on the tenth story of the day while i was out trying to obtain medical supplies from a con x box a mortar round that point i was propelled backward back at that point i noticed that i was becoming more of a liability than an asset because i'd go out on patrols and i couldn't see well enough to fire my weapon i went to my battalion surgeon and i'm losing my si come can come back and say well we can't provide this care that care because it's too costly i never said it was ever too costly so why should these agencies say the same to me thank you thank you finally doctors and very he's the director of government affairs for the blinded veterans association and is here to discuss the nationwide implications of t b i related vision problems thank you thank you mr chairman and ranking member and other members of the committee for as having this hearing today the blinded veterans association has been in existence for sixty three years since the into world war two and  trying to dedicate ourselves to helping all of our nation's blinded veterans and their families it's an honor for me to be here today with these two witnesses who serve their  country and and did a great job and it's sad though that in preparing for this hearing when i was asked how many witnesses do you have possibly come in speak there's at least twelve others with similar stories and i should be very disturbing to the members in this room these are not a couple quote accidents that fell through the cracks and there's other cases out there that are very similar to this and so hopefully at the conclusion of this hearing today there'll be some major steps taken towards fixing this and regards to administratively and clinically better coordination between the department of defense and the v a in regards to pall of the i injured casualties returning the numbers seem to be a moving target here when i first started this job three years ago just asking people how many injured have come back from either rock 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 years ago it was there drastically lower and in reality if people had really started to look at this issue earlier they would realize from looking at the i c d nine codes that the v a had and also d o d that the numbers were growing rapidly as early as in two thousand and five here we are in two thousand and eight the the most recent numbers that i can come up with is close to four thousand five hundred combat injured battle injured and there's another component which is the reason for this hearing is the traumatic brain injuries in the visual impairments associated with t b i so individuals who can have the penetrating injuries from from battle related injuries the obvious but the ones that come back to have had repeated head concussions and it suffered from a traumatic brain injury like with glenn many and sergeant pierce their injuries in the back of the brain are affecting their vision and with their other emphasis on other types of manifestations neurologically of these t v eyes 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 have come up to them and said well your eyes look ok mustn't be anything else wrong the neurologic pathways in the brain i put a lot in my testimony not to overwhelm anybody but i think it's important that people understand one critical thing here today that the vision is seventy percent of our awareness of our environment the other senses that you're learned about in school as far as the hearing touch smell taste where we're visual animals and so if you have a traumatic brain injury and any of those different pathways are disrupted as it is in my written testimony it can cause a huge number of different types of  ual problems anywhere from color blindness to loss of peripheral feel vision depth perception and all of these various neurological complications from from t b i that affect vision will affect everything else rehabilitation vocational training it certainly is going to have a negative impact on employment  so we worked with congress last year to get the military i trauma center of excellence included in the national defense authorization bill as part of the wounded warrior legislation a p t s d center of excellence and a military trauma center of excellence and that the centers would collaborate work jointly provide follow up best practices look at what's going on regards to the specific types of neurological research both and high in vision research but also in other areas that they would  things that is bothered me the most about this is when i meet with a lot of these service members families who have had i injuries are rarely given much information about what is low  for low vision blind veterans and they've implemented and started to open a large number of outpatient specialized clinics with ophthalmologists optometrist and with blind ideal for not only the aging population of veterans that they were created for with degenerative diseases but for this generation who have different types of visual impairments that need care people i doubt it and so my experience has been that the moving numbers here mazing basically included a lot of recommendations is i'm amazed and impressed at their ability and if you go back historically and look at the results of trauma from world war two most of those soldiers just lost their eyes they they were surgically removed in today due to the van skills of the ophthalmologist serving in iraq and long still germany and the surgeons at walter reed and bethesda i have the greatest respect for that what they're doing is just simply amazing and so this is in the hearing about health care problem in the sense of is are they not doing something medically that they should be doing and i just wanted to stress that this is about the faisal problems of two brocker sees talking to each other facilitating the implementation of this military i trauma center of excellence as dr carson bozeman and i had hoped and make this work and so again i appreciate this opportunity testified today be willing to answer any questions and thank you is there needs to be more of a communication between when individuals in the military they have a health record jacket i had mine so the v a was able to go back and look at that but there are guys that come into the v a system that do not have a health record so when they start their process their transition there is no health record so the v a has to start from ground zero and this service member has every physical exam every bit of treatment that he went through through once again through the v a if the records were taken from  because every every eye exam which some are painful that i've had to go through i had to go through three or four times because the v a said well we don't have copies of your military health record we have to do it all over again just so happens been 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 thank you for that same story since we've been having these hearing iraq and what is the final number as maybe the beginning of this year even because there seem to be conflicting person percentages and official report that you said estimated to be yes thank you the numbers i think are like trying to get the accurate numbers on traumatic brain injuries at large and unfortunately i've been told recently that the number last september was was this number that i put in there of eleven one hundred sixty two as of september blind is a small percentage really of the total number though have suffered major injuries and what one of our biggest fears is that the ones that had initially successful surgeries the other eleven hundred are at risk if they get lost between the systems and don't get follow up of complications and there's three common complications to make a short answer long that most ophthalmologist are very concerned about with this population of veterans and that is traumatic cataracts glaucoma that can occur seemingly almost that any time after somebody is sustained a traumatic injury and these are types of things that normally in the private sector ophthalmologist or optometrist would see in a very old population of of individuals we think of go calma as something that our parents get we think of cataracts as something a seventy year old gets but i've met a twenty four year old army sergeant with cataracts i met a twenty eight year old army lieutenant who was blinded in his right eye his right eye was a nucleated in iraq and surgically removed his left eye was quote normal but they found that walter reed fortunately when they tested him just before he was to be discharged he had glaucoma pressures equivalent to what a sixty five year old might have so th e actual number of blinded individuals that are unrolled in the visual impairment service team program is about one hundred four but there's these other eleven one hundred or twelve hundred out that have sustained major eye injuries and then the experts who will testify later may tell you that there are narrow ophthalmologist who believe looking at the t b i data in private research numbers that as many as seven thousand t b i patients probably which is in my testimony have some type of visual t b i 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 haven't really started to add up and look at that thank you thank you very much the conditions you there was recently a survey the national institute did a survey of americans and they asked him you know do you recognize information or do you know about glaucoma and only eight percent of the americans that they surveyed said they had any idea that a coma doesn't cause any symptoms there's no pain there's a national you know 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 they will go blind and where is cataracts can be operated on and removed in the visual will return i guess one of the interesting things about cataracts though is when you do cataract surgery in a seventy year old most ophthalmologist are well aware of ten years later what  i don't think many people have a lot of experience with twenty four year olds who have had cataract surgery what will happen to them when they're forty five years old or sixty years old so there's a great need here for a lot of chairman mr manning how much time expired between the date of your injury and the date you were diagnosed with traumatic brain injury my injury was in april of two thousand and five and i want to say i was diagnosed with a traumatic brain injury wary of two thousand and six so roughly ten months and that would have been after the m r i now the m r i is what discovered the dr brain injury that you weren't diagnosed until you had the m r i done right i understand that was recommended by a veterans administration they had recommended it but i was at camp as you of scale was in the jurisdiction of the department of defense and had been a number of medical providers prior to that were obviously aware that you'd been subjected to a blast and were having vision problems throughout that entire period a deteriorating condition no less correct do you have any idea as to why no one thought of doing an m r i prior to two thousand and six no i did not i just think that they were just focused on the eyes and they didn't want think outside the box and think that maybe the the there was a boy an injury that was related to the i do not know had the department of defense diagnosed t b i let's say within six weeks or month or week after your injury would that have made the condition there a difference in the your prognosis for recovery it may have made a difference in the in my recovery i could have started my speech therapy sooner i could have started my brain injury manifest itself in any other way yes i have i have cognitive thinking disorder i have short term memory loss there are things that happened before my injury in my life that i don't remember now and i have some associative disorders that i have to go through speech therapy with i can be speaking and sometimes tracking or effectively screening and or diagnosing t b i and or optimal optimal logical conditions that might not otherwise be readily apparent from a visual  inspection thank you the i guess sort of the gold standard that i've really been impressed with is what's going on at paul though they've just dying some exceptionally great screening out there and   implementation of the military i trauma center of excellence that you referred to your testimony be of assistance in that regard yes it would be huge because you know i think most people in vision that the i trauma center of excellence would be sort of the the the lead coordinator of this and make sure that people like angie and and and glen mini's gretchen that they get information together families need to have information about where in the v a they can get help and assistance and the i trauma center of excellence should 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 i hate to say this but you know because you fund the v a a huge amount and  e funded d o d a large amount but i've been sort of told it well the five million dollars wasn't included to cover the military i trauma center of excellence therefore we're going to set up a computer registry which is important part of this and there are actually d o d and ophthalmologist and optometrist that are working from a clinical standpoint to develop a computer registry but that's not the end of this i mean you know these guys i'm not a number in the computer registry with a diagnosis and for full field measurements and a surgical op you know or whatever other various things that are in that registry which is important but these other things the research and the the best practices in the continuing education of the other providers in so you know i'm just stunned when i'm told well the congress didn't include the five million dollars so therefore we're not going to implement this but we will set up the computer part  patients people that had impaired vision for a long time actually set up the low vision clinic at the blind school in arkansas the very first oneself i really do have a lot of experience in that regard i can say that that you know what you all went through early on you know being somebody that treats folks in that can you know i'm not a sergeant but but again you know being in the position of trying to figure out what's going on i think with the literature that was available there are experiences are available you know you could almost look at your your care and understand what was going on now there's a difference now because of the prevalence of t b i this is something that you know we got to pursue as a result we were able to work with most of the committee several others  doctors and berries being wonderful in helping us stablish the the department of defense x is the center you know that we've been talking about the problem again it is funding and so the laws in place i really you know i appreciate your test my doctor i mean sergeant perisher six things that we need to do you know that this does that ok exactly and in a lot of other  things we need to follow on and get you guys fixed up i'm not real upset that what happened to you happened in the way it did in the sense that you know generally recognized things are practiced where i'm going to be very upset is the guys it happened you know this too since this last past as doctors empiric you know referred to it hasn't been funded and isn't being done and that's where we're going to get upset there's no excuse now again based on what we've learned from you guys there's no excuse now not to follow up on that and this particular law actually came from the out are out there fighting the battle they came to us and said look you know we need to do this so i really do appreciate your testimony you know healthy at this point you know we'll go forward and  sure the individuals to run through the same problem because of the fact that we've identified the problems that you've had now that we can go forward and then also continue to get the treatment that you need let me ask poly trauma centers as far as as what they've got available to treat i injuries can you address that i mean is that is that acceptable in a sense that you know that that we're we're better off you know kind of  you know one thing should all of these be offering the same thing or are we better off having the specialized you know some centers versus the other yes the i guess again the model  drop on some of that expertise from their blind center staff and this t b i screening program but but i think that the important take home message for some folks is a the when you look at the wo warrior legislation in fact it was almost like they had a list of all the occupations that are vital for the t b i poly trauma centers and then i remember looking at the senate legislation and i was astounded because down at the and i forget who else in but up at the top of the list of the major people would have to be involved they got reparations there course the physical therapy and occupational therapy and those are everybody's the first person i want making rounds every day on the team is and i amala just an optometrist with low vision credentials and to be told again you know well you know they're part of the team but they're over there well i got news you know i get real mad today there's no or ology clinics to i worked in the v a for nineteen years that's why i think that here take people because i have health care experience to ensure and there's physical therapy clinics in every v a hospital so why do you have to have them and side the poly drama there's dieticians in every hospital so i don't know that game stops today that there  is a multi dissimilar a team approach or it isn't and you don't put others as a sign not not for this both of these gentlemen can tell you that when you lose ninety eight percent of your vision your life is changed forever the employment figures in this is an unemployment hearing but nationally the employment rate for blind individuals is thirty two percent and that has not changed in ten years and it should be an astounding thing to consider what these individuals are up against in if nothing else from that perspective alone we have a long ways to sergeant 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 to get this right so i think it will be in there and i will not for a minute allow anyone to forget that our warriors don't fight alone their families fight with them and your care now is going to forever change your life it's going to change your career trajectory it's going to change a lot of those things and the realization that needs to come out of congress and needs to come out that the american people want to make sure that you're fully cared for two and that you're made as whole as possible doing these things is not winning the lottery this  responsibility that this nation has provided it also sends a message to future generations who wish to serve this nation that when you come back you're not going to fight us and have to come here so 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 their position against yesterday having oil company executives here and them telling us the eighteen point six billion we gave them needs to continue on and you're not getting your five million of that escapes anyone in this country shame on them  just a couple of things that i would like to say i can tell chairman mitchell and this committee and having dr bozeman on here as an expert is critically important and i'm very appreciative of that understanding and i think you all get this very clearly and that i think it's a it's a sense of optimism but also a prostration on this issue of communications electronic medical records and the ability to disseminate that across into the we went to iraq and afghanistan and iraq in january with the specific purpose of taking a look at this of trying to break the silos down and get them to communicate and one thing i've been expressing in my district and i want to thank you for bringing this board that i think turned us on to the traumatic brain injury and i think ms piers 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 that understanding we're going to do that 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'm deeply concerned about i'm glad that you brought this up because i can and to paid already now we've got an agent orange scenario on our hands i've talked to warriors over there who got blown up five  times blown up five times i got up dust myself off they're going to come in five maybe ten maybe shorter maybe longer and they're going to go to the v a and they're going to complain of vision and they're going to complain of memory lapses and all that and then they're going to be asked what happened to you was blown up near baghdad prove it and we have the electronic medical record to be able to record these and what the work that has been done on this serial injuries especially it seems like an oxymoron but the mild traumatic brain injuries that are happening are leading to this and i don't know why we're not taking i think we're moving forward on that we're 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 place so a couple things i would ask on this mr many with your blast recorded on your record or was it going in to be seen about the i i mean did your medical record record the blast as being significant in this so it was on there ok but thank goodness you had it and you carried it through we had it the all right very good  well no i'll leave it at that i'm with dr them period i 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 do 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 you do that we're not going to forget for a minute your suggestions are based on personal experience but they're also based on when researchers are looking on this they come to the same conclusion right where you're at so there's so it's a lining there i'm optimus we started to make movement as dr bozeman alluded to there were things that are going right but there's more that needs to be done and our commitment needs to be there with you so again thank you for that and thanks for your service back thank you m chairman i don't have any questions i just want to thank the white spouse for their service to the country and you can rest assured that i will be supporting the committee and whatever they issues affecting the veterans thank you very much for allowing me to testify as mentioned i'm a professor of neurology and chief of the stroke division that columbia university in new york conduct research in the area of recovery after brain injury and see patients in that capacity as well the science of brain reorganization and neural plasticity is one of 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 two thousand and three the nova vision company has been offering an exciting new option for treating partial visual loss after brain injury it's known as visual resin restoration therapy or  now over forty centers across the u s offering the therapy including clinics in scottsdale arizona clearwater florida cincinnati i institute and sharp memorial hospital in san diego california columbia where i practice was the fourth site to begin treating brain injured patients using one of the most memorable patients for me was part of goldstein whose soul was featured in a recent n b c nightly news story bart was in one thousand year old young man who had suffered a devastating motor vehicle accident three years before he underwent v r t and not only regain some of his lost vision but improved his attentional capacity as well he was able to leave home live independently and begin  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 neurologic deficit such as attention are common in this condition mr chairman finally with respect to the veteran population no vision has donated five devices to treat veterans in the tampa poly trauma center the first of the veterans are now being treated i'm confident that will be a very important adjunct to the rehabilitation treatment that we can offer these veterans thank you very much thank you mr warner i mean to provide this testimony in favor of the dyna vision i am an associate professor at the university of alabama at birmingham and an occupational therapist i have worked for thirty years in clinical practice with persons who have had 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 dyna vision 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 for our clients it is a piece of athletic equipment that we modified in use 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 therapy and speech therapy about the incidence of speech deficit intermeddle brain injury is the same as that as vision therapy as vision deficit sorry so why is vision therapy not part of the  were being told that vision is not important in their early intervention in a strongly for twenty years we have been working with patients from day to following trauma and implementing vision therapy program it's it's awful to hear that there is a real issue and research has stated that fifty percent of people that already have been admitted to hospital go undiagnosed with vision related deficit these people can be five years ten years out and still be under diagnose her vision deficit problems that are occurred and this should not happen to your veteran associated to a 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 trying in the different programs and your logical vision impairment intervention vision therapy is totally different for this group of veterans they have to think bryan and not eyeball and that is again what we've heard today that i should in the form of can they help identify service members that are suffering with vision issues or do the only help service members once they've been a dental problems the n b t programme is an assessment and training program  special concepts around them we can work with them from day one so donna vision is primarily a training tool but in the hands of a good clinician oftentimes we uncover visual processing deficit that begin with an assessment of the visual field loss that will then lead to a targeted therapy the first step is a mapping of the visual field there's both a comprehensive map that's done by a clinician when there's a problem known but  no vision company also has a screening module that's a more rapid assessment typical process that an individual goes through when they're referred to your service well they're referred generally by 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 worked on making activities whatever they need to do to increase their vision that's a very interesting question i'll leave aside the question of misdiagnosis as far as treatment goes most of the patients treated with have been treated in the chronic phase after three to six months after injury because of the fact that there's 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's a lot of interesting information coming out in other areas of brain recovery and other modes allergies motor recovery language recovery 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 a early time period that may actually be more effective that's actually there's a study being proposed at the moment to try more acute therapy and it's something we've been very interested in and would you be willing to provide us with copies of the results of that study when upon completion eight and compared fixation training with technique it hasn't been as far as i know specifically tested against other types for example psychotic training and others however most was mentioned here some of the others address a compensatory mechanism for overcoming the deficits that are in existence ok do you all do any of you all have financial interest in the company i have not kno diversion for twenty years i was actually the first occupational therapist because as part of sports training i saw and realized that it was an apparatus that i could use with my clients who had vision problems particularly those who had them and then attention so i brought it into rehab and over the years a lot of other therapists have adopted it because we find it to asking and need to be answered you know based on good studies and things and certainly you know nine hundred ninety eight studies one thing but you know now we're into you know two thousand and eight and a lot's happened you know testimony of the veterans previously and i also want to praise their service to our country after all that's really why we're here to provide the highest quality and safest care to our veterans i'm also and thank you for the opportunity to discuss the department of veterans affairs position the provision of care for veterans needing support for visual impairment and traumatic brain injury i'm joined by dr barbara and i will be doing the oral presentation for the both of us she's a national program visual impairment and our work in treating t b i dating back to the creation of four national t b i centers in one thousand nine hundred two is unmatched our probably trauma system of care each uniquely positioned to address the complex needs of veterans and service members exhibiting these two conditions and others simultaneously my testimony today will provide an overview of the continuum of care provided veterans and service members to ensure they receive the right care and the right way at the right time however this data is from a small select population sampling a larger cohort with scientific scrutiny must demonstrate the same results before a system wide changes would occur future research should include pre injury data visual functioning  conditions improve naturally over time we want to be certain that any changes in our care are to the benefit of our veterans the best scientific evidence available continually reviews and improves our care for these wounded and injured  i hosted a conference in december of two thousand and seven 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 poly trauma rehabilitation center as well as line rehabilitation specialists tama trysts and ophthalmologist from both departments and provide an opportunity to initiate a consensus validation process validation process will identify and disseminate the most effective strategies for treatment when they are known or  jointly conducted with the blinded veterans of america who are experts and representatives can discuss new treatment methods and further areas of cooperation have developed several initiatives to transfer for veterans and service members transitioning from the military service and operation enduring freedom and operation iraqi freedom for example blind rehabilitation service involvement often began from the injured service members still a patient at a military treatment facility transferred to a  most intensive specialized care and comprehensive rehab available for combat injured patients transferred for military treatment facilities as veterans recover and transition closer to their homes the pilot thomas system of care provides a continuum of integrated care evaluation evaluation process includes a standardized evaluation template for common problems following brain injury the template includes checks for visual impairment visual treatment specialist conduct comprehensive visual examinations for findings associa team coordinated provide lifetime case management for all the lead lined veterans and all e f l i have patients as they will impairments additionally thirty eight by and rehabilitation operations specialist provided by and rehabilitation training to patients were unable to travel to the blind cent time thank you very much dr caucus chairman mitchell ranking member brown wade and members of the committee thank you for this opportunity to testify i am a company 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 public trauma rehabilitation center and public trauma network site on samples of just over one hundred patients including both veterans and active duty service members a common injury of operation enduring freedom operation iraqi freedom veterans w trauma is traumatic brain injury caused by explosive devices the precise incidence of by injuries and visual disability occurring in operation is currently on known to be a public trauma rehabilitation centers recognize the importance of early intervention for visual impairment structured inner disciplinary teams to include line rehabilitation specialist in addition neuropathology was done a five as a key consultation of service all poly trauma rehabilitation centers conduct  examinations on their patients as needed dr goodridge and i began studying this area after noticing abnormalities in visual function and doctor injuries despite normal or near normal visual acuity our research seeks to determine if this patient population is typical of other veterans and service members with poly trauma before continuing i must note that this is preliminary research and much more work needs to be done to determine conclusively the risk for this population  research is focused on two groups first veterans and service members receiving inpatient care at the palo alto poly trauma rehabilitation center who have sustained visual impairments associated with life threatening poly trauma injuries and second outpatient receiving care at the palo alto pianists who have visual dysfunctions associated with mouth 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 apollinaire research suggest both groups may have increased rates of visual impairment or dysfunction among the palo alto poly trauma patients with moderate to severe traumatic brain injury study 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 poly trauma rehabilitation center with a traumatic brain injury caused by combat blast abnormalities in visual field in contrast sensitivity were discovered in some patients despite normal or near normal visual acuity by conventional testing i examinations by ophthalmologist and neuro upham ologist detected damage to vitalize structures including cornea retina and optic nerve that could result in visual loss in the future and other patients in this population problems such as double vision and ability to track moving objects 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 relatively small and selected population samples that is not definitive and conclusion should not be drawn from it the need for additional study is recognized our preliminary data has allowed us to obtain funding from to enlarge our study group to develop a comparison group and to determine the natural history of our findings over time understanding these visual entries and developing an evidence based treatment has involved a collaborative effort utilizing the expertise and resources of many disciplines  experience with vision related injury 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 thank you pioneer in treatment for our warriors who are suffering from visual impairment related to any cause including combat injury as the director of the center of excellence for psychological health and brain injury i have a deep and abiding commitment new center as a vision impairment often results from traumatic brain injuries visual experts in both the military and veterans affairs health systems have recognized the importance of the continuum profoundly injured patients in the united states where they require extensive care and rehabilitation and we continue the process of establishing the psychological health and traumatic brain injury center to focus more them and do better we owe them our best in addition to visual deficits caused by direct injury problems also may present individual suffering traumatic brain injury this may include injury due to repeated mild concussion as well as other more severe traumatic brain injuries t b i can disrupt the visual process interfering flow and processing of information visual problems resulting from t b i can be overlooked during initial diagnosis and treatment of the injury 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 chording a program or network of excellence with multiple sites located throughout the department 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 the visual nervous system clinical activities of the center as in the other centers will be bolstered by an active research capability having strong ties to leading academic private and international injury research centers this research capability will allow the latest advances in care technology and rehabilitation to be rapidly integrated into the programs best practices and guidelines the department proposes expansion of its current network of research partners with an increased investment  technologies focused on preventing diagnosing and restoring visual functions lost the role of the center with its collaborative networks within the military the veteran system in the private sector its research programs its development of best practices and clinical guidelines its training for caregivers outreach to families for inclusion in patient rehabilitation and importantly its advancement for prevention care treatment and rehabilitation underscore its value as a national asset in closing mr chairman injuries resulting from combat do demand an integrated and holistic response to prevention treatment 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 every day have been very engaged with one another  starting last summer they began working together and in september there was a combined visual professional seminar out in seattle agencies and they 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's been going on and that work up is going to be instrumental in our future because we have to look at the mitigation of these injuries whenever that's possible the other piece that i think is very good news is we've identified the different data sources that might have information about any of these service members who are suffering from visual challenges and we're now running them together to say ok have we missed anyone or other people that are falling through the gaps so the clinicians are very very engaged we've gotten the people engaged and i think that you'll be pleased with the that i'm aware of in this particular population yes or thank you or general pollock the one in the two thousand and eight national defense authorization act directed the v a and the d to develop a cooperative program for service members and veterans with t b i for quote vision screening diagnostic rehabilitative research now the question is why would you want to separate excellence two different issues there definitely needs to be attention directed at the visual consequences of traumatic brain injury and that most working very very close collaboration with the center of excellence  help us because we'll understand what we expect therefore what are the most appropriate screening tests to be able to do but i think it's not going to be just those who second and third order effects of the work clinicians and researchers are doing is going to demonstrate gaps in our health care system that we need to address so that we can ensure after people are injured for any that's something that's it's got to be improved upon between the two departments mr area 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 a very very challenging job especially as we you know start to  see things that we haven't seen before and i know in this ng with our optometrists an ophthalmologist you know that the the way that 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 couldn't concentrate you know they couldn't stand that the way they were before you can imagine if you're a national guardsman and you were an accountant or you know taught english or really whatever your profession was all of a sudden came home and you couldn't concentrate or whatever then that becomes very frustrating and you know it can cause all kinds of problems so i think that's why you know you alluded to a lot of different things i think that's why the registry is so important that we can information on these guys come back with these injuries you know we'll be able to treat them better and then also be on the rehabilitate them better and then the other part of that is to prevent them  blatant cases you know the ones that are really hard are the questionable symptoms you know where this and that they're much little bit harder sometimes to figure out although that can be equally as troublesome in their performing of to get done so if you've got a timeline for us military service they don't just recruit a soldier or recruit a family and that's so important because the family is an important part of the whole healing process and to hear  redeployed or not would you like to comment on that i think it's a little outside of my sphere i can speak about the problems we're finding and in the small sample we've looked one of our programs which allows us to develop this cross collaborative research and the needs for the so that's another piece that i know we have in place currently thank you and thank you all for being here and we're all working