
periodically during the exercise run. The user must call out the 
numbers while striking the target buttons, a task that requires the 
ability to monitor and shift visual attention smoothly between the 
central and peripheral visual field. This program option significantly 
increases the cognitive demands on the user. Other instructional 
variations can be used to increase the cognitive requirements of the 
training tasks. For example, the user may be asked to multiply or add 
the digits in the LED display while striking the lights on the board. 
Or, on B mode, the user may be required to refrain from hitting lights 
when they appear in certain areas of the board or to strike lights with 
a certain hand only.
    On completion of an exercise run, the Dynavision prints outs an 
analysis of the user's performance, including a comparison of reaction 
time and accuracy in the four quadrants of board. This provides the 
clinician with objective data on the user's strengths and weaknesses in 
performance and assists in evaluation, treatment planning and 
documentation.

Application of the Dynavision in Rehabilitation
    The design of the Dynavision board in terms of size, button 
configuration, and number of program options enables the device to be 
used to treat persons with a range of capabilities and medical 
conditions. The simplicity and straightforwardness of the response 
required (striking the button) enables persons with limited 
comprehension to understand the demands of the task. The ability to 
limit presentation to the inner ring of lights, coupled with the 
ability to lower the position of the board permits use by persons with 
restricted upper body mobility and wheelchair users. Although precision 
in the striking the button is required, the button can be struck with 
any part of the hand such as the palm, fingers, or back of the hand. 
This allows persons with limited prehension from conditions such as 
quadriplegia, hemiplegia or amputation to successfully work the board.
    Ability to select different speeds of stimulus presentation from 
the self-pacing of mode A to the automatic presentation of mode B 
enables use with persons with varying speeds of information processing. 
The Board in mode A can be used to facilitate visual scanning and 
increase visual reaction time in persons who have difficulty executing 
adequate search patterns due to oculomotor impairment, hemi-inattention 
and neglect, and hemianopsia. Mode B and the digit flash option can be 
used to challenge high functioning persons who must demonstrate rapid 
information processing and mental flexibility in order to resume 
demanding tasks such as driving, engaging in sports activities and 
work. Varying the length of the presentation from 30 seconds to 240 
seconds allows the therapist to prevent fatigue in persons with limited 
endurance and also challenge sustained attention in persons who have 
difficulty maintaining vigilance. Both modes A and B can be used with 
persons with upper extremity limitations to increase active range of 
motion and coordination.
    The most unique and important contribution of the Dynavision to 
rehabilitation is its capacity to challenge the efficiency and speed of 
visual search. The size of the Dynavision board automatically elicits a 
combination of head turning and eye movement, which is the natural 
scanning strategy used when searching the environment. The light 
buttons are identical which eliminates the need for discrete 
identification and elicits a more automatic visual search response. 
This capacity enables the Dynavision to develop the attention skills 
needed for driving, and orientation to and negotiation of the 
environment. One of the great advantages of the device as a tool 
specifically for the rehabilitation of wounded soldiers is its 
competitive nature. Dynavision drills are presented as games of skill 
by instructing the persons to strike as many lighted buttons as 
possible within the allotted time. This challenges the client to give 
their best effort each time. The device records and analyzes 
performance showing the client where deficiencies exist to enable the 
client to improve performance on the board. Clients can compare their 
performance and compete with each other. Because the device was 
designed for athletes, the lights can be programmed to move at very 
high speeds and it is impossible to beat the board, which draws out the 
competitive nature of young men who use it. Also because it is used to 
train athletes, less stigma is attached to the exercises as using the 
board is regarded as athletic training.

Evidence
    Published research supports the validity and reliability of the 
device in rehabilitation.5-10 Most notably, Dr. Peter 
Klavora and his collaborators at the University of Toronto have 
published several studies on the ability of the Dynavision to predict 
driving performance in persons with brain injury and to rehabilitate 
driving performance in persons post stroke.7-8
---------------------------------------------------------------------------
    \6\ Klavora P, Heslegrave RJ, Young M. Driving skills in elderly 
persons with stroke: comparison of two new assessment options. Arch 
Phys Med Rehabil, 2000;81:701-705.
    \7\ Klavora P, Gaskovski P, Heslegrave R, Quinn R, Young M. 
Rehabilitation of visual skills using the dynavision: a single case 
experimental design. Canadian J Occup Ther, 1995;62:37-43.
    \8\ Klavora P, Gaskovski P, Forsyth R, et al. The effects of 
dynavision rehabilitation on behind-the-wheel driving ability and 
selected psychomotor abilities of persons post-stroke. Am J Occup Ther 
2000;49:534-542.
    \9\ Klavora P, Gaskovski P, Forsyth R. Test-retest reliability of 
three dynavision tasks, Percep & Motor Skills 2000;80:607-610.
    \10\ Klavora P, Gaskovski P, Forsyth R. Test-retest reliability of 
the dynavision apparatus. Percep & Motor Skills 1994;79:448-450.
---------------------------------------------------------------------------
                   Figure 1: The Dynavision Apparatus

[GRAPHIC] [TIFF OMITTED] T3045A.001


                                 

      Prepared Statement of Gayle Clarke, Chief Executive Officer,
       Neuro Vision Technology Pty. Ltd., Torrensville, Australia

Introduction
    Chairman Mitchell, Ranking Member Brown-Waite, and Members of the 
House Veterans' Affairs Subcommittee on Oversight and Investigations; 
on behalf of Neuro Vision Technology (NVT) I would like to thank you 
for this opportunity to present testimony on Traumatic Brain Injury 
(TBI) as it relates to vision.
    Neuro Vision Technology Pty. Ltd. has developed the NVT 
Neurological Vision Rehabilitation System which specializes in the 
assessment, training and management of people with Neurological Vision 
Impairments (``NV Impairments'') following traumatic brain injury. NVT 
provide the equipment and training to professional paramedical and 
rehabilitation staff who are then responsible for assessing and 
training the patient with neurological vision deficits.
    No comparable equipment and training program exists internationally 
outside of Australia despite recognized need within the Acute and 
Rehabilitation Hospital sectors and blindness services.

Prevalence of Neurological Vision Impairments
    Previous research indicates:

       Between 30% and 35% of the population diagnosed with 
acquired and traumatic brain injury suffer from associated neurological 
vision impairment \1\
---------------------------------------------------------------------------
    \1\ Zihl, Josef. ``Oculomotor scanning performance in subjects with 
homonymous visual field disorders'', Visual Impairment Research 1999. 
Vol. 1, No. 1, pp 23-31.

    NV Impairment can be a result of stroke or traumatic event such as 
a car accident or military injury.
    NV Impairment rehabilitation in the past has ``fallen through the 
gaps''. The primary vision impairment agencies such as the not for 
profit Blindness agencies and Blind Rehabilitation Centers (BRC) have 
either been unaware or have not invested significant resources in NV 
Impairment rehabilitation. Major stroke and rehabilitation hospitals 
have also neglected the need for a standardized functional visual 
assessment as part of a minimum standard of clinical care in the 
rehabilitation of brain injury.
    Historically, rehabilitation programs have focused on the physical 
recovery (Physiotherapy programs), implementation of strategies 
designed to maximize independence in activities of daily living 
(Occupational Therapy programs) and Speech Therapy. The incidence of 
language deficits following TBI is equivalent to that of NV impairment 
following TBI, however, assessment and specific therapy to reduce the 
impact of NV impairment is currently not standard practice in the 
majority of rehabilitation programs. Assessment and training should 
immediately become part of the clinical standard of care for the 
rehabilitation of Neurological Vision Deficits.
    Some statistics which have been released by the Department of 
Veterans Affairs Polytrauma Unit and Western Blind Rehabilitation 
Center, Palo Alto, indicated that:

       ``67% of polytrauma patients seen to January 2006 have a 
severe vision impairment''
       ``90% injured as a result of combat, have a severe 
neurological vision impairment''

Definition of Neurological Vision Impairment
    The most common field deficit following TBI is Homonymous 
Hemianopsia (HH); half of the vision is lost in both eyes. HH impacts 
on all areas of activities of daily living, writing, reading, shaving, 
eating, dressing and mobility in busy or unfamiliar areas.
    Additionally patients can be unaware of the extent of vision loss 
which is call Visual Neglect. The patient may only eat half the food on 
his plate, shave half of his face, be disorientated in space because he 
only sees one side of the world, e.g. moving from his room to 
physiotherapy he sees one side of the corridor and on the way back only 
sees the other side and therefore thinks he is in a totally different 
place.
    Patients can also suffer from Visuo-spatial deficits whereby they 
cannot recognize their environment no matter how familiar it was 
previously, they may not recognize familiar faces of their mothers, 
wives or family members. These patients quite often do not have a 
visual field loss or ocular motor problem and therefore it is extremely 
hard to diagnose.
    NVT have developed a standardized Vision Rehabilitation System that 
offers an assessment, training, outcome measures, management and 
research solution for the rehabilitation of NV Impairment.
Rehabilitation of Neurological Vision Impairments
    While clinical vision assessments may be provided by Optometrists 
and Ophthalmologists, these usually occur much later than other 
rehabilitation assessments, sometimes the delay can be as long as many 
months. Many of the more complex visual perceptual deficits go 
undiagnosed and untreated for even years.
    World leading neuro-psychologists and professionals in neurological 
rehabilitation centers are outlining the real issue with neurological 
vision impairment. In research studies in the U.S. it has been 
disturbing to find published articles which outline the following:

       ``50% of the patients in a head trauma rehabilitation 
centre show visual systems disorders not assessed before, although most 
of the patients were chronic and had been treated in other hospitals 
previously'' \2\
---------------------------------------------------------------------------
    \2\ Gianutsos, R. ``Vision rehabilitation following acquired brain 
injury. In: Gentile, M. ed Functional visual behavior. A therapist's 
guide to evaluation and treatment options. Bethesda, MD: American 
Occupational Therapist Organization, 1997:267-294.

    This in part is due to vision assessment not being part of a 
clinical standard and partly due to the staff not being trained in 
appropriate assessment and rehabilitation techniques for neurological 
vision deficits.
    Patients referred to Blind Rehabilitation Centers and/or Low Vision 
Clinics are often provided with programs designed for ocular disorders 
e.g. glaucoma, macular degeneration. Most staff have minimal 
understanding of the additional cognitive and physical deficits 
associated with traumatic brain injury and may provide ineffectual or 
inappropriate interventions.
    It can be argued that Neurological Vision Rehabilitation Therapy 
should be provided by a specialized profession equivalent to 
traditional therapy providers such as Speech Therapists given that the 
incidence of vision deficits following TBI is equivalent to that of 
language deficits following TBI.
NVT Neurological Vision Rehabilitation System
    NVT Vision Rehabilitation System is not just a device but a therapy 
intervention program that actively transfers skills learnt in early 
phase recovery into functional tasks graded for a variety of settings, 
thus catering for the different entry and exit levels of a patient's 
performance.
    It is based on assessment and training therapy programs which have 
been successfully provided in acute and rehabilitation hospitals in 
Australia for over 20 years to clients suffering from a Neurological 
Vision Impairment due to Acquired and Traumatic Brain Injury.
    The NVT Neurological Vision Rehabilitation System's main objective 
is to assess and train the patient in compensatory scanning techniques 
which can be transferred in all activities of daily living such as 
mobility, orientation, reading, personal safety and quality of life. It 
is designed for early intervention following trauma and to be conducted 
in an interdisciplinary setting to support other rehabilitation 
therapies.
    The Assessment is holistic in its format and has many components 
including neurological behavior checklists, activities of daily living, 
functional vision screening, quality of life measure and mobility 
assessment. The Assessment also includes the NVT Scanning Device which 
displays various sequences of lights to diagnose the presence of visual 
field loss, scanning deficits and other visual perceptual deficits 
including visuo-spatial neglect. The light box has a series of colored 
lights spanning 1.8 meters in length to simulate the degree of scanning 
required for mobility tasks, such as crossing roads.
    The Training is designed to provide scanning exercises that 
encourage use of residual vision in compensatory scanning techniques. 
The device is portable to allow training to be carried out in the acute 
hospital, rehabilitation hospital or the patient's home. Therapy 
intervention can be evaluated by using the standardized assessment 
component post training to demonstrate patient improvement by evidence 
based outcomes.
    Attention to required Research protocols within the software, which 
are based on standardization of assessments and therapy, allow for 
comparisons between base level and post intervention over a number of 
outcome measures.
    Validation in the form of clinical trial/trials with ethics 
approval, for comparisons between patients with immediate and delayed 
NVT Vision Therapy intervention has commenced and will be completed in 
2009/10. The study is being conducted by an independent organization 
(the Royal Society for the Blind South Australia ``RSB'') using 
patients drawn primarily from Stroke Rehabilitation Unit of the 
Repatriation General Hospital, Adelaide South Australia and in 
conjunction with Flinders University.
    International interest in collaborative research has been marked 
and currently two grant applications have been lodged in the U.S. It is 
likely in the next six months another grant application in Scotland 
will be lodged.

Training of Rehabilitation Staff
    An integral part of the NVT Neurological Vision Rehabilitation 
System is the training of staff in the use of the assessment and 
training protocols and tools. NV Impairment has been a neglected area 
of primary health care and coverage for many years. Brain Injury 
Rehabilitation programs have traditionally focused on physical, 
cognitive and language therapies and often ignore the impact of visual 
deficits. This is due in part to the lack of quality assessment and 
therapy intervention tools.
    The complexity of injuries, in addition to vision loss, made these 
cases challenging for vision rehabilitation programs, especially when 
the injury involved a traumatic brain injury. Staff are challenged 
because historically Blind Rehabilitation programs are designed to 
address the needs of an aging veteran population with age-related eye 
disease and ocular problems. Staff need to understand and be trained in 
recognizing the difference between ocular intervention and neurological 
vision impairment intervention e.g. brain not eyeball.
    The advents of the Iraq and Afghanistan conflicts have highlighted 
Traumatic Brain Injury and subsequently the relationship of 
Neurological Vision Deficits. Rehabilitation professionals are 
realizing they are not equipped to provide support and training and see 
the NVT Vision Rehabilitation system as a concrete means of providing a 
standardized assessment and training program with built in outcome 
measures.
    The NVT professional training program is delivered in a structured 
manner and provides VIST's, BROS and Occupational Therapists with:

       Theoretical aspects of Traumatic Brain Injury and the 
Cortical Vision System.
       Training in the use of the NVT Scanning Device as an 
assessment tool for determining the presence of Homonymous Hemianopia 
and/or visuo-spatial neglect.
       Training in the use of the NVT Scanning Device as a 
therapy tool for enhancing visual function.
       Skills that will enable the Vision Therapist to transfer 
these scanning strategies to the veteran's home and community setting.
       Comprehensive manuals, workbooks lecture notes to 
support the training program.
       Currently requires four weeks intensive face to face 
contact with service provider.
       Competency measured after three months practical 
experience.

    The Palo Alto Blind Rehabilitation and Polytrauma staff, and the 
Tampa Polytrauma rehabilitation staff, who have trained with the NVT 
system rightly see themselves as world leaders in the area of 
Neurological Vision Rehabilitation and have already seen many success 
in the short time they have been working with veterans. They are 
finding many advantages in providing the Neurological Vision 
Rehabilitation programs as part of the comprehensive interdisciplinary 
rehabilitation service within the Polytrauma Rehabilitation Centers.
Overview of Case Studies
    I have outlined briefly four veterans with Traumatic Brain Injury 
who have made good improvements in their visual functioning and 
rehabilitation following NVT assessment and training at Palo Alto since 
NVT training commenced in October 2006.

       22 yr old Veteran injured in Iraq by IED, Level 4 Coma 
Stim, suffering from right homonymous hemianopia, visual neglect, 
language deficits, and related cognitive issues, injured lower limbs, 
right hemiparesis.

    Training intervention: Over a period of four weeks the BROS was 
able to attain systematic scanning in intact field of view and in 
deficit field where there was a strong presence of visual neglect. 
Veteran's deficit right field of view was stimulated so that 
spontaneous scanning was initiated by the veteran. Other nursing and 
rehabilitation staff were provided with strategies for use in day-to-
day therapy programs where vision rehabilitation could be integrated.

       24 yr old Veteran injured in Iraq by IED, loss of limb, 
loss of speech, Frontal-parietal-occipital lobe damage, wheelchair 
mobility, bi-lateral visual field loss.

    Training intervention: On assessment this client was unable to 
travel safely or independently and was maneuvering his wheelchair from 
one side of the corridor to the other. He was disorientated in space 
and unaware of the need to scanning bi-laterally to compensate for his 
field loss. Outcomes on training intervention included safe independent 
wheelchair mobility to therapy sessions, dining room and some outdoor 
travel.

       22 yr old female veteran who was involved in a motor 
vehicle roll over in Germany, July 2006. Frontal lobe, bi-temporal, bi-
parietal lesions and occipital craniotomy, visuo-spatial/perceptual 
deficits, quadrantanopia, hip and leg injuries, related cognitive 
deficits including visual inattention.

    Training intervention: The veteran had difficulties with spatial 
orientation and finding her way to therapy sessions. She was easily 
distracted and had balance and gait problems. On completing her vision 
rehabilitation training with the BROS at Palo Alto she was able to live 
independently, return to study, plan her weekly schedules and visit the 
local supermarket to do her weekly shopping.

       Veteran injured in Korea in 1951, gunshot wound to the 
head, received no vision therapy until February 2007, has a remaining 
vision intact field of superior right quadrantanopia.

    Excerpt from his testimonial: On June 13, 1952, I was shot through 
the head during Korean war combat. The bullet went through the skull 
behind the ears, blew off the back of the skull, damaged the occipital 
lobe, and left me legally blind. I lost 75% of the visual field in both 
eyes. After a lengthy stay in an Army hospital, I was discharged 
without the benefit of any rehabilitative therapy for my loss of 
vision.
    Fifty-five years later I discovered the Veterans Administration 
Western Blind Rehabilitation Center (WBRC) in Palo Alto, California.
    I was admitted to the Center on January 10, 2007: The staff and I 
soon realized that their standard program was geared to helping people 
suffering from vision loss due to eye pathology, not loss of vision due 
to traumatic brain injury.
    Therapy for loss of vision due to eye pathology relies heavily upon 
magnification devices. A person with vision loss due to traumatic brain 
injury does not need magnification aids, but does need to be trained to 
bring those objects, which he may not see, into the undamaged portion 
of his visual field.
    Upon realization that the normal curriculum at the Center was not 
appropriate for traumatic brain injury vision loss, Elizabeth Jesson, 
WBRC Director, removed me from their standard program and assigned 
Visual Therapist Scott Johnson as my coordinator.
    Mr. Johnson employed a system developed in Australia by Gayle Clark 
entitled Neuro-Vision Technology. This system trains a person to move 
the undamaged portions of his visual field to cover areas where vision 
is unimpaired.
    Even though I was 55 years late in receiving any visual therapy, I 
feel this system was beneficial. The Neuro-Vision Technology System 
would be even more successful if applied as soon as the WBRC becomes 
responsible for a veteran's rehabilitation.
    Mr. Johnson has been assigned to develop a program for the WBRC 
utilizing the Neuro-Vision Technology System. This program will give 
the WBRC the capability of providing vision loss rehabilitation to the 
large number of veterans who have received traumatic brain injuries 
from roadside bombs and other explosive devices in the OIF and OEF.
    Please lend your support and encouragement to this proposed program 
when it comes to your attention.

            Sincerely,
                                                 Rodger L. Thisdell

Conclusions
    The NVT Neurological Vision Rehabilitation System and was recently 
featured favorably in the San Francisco Chronicle.\3\ Staff have been 
trained in Australia and the UK including staff funded by the Scottish 
War Blinded. The current technology is targeted at improving mobility 
and functional field of vision via specialists in the rehabilitation, 
optometry and neuro-ophthalmology services.
---------------------------------------------------------------------------
    \3\ ``Fernandez, E (2008) ``New Treatments for Traumatic Eye 
Injuries,'' San Francisco Chronicle, March 9, 1.
---------------------------------------------------------------------------
    The Department of Defense (DoD) and VA Health systems are seen as 
the gold standard in health services. The implementation of the NVT 
Vision Rehabilitation System within the VA Health system promotes the 
knowledge that it is a leader internationally in providing the best 
possible care for those veterans with TBI and related neurological 
vision impairments. It recognizes that Neurological Vision Impairment 
requires early assessment and rehabilitation intervention and that 
vision therapy is an integral part of the holistic rehabilitation 
required for the OIF and OEF servicemembers.
    The NVT Neurological Vision Rehabilitation System's main objective 
is to assess and train the patient in compensatory scanning techniques 
which are then transferred into all activities of daily living such as 
mobility, orientation, reading, personal safety and quality of life. It 
is designed for early intervention following trauma and to be conducted 
in an interdisciplinary setting to support other rehabilitation 
therapies.
    It must be remembered that there is no ``short cut fix'' when 
talking about rehabilitation for Traumatic Brain Injury, in most cases 
this is a lifelong process, but experience has shown that early 
intervention and specific intervention for vision deficits improves 
quality of life, decreases the level of medical intervention and 
decreases the level of support required in the community setting once 
veterans are discharged from rehabilitation programs.
    Chairman Mitchell and Ranking Member Brown-Waite and members of the 
Subcommittee, I would ask that you consider the following:

    1.  While clinical vision assessments may be provided by 
optometrists and ophthalmologists, these usually occur much later than 
other rehabilitation assessments. Sometimes the delay can be as long as 
many months. Many of the more complex visual perceptual deficits can go 
undiagnosed and untreated for even years.

    Recommendation: The assessment and training of veterans with 
Neurological Vision Deficits should be implemented in the early stages 
of recovery and become part of the clinical standard of care for the 
rehabilitation of Traumatic Brain Injury.

    2.  Patients referred to Blind Rehabilitation Centers and/or Low 
Vision Clinics are often provided with programs designed for ocular 
disorders, e.g., glaucoma, macular degeneration. Most staff have 
minimal understanding of the additional cognitive and physical deficits 
associated with traumatic brain injury.

    Recommendation: BROS, VISTs and Occupational Therapists be trained 
to provide Neurological Vision Therapy assessment and intervention 
programs in the interdisciplinary settings of Polytrauma, Polytrauma 
Network Sites and Blind Rehabilitation Centers.

    Chairman Mitchell, I have spent 25 years of my life working as a 
clinician in the area of vision rehabilitation for patients with 
neurological vision impairments. I have seen many successes over the 
years and have many stories to tell. My key motivator is improving 
patient quality of life and as such I believe passionately that a 
comprehensive commitment to vision equipment such as Dynavision, Nova 
Vision and Neuro Vision Technology will provide internationally 
recognized, gold standard rehabilitation services to U.S. veterans whom 
deserve only the best.
    Neuro Vision Technology strongly supports the recommendations of 
the Blinded Veterans Association and thanks you sincerely for the 
opportunity of testifying to the Subcommittee today.

                                 

                Prepared Statement of James Orcutt, M.D.
        Chief of Ophthalmology, Office of Patient Care Services,
  Veterans Health Administration, U.S. Department of Veterans Affairs

    Good morning, Mr. Chairman and members of the Subcommittee. Thank 
you for the opportunity to discuss the Department of Veterans Affairs' 
(VA's) provision of care for veterans needing support for visual 
impairment and traumatic brain injury (TBI). I am accompanied by Dr. 
Barbara Sigford, National Program Director for Physical Medicine and 
Rehabilitation.
    VA and the Department of Defense (DoD) have a longstanding 
memorandum of understanding allowing VA to provide medical care and 
rehabilitative services for severely injured active duty 
servicemembers, such as those with blindness, traumatic brain injury, 
and spinal cord injury. The Veterans Health Administration (VHA) has 
developed one of the most extensive rehabilitation systems in the 
country for visual impairment, and our work in treating TBI, dating 
back to the creation of four national TBI centers in 1992, is 
unmatched. Our Polytrauma System of Care (PSC) is uniquely positioned 
to address the complex needs of veterans and servicemembers exhibiting 
these two conditions, and others, simultaneously. My testimony today 
will provide an overview of the continuum of care VA provides veterans 
and servicemembers to ensure they receive the right care, in the right 
way, at the right time, to further their goals of rehabilitation and 
reintegration.
    VA has developed several initiatives to facilitate the ease of 
transfer for veterans and servicemembers transitioning from military 
service in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom 
(OIF). For the seriously injured, ill, or wounded, VA and DoD have 
created a new Federal Recovery Coordination Program (FRCP) that will 
assign Coordinators capable of working within and between VA, DoD and 
the private sector to monitor and support our severely wounded veterans 
and servicemembers. VA's OEF/OIF Case Management Program provides a 
fully integrated team approach at every VA Medical Center (VAMC), and 
includes a Program Manager, Clinical Case Managers, a Veterans Benefits 
Administration (VBA) Veterans Service Representative, and a Transition 
Patient Advocate. OEF/OIF veterans with severe injuries are 
automatically provided a case manager; all other OEF/OIF veterans are 
assigned a case manager upon request. Clinical Case Managers, who are 
either nurses or social workers, coordinate patient care activities and 
ensure all VHA clinicians are providing care to the patient in a 
cohesive, integrated manner. VBA team members assist veterans by 
educating them on VA benefits and assisting them with the benefit 
application process.
    The Transition Patient Advocates (TPAs) serve as liaisons between 
the VAMC, the Veterans Integrated Service Network (VISN), VBA, and the 
patient. TPAs act as communicators, facilitators and problem solvers. 
The team documents their activities in the Veterans Tracking 
Application (VTA), a web-based tool designed to track injured and ill 
servicemembers and veterans as they transition to VA. VHA is also using 
the Primary Care Management Module (PCMM), an application within VHA's 
VistA Health Information system, to track patients assigned to an OEF/
OIF Case Management team.
    VA provides clinical rehabilitative services in several specialized 
areas employing the latest technology and procedures to provide our 
veterans with the best available care and access to rehabilitation for 
Polytrauma, TBI, visual impairment, and other areas. Whenever an OEF/
OIF veteran requires specialized rehabilitative services, the assigned 
OEF/OIF case manager engages with the clinical case manager appropriate 
for that area of rehabilitation (e.g., polytrauma, spinal cord injury, 
blindness) and coordinates with the appropriate clinical case manager 
regarding the veteran's progress and rehabilitation.
    Over the past two years, VA has implemented an integrated system of 
specialized care for veterans sustaining traumatic brain injury (TBI) 
and other polytraumatic injuries. The Polytrauma System of Care 
consists of four regional TBI/Polytrauma Rehabilitation Centers (PRC) 
located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA. 
A fifth PRC is currently under design for construction in San Antonio, 
TX, and is expected to open in 2011. The four regional PRCs provide the 
most intensive specialized care and comprehensive rehabilitation 
available for combat injured patients transferred from military 
treatment facilities. As veterans recover and transition closer to 
their homes, the Polytrauma System of Care provides a continuum of 
integrated care through 21 Polytrauma Network Sites, 76 Polytrauma 
Support Clinic Teams and 54 Polytrauma Points of Contact, located at 
VAMCs across the country. Throughout the Polytrauma System of Care, we 
have established a comprehensive process for coordinating support 
efforts and providing information for each patient and family member. 
On February 27, 2006, VA established a national Polytrauma Call Center 
available 24 hours a day, seven days a week, to families and patients 
with questions. This Center is staffed by healthcare professionals 
trained specifically in polytrauma care and case management issues and 
can be reached by calling 1-888-827-4824.
    The care coordination process between the referring DoD military 
treatment facility and the PRC begins weeks before the active duty 
servicemember is transferred to VA for healthcare. The PRC physician 
monitors the medical course of recovery and is in contact with the MTF 
treating physician to ensure a smooth transition of clinical care. The 
admissions nurse case manager maintains close communication with the 
referring facility, obtaining current and updated medical records. A 
social work case manager is in contact with the family to address their 
needs for psychosocial and logistical support. Before transfer, the PRC 
interdisciplinary team meets with the DoD treatment team and family by 
teleconference as another way to ensure a smooth transition. The PRCs 
provide a continuum of rehabilitative care including a program for 
emerging consciousness, comprehensive acute rehabilitation, and 
transitional rehabilitation. Each of our PRCs is accredited by the 
Commission on Accreditation of Rehabilitation Facilities (CARF). 
Intensive case management is provided by the PRCs at a ratio of 1 case 
manager per 6 patients, and families have access to assistance 24 hours 
a day, 7 days a week. The interdisciplinary rehabilitation treatment 
plan of care reflects the goals and objectives of the patient and his 
or her family.
    From March 2003 through December 2007, the PRCs provided inpatient 
rehabilitation to 507 military servicemembers injured in combat 
theaters. The transition plan from the PRCs to the next care setting 
evolves as the active duty servicemember progresses in the 
rehabilitation program. Families are integral to the team and are 
active participants in therapies, learning about any residual 
impairments and ongoing care needs. The team collaborates with the 
family to identify the next care setting, and determine what will be 
needed to accommodate the transition of rehabilitative care. The 
consultation process includes a teleconference between the PRC team, 
the consulting team, the family, and the patient. These conferences 
allow for a coordinated transfer of the plan of care, and an 
opportunity to address specific questions.
    Before discharge, each family and patient is trained in medical and 
nursing care appropriate for the patient. Once a discharge plan is 
coordinated with the family, VA initiates contact with necessary 
resources near the veteran's home community. Based upon the patient's 
desired discharge location, a transition plan is prepared with one of 
the 21 VA Polytrauma Network Sites or another provider in the 
Polytrauma System of Care within the patient's chosen community. As 
veterans and servicemembers transition to their home communities, 
ongoing clinical and psychosocial case management is provided by a 
rehabilitation nurse and social worker from one of 76 Polytrauma 
Support Clinic Teams. VA social work case managers follow each patient 
within the Polytrauma System of Care at prescribed intervals contingent 
upon need. For example, there are four levels of case management: 
intensive case management, where contact is made daily or weekly; 
progressive case management, where VA contacts the patient monthly; 
supportive case management, quarterly; and lifetime case management, 
annually. For the many patients who are still active duty 
servicemembers, the military case managers are responsible for 
obtaining authorizations from DoD regarding orders and follow-up care 
based upon VA medical team recommendations.
    VA reviews and improves our care for these wounded or injured 
warriors. VA assembled a national research task force last summer to 
review and evaluate the long term care needs of our most seriously 
wounded or injured returning OEF/OIF veterans. This task force recently 
completed its work and made several recommendations, which are being 
submitted to the Secretary for his review. Also, in compliance with the 
2008 National Defense Authorization Act, VA is collaborating with the 
Defense and Veterans Brain Injury Center to design and execute a 5-year 
pilot program to assess the effectiveness of providing assisted living 
services to eligible veterans to enhance their rehabilitation, quality 
of life, and community integration.
    We also co-hosted a conference in December 2007 with DoD on the 
visual consequences of TBI. This conference was attended by members of 
the visual team for each Polytrauma Rehabilitation Center as well as 
blind rehabilitation specialists, optometrists, and ophthalmologists 
from both Departments and provided an opportunity to initiate a 
consensus validation process, which will identify and disseminate the 
most effective strategies for treatment and services when they are 
known or to determine where additional research is needed. VA has also 
assembled teams of specialists, to develop questions for determining 
evidence-based treatments; we anticipate this process will be completed 
in the summer. VA holds an annual conference, portions of which are 
jointly conducted with Blinded Veterans of America (BVA), at which our 
experts and BVA representatives can discuss new treatment methods and 
further areas of cooperation.
    Any OEF/OIF veteran seen at a VA medical facility is automatically 
screened for TBI. Veterans for whom the screen is positive are referred 
for a full, in-depth evaluation. The evaluation process includes a 
standardized evaluation template of common problems following brain 
injury. This template includes checks for visual impairment. Our visual 
treatment specialists conduct full visual examinations including but 
not limited to acuity, full visual field testing, pressures within the 
eye, and imaging of both the retina and the cornea to assess damage to 
these structures. In all, this screening process includes a 22-item 
checklist, including an evaluation for visual impairment and presence 
of visual symptoms. For veterans and active duty personnel with visual 
impairment, VA provides comprehensive Blind Rehabilitation services 
that have demonstrated significantly greater success in increasing 
independent functioning than any other blind rehabilitation program--
anywhere. Currently, 164 Visual Impairment Service Team (VIST) 
Coordinators provide lifetime case management for all legally blind 
veterans, and all OEF/OIF patients with visual impairments. 
Additionally, 38 Blind Rehabilitation Outpatient Specialists (BROS) 
provide blind rehabilitation training to patients who are unable to 
travel to a blind center. These Polytrauma Blind Rehabilitation 
Specialists have certification in two areas, low vision rehabilitation 
and orientation and mobility training. They work in close collaboration 
with our neuro-ophthalmologists and low vision optometrists who 
evaluate, diagnose, and recommend treatment for our patients with 
visual impairments. Each Polytrauma Rehabilitation Center and 
Polytrauma Network Site has dedicated funding for a BROS on the 
Polytrauma team.
    Blind Rehabilitation Service involvement often begins while the 
injured servicemember is still a patient at a military treatment 
facility. The patient is transferred to a VA Blind Rehabilitation 
Center as soon as it is medically needed and at the patient's request. 
There is no waiting time for OEF/OIF veterans for this service.
    The VA Blind Rehabilitation Continuum of Care, first announced in 
January 2007, further extends a comprehensive, national rehabilitation 
system for all veterans and active duty personnel with visual 
impairments. Program expansion during 2008 will add 55 outpatient 
vision rehabilitation clinics, 35 additional BROS at VAMCs currently 
lacking those services, and 11 new VIST positions. The continuum of 
care will provide the full scope of vision services--from basic, low 
vision services to blind rehabilitation training--across all Veteran 
Integrated Service Networks (VISNs).
    This continuum of care will allow early intervention for patients 
whose vision loss results from progressive eye degeneration. Providing 
services at the earliest point in the continuum will maximize 
independence and substantially reduce demands on the family, community 
and VA. Providing a wider array of outpatient services across the 
continuum of visual impairment, coupled with the ability for a veteran 
to move through the continuum of care based on individual visual and 
psycho-social needs will reduce wait times for rehabilitation services. 
The continuum of care provides basic low vision services, intermediate 
low vision services, and advanced ambulatory low vision services in all 
VISNs. Advanced blind rehabilitation services are provided in all VISNs 
that do not already have an inpatient blind rehabilitation center.
    VHA is expanding our capacity to provide care for the growing 
number of veterans returning from service in Iraq and Afghanistan with 
wounds and trauma resulting in blindness and visual impairment. We have 
provided additional funds to ensure visually impaired veterans receive 
appropriate care and the latest technological devices when needed and 
in locations convenient to them. To date, VA has provided inpatient 
blind rehabilitation services to 53 veterans and active duty 
servicemembers from OEF/OIF, while 156 OEF/OIF veterans and 
servicemembers have received some level of care from VHA Blind 
Rehabilitation Service.
    VA has consistently been a leader in the development of sensory and 
prosthetic research aids. Each Blind Rehabilitation Center is actively 
involved in research, development and evaluation of devices. Many 
devices that were involved in research programs in past years are now 
regular features of service at our Blind Rehabilitation Centers. As new 
devices are crafted, VA will be among the first to evaluate them. Our 
goal in research and treatment is to improve the quality of life for 
all blind or visually impaired persons, veterans and non-veterans 
alike.
    VA has been a national leader in the care and rehabilitation of 
veterans with TBI and visual impairments, and we are committed to 
maintaining that status. Thank you again for you the opportunity to 
meet with you today. I would be pleased to address any questions that 
you have at this time.

                                 

              Prepared Statement of Glenn Cockerham, M.D.,
 Chief of Ophthalmology, Veterans Affairs Palo Alto Health Care System,
  Veterans Health Administration, U.S. Department of Veterans Affairs

    Chairman Mitchell, Ranking Member Brown-Waite, and members of the 
Committee, thank you for the opportunity to testify. I am joined today 
by Dr. Glenn Cockerham, Chief of Ophthalmology at the VA Palo Alto 
Health Care System. We are here today to discuss our research on vision 
issues and traumatic brain injury (TBI). This research was conducted at 
the Palo Alto Polytrauma Rehabilitation Center (PRC) and Polytrauma 
Network Site (PNS) on a samples of just over 100 patients, including 
both veterans and active duty servicemembers. This is preliminary 
research and much more work needs to be done to determine conclusively 
the risks for this population and best clinical steps forward. My 
research has focused on two groups: first, veterans and servicemembers 
receiving inpatient care at the Palo Alto PRC who have sustained visual 
impairments associated with life-threatening polytrauma injuries; and 
second, outpatients receiving care at the Palo Alto PNS who have 
sustained visual dysfunctions associated with mild TBI.
    While the inpatient and outpatient groups seem far apart in terms 
of the severity of their injuries, they have two common factors: the 
most common cause of injury to both groups is a blast event, and both 
groups have sustained a traumatic brain injury (TBI), although to 
varying levels of severity. Our preliminary research suggests both 
groups have rates of blindness, visual impairment, or visual 
dysfunction that appear to occur at rates higher than in prior 
conflicts.
    During the Vietnam War eye injuries accounted for between 5% and 
10% of all injuries. In the Persian Gulf War, eye injuries accounted 
for approximately 13% of all casualties. The precise incidence of eye 
injuries occurring in Operation Enduring Freedom (OEF) and Operation 
Iraqi Freedom (OIF) are currently unknown. Preliminary data suggests 
these rates are at least comparable to the Persian Gulf War. Our 
research suggests that, in addition to injuries to the eye, damage to 
the visual system within the brain can create significant functional 
impairments for many troops and veterans.
    In analyzing data from our early studies, exposure to a blast seems 
to be most closely associated with vision dysfunctions in the 
populations we have studied in Palo Alto. Among the 108 patients 
studied, those who have injuries stemming from a blast event are about 
twice as likely to have a severe visual impairment, including 
blindness, as are those whose injuries are caused by all other events. 
Overall 26% of this population is blind or has a best-corrected visual 
acuity of 20/100 or less or a very severe visual field loss. In other 
work done by Dr. Cockerham, looking specifically at veterans in the PRC 
with TBI caused by combat blast, significant abnormalities in visual 
function were found, despite normal or near-normal visual acuity by 
conventional testing. Rigorous eye examinations by ophthalmologists, 
including neuro-ophthalmology, detected significant damage to eye 
structures including cornea, retina, and optic nerve. In many instances 
patients were asymptomatic and unaware of underlying eye damage. In 
other patients in this population, problems such as double vision, 
inability to effectively track moving objects, and other visual 
dysfunctions are present. The consequence of these visual impairments 
and dysfunctions potentially impede independent functioning and may 
contribute to a reduced quality of life. Patients with traumatic eye 
injuries risk development of sight-threatening complications later in 
life and will require ongoing eye care. In addition, these visual 
impairments and dysfunctions can complicate other rehabilitation 
efforts and impair the individual's ability to pursue education, obtain 
employment, and social functioning. Most, if not all, of these 
conditions usually respond to therapy and rehabilitation, and the 
resulting disability can be minimized. VA's Blind Rehabilitation 
Service provides ample evidence of the effectiveness of vision 
rehabilitation treatment.
    Our clinical observations suggest addressing these visual issues 
during the rehabilitation process can facilitate the rehabilitative 
efforts of other members of the rehabilitation team and can provide 
valuable information that may help families better understand the 
problems facing their loved ones. VA's Polytrauma Rehabilitation 
Centers recognized the importance of early intervention for visual 
impairment and structured interdisciplinary teams to include blind 
rehabilitation specialists as team members. In addition, the need for 
neuro-ophthalmology services was identified as a key consultative 
service.
    Our preliminary research also suggests blast events may have 
significant negative effects on visual function, even when overall 
physical injury appears to be minor. Since early 2007, we have studied 
outpatients at the Palo Alto PNS clinic. These patients have been 
diagnosed with mild TBI and often have PTSD, persistent pain, and 
hearing impairment. We have gathered self-reported data and conducted 
visual screenings on 125 OEF/OIF patients served by the PNS clinic. 
Examination data suggests severe visual impairment is present in less 
than 2% of this population. However, data from optometric screenings 
suggest that as many as 40% of these patients have one or more 
binocular vision dysfunction symptoms. These binocular dysfunctions 
often manifest as an inability of the two eyes to effectively function 
together and may result in double vision eye fatigue, and other visual 
conditions which impair everyday visual function. When analyzing the 
self-reported conditions, more than 60% of these patients indicated an 
inability to perform sustained reading, and three out of four patients 
reported a vision complaint ranging from light sensitivity to eye 
strain and double vision. It is important to stress this is self-
reported data and we cannot conclude the cause of these complaints.
    In conclusion, I wish to emphasize our testimony is based upon 
findings from early studies with relatively small and selected 
population samples--this data is not definitive and conclusions should 
not be drawn from it. Instead, additional studies are needed and are 
ongoing. Uncovering these visual injuries and developing effective 
treatments has involved a collaborative effort utilizing the expertise 
and resources of many disciplines. VA's experience with vision related 
injury and impairment supports the claim that these patients can be 
effectively treated. Thank you again, Mr. Chairman, for inviting me 
today. At this time my colleague and I will answer any questions that 
you or other members may have.

                                 
     Prepared Statement of Colonel (P) Loree K. Sutton, M.D., USA,
    Special Assistant to the Assistant Secretary of Defense (Health 
                               Affairs),

     Psychological Health and Traumatic Brain Injury, and Director,
  Department of Defense Center of Excellence for Psychological Health
          and Traumatic Brain Injury, Department of the Army,
                       U.S. Department of Defense

    Mr. Chairman and distinguished members of the committee, thank you 
for your concern for our wounded warriors, especially those who have 
sustained ocular and vision impairment due to combat. As the Director 
of the newly established Defense Center of Excellence (DCOE) for 
Psychological Health and Traumatic Brain Injury (TBI), I have a strong 
interest in the creation and operation of the Ocular Center of 
Excellence due to the needed collaboration for those warriors who 
sustain ocular injury and vision impairment as a result of traumatic 
brain injuries.
    The Department of Defense (DoD) is committed to providing 
excellence across the board in protection, prevention, diagnosis, 
treatment, recovery, and care transition for our military members and 
their families who sustain injuries or experience adverse health 
conditions as a result of the Global War on Terror. In accomplishing 
those objectives, we work hand-in-hand with our federal partners in the 
Department of Veterans Affairs (VA), the Department of Health and Human 
Services (HHS) and others, as well as public and private sector experts 
across the Nation and around the world. For our DCOE, we gratefully 
acknowledge the funding support from Congress to assist us as we move 
forward in providing our military personnel and military families with 
the care and support they deserve.
    Overall, the Military Health System offers a continuum of care for 
medical specialties, which encompasses:

       Resilience, prevention, and community support services;
       Early intervention to reduce the incidence of potential 
health concerns;
       Deployment-related clinical care before, during, and 
after deployment;
       Access to care coordination and transition within DoD/VA 
systems of care; and
       Robust epidemiological, clinical and field research.

    In centers of excellence, these facets of the care continuum are 
integrated, and, as a consequence, our patients receive more 
comprehensive and better coordinated care.

NDAA 2008 Requirements for Vision Care
    Congress directed that the Department, in collaboration with the 
VA, plan for and establish a center of excellence that would build and 
operate the Military Eye Injury Registry. In fact, planning for that 
registry is underway by working groups comprised of military and VA 
subject matter experts. These specialty leaders recognize the value and 
contribution such a registry will make toward improved care and 
rehabilitation of their patients. Other registries are also underway 
within the Department including one for TBI. This registry once 
operational will track ocular and vision impairments associated with 
traumatic brain injuries.
    In December 2007, DoD and VA sponsored a combined conference in San 
Antonio that focused on visual aspects of TBI, and DoD's tri-service 
consensus workgroup on Special Issues in mild TBI at medical treatment 
facilities included recommendations for visual screening for TBI 
patients. These recommendations currently are being staffed within the 
Department. On February 28, 2008, senior military health leaders met 
with their VA counterparts to discuss the concept and planning needed 
to establish an Ocular Center of Excellence. The general consensus was 
that the Ocular Center of Excellence should be a separate entity rather 
than combined with an existing center of excellence, but it must build 
strong collaborative relationships with the DCOE.
    Moreover, Congress directed that the two Departments ``conduct a 
cooperative program for members of the Armed Forces and veterans with 
traumatic brain injury by military medical treatment facilities . . . 
and medical centers of the Department of Veterans Affairs . . . for . . 
. vision screening, diagnosis, rehabilitative management, and vision 
research, including research on prevention, on visual dysfunction 
related to traumatic brain injury.'' The plan for the Ocular Center of 
Excellence will include such a cooperative program, and the DCOE will 
collaborate with the Ocular Center on these efforts. Moreover, a key 
responsibility of centers of excellence is to find programs throughout 
medicine, regardless of where, that have proven to be successful; then 
determine whether these programs demonstrate ``best-practices.'' If 
they are, details on how to operate these programs will be disseminated 
throughout military and veterans' health systems.

DoD-VA Transition
    We must effectively establish a patient- and family-centered system 
that manages care and ensures a coordinated transition among phases of 
care and between healthcare systems. Transition and coordination of 
care programs help wounded warriors and their families make the 
transition between clinical and other support resources in a single 
location, as well as across different medical systems, across 
geographic locations, and across functional support systems, which 
often can include non-medical systems.
    In terms of transition, we seek better methods to ensure provider-
to-provider referrals when patients move from one location to another 
or one healthcare system to another, such as between DoD and VA or the 
TRICARE network. This is relevant most especially for our Reserve 
component members.
    Care coordination is essential for patients who may have multiple 
health concerns, multiple health providers, and various other support 
providers. Frequently, they are unsure of where to turn for help. 
Proactively, the DCOE will offer accurate and timely information on 
benefits and resources available. Meanwhile, the Army and the Marines 
have established enhanced care coordination functions for their 
warriors.
    For Psychological Health issues and TBI, newly hired care managers 
will support and improve transition activities. The Marine Corps 
created a comprehensive call center within its Wounded Warrior Regiment 
to follow up on Marines diagnosed with TBI and Psychological Health 
conditions to ensure they successfully maneuver the healthcare system 
until their full recovery or transition to the VA. The Navy is hiring 
Psychological Health coordinators to work with their returning 
reservists, and the National Guard is hiring Directors of Psychological 
Health for each State headquarters to help coordinate the care of 
Guardsmen who have TBI or Psychological Health injuries or illnesses 
related to their mobilization. The other Reserve components are looking 
closely at these programs to obtain lessons learned as they set up 
their own programs. These many programs for easing the transitions of 
our wounded warriors serve as examples to build upon or to replicate as 
the patient demand requires.
    Information sharing is a critical part of care coordination. DoD 
and VA Information Management offices are working cooperatively to 
ensure that information can be passed smoothly and quickly to 
facilitate effective transition and coordination of care. These offices 
will play significant roles in the establishment of the Military Eye 
Injury Registry and the TBI registry. This one endeavor is vitally 
important to the continuum of care for all of our wounded warriors 
regardless of their injury or health condition.

Research
    Research and development provide a foundation upon which other 
programs are built. Our intent is to rely on evidence-based programs; 
our assessment identifies the need to develop a systematic program of 
research that will identify and remedy the gaps in knowledge. To that 
end, we have established integrated individual and multi-agency 
research efforts that will lead to improved prevention, detection, 
diagnosis, and treatment of deployment-related injuries and health 
issues.
    At the DCOE, we will fund scientifically meritorious research to 
prevent, mitigate, and treat the effects of traumatic stress and TBI on 
function, wellness, and overall quality of life for servicemembers and 
their caregivers and families. Our program strives to establish, fund, 
and integrate both individual and multi-agency research efforts that 
will lead to improved prevention, detection, diagnosis, and treatment 
of deployment-related Psychological Health problems and TBI. We will 
collaborate with the Ocular Center on research that examines ocular 
injury and vision impairments as a consequence of TBI. The importance 
of this collaboration rests in the ``miracle'' of vision. Our visual 
track passes directly through the center of the brain. The visual 
cortex is so highly organized and the process of composing ``vision'' 
is so complex that it is truly a miracle that we ``see.'' With physical 
and cerebral compromise, our ability to make fine tracking motions, use 
the eyes in perfect tandem, binocularly fuse objects, converge, 
diverge, and focus in tandem with fusion and eye movement easily may be 
upset. One can imagine how severe TBI might upset such an equilibrium 
that allows us to work, read, and view the world in comfort. Most of 
these visual dysfunctions are related to the elements of binocularity 
and accommodation and how those independent systems work in tandem. 
With recovery of the brain and overall physical health, we hope that 
most of these dysfunctions will return to normal. However, at this 
point, ``we do not know what we do not know.'' Consequently, we have 
the compelling need for research and evidenced-based studies upon which 
we may base clinically sound programs.

Conclusion
    Mr. Chairman, distinguished members, thank you for caring and for 
understanding the needs of our Warriors and their Families. Thank you 
also for providing the resources and support to design and implement 
programs to meet these needs. The military Services with the Army 
taking the lead, in collaboration with experts from the VA and public 
and private sector, will bring about an Ocular Center of Excellence 
that will offer our wounded warriors the integrated care and 
rehabilitation they need and deserve. It is an honor and a privilege 
for me to work toward improving and maintaining the health of those 
whom we serve.

                                 
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