“We’ve purposefully funded these projects as a group because we believe they will work together most quickly and effectively to develop treatments and products to save the sight of our warfighters,” TATRC Director Col. Karl Friedl said. “In this time of closely examining the federal budget, this is a relatively small investment that could produce immense future savings, not only in health care costs, but through maintaining military personnel as active, productive members of our nation’s fighting force and workforce.”

Among the multiple lines of investigation being pursued is one to develop computational models of all the ways the eye can be injured in a blast, which could be used not only in preventing vision loss but also in evaluating improvements in protective eyewear. That effort is being funded by the Peer Reviewed Vision Research Program line item in the DoD appropriations budget.

“This line includes vision research that is not conducted by the Veterans Administration, elsewhere within DoD, or by the National Eye Institute within NIH,” NAEVR Executive Director James Jorkasky noted. “It addresses immediate battlefield needs.”

Another vision-related project, funded by the VA with support from its Atlanta Vision Loss Center, hopes to design a computer-based system to overcome the limitations of GPS-based guidance devices for the blind. Even when not blocked by tall buildings or other obstructions, GPS location is only accurate to within about 10 feet – a potentially fatal margin of error for someone attempting to navigate sidewalks next to busy streets.

One approach is similar to that used in combat, where live images of a target area are compared to known maps and older photographs to better guide warfighters to their goal. In this instance, a laptop in a backpack (eventually, software on a smartphone) is linked to a stereo headset and a small camera on the wearer’s chest. The system compares the camera image with stored photographs, then uses beeps and vocal instructions – similar to a car navigation system – to lead the user to a specified destination. GPS, Google Maps, inertial navigation units, and other systems also are expected to be employed.

Atlanta VA researchers are pursuing a variation, replacing the laptop with a smartphone used to link to a remote server. The phone’s camera streams real-time images to the server, which analyzes them, including comparisons to stored images, then sends navigation details back to the phone for the user to hear. Although requiring less on-body equipment, a current drawback is transmission speed.

Researchers believe a combination of the two systems may be the best solution, perhaps with the addition of other research separate from those. One of those would recognize money (including denomination), while another utilizes “natural speech,” with the user asking questions as he or she would of another person and receiving computer voice-generated answers in complete sentences.

Further down the line of research would be the inclusion of facial recognition, possibly even the ability to “read” facial expressions.

Overall, the VA, MRMC, and TATRC programs are dealing with nine critical gaps in vision research and how war-related eye traumas are treated, from point of injury to vision rehabilitation, mechanical assistance, neurological prostheses, and even regeneration.

“Each partner is working on a very important piece of the puzzle,” according to Robert Read, who manages TATRC’s vision research portfolio. “We chose these 12 recipients from 120 research submissions because they best address these critical areas.”

Ultimately, regeneration is key to future treatment of many of the most severe cranial, dental, ocular, and auditory combat injuries. While many advanced approaches are still years away from becoming standard clinical practice – and research to keep pushing the science will never end – what already is being done often seems the stuff of science fiction rather than real medicine.

“We are working to improve the quality of life. We [already] can regenerate skin, which is one of the easiest tissues for us to work with and regenerate. But for the face, you have to have a higher requirement than just closing the wound – it has to have elasticity, be shaped and the right color for aesthetics, then you have delicate contours and boundaries between facial features,” Hale said. “In our burn patients, if there is a really badly scarred face, there isn’t much that can be done other than a face transplant, which is a consideration. But if in the next few years we can regenerate the face, that would be better.

“In 2005, when I returned from Afghanistan, the world’s first face transplant was done in France and shook the whole professional world. Some said it was horrible, with bad consequences. But I was an active proponent of face transplantation as a technique for us to understand and develop for those very few situations where it would be best. Why best? Because rebuilding the face with other body parts could take up to 30 operations – and still look horrible – where a face transplant is only one operation. But you must find a good donor match, then face the daily burden of taking suppressants [against rejection].”

Face and hand transplants, healing severe burn wounds without scarring, restoring – or at least providing a workable replacement for – vision and hearing, reconstructing teeth and jaws without dentures or wires, finding and dealing with the relationships TBI and PTSD may have with the teeth – those are among the goals of military medical research. Some already are in various stages of implementation, others at the earliest level of research.

There are two other major changes stemming from the war in Southwest Asia and the often startling advances in combat medicine: Both doctors and wounded warfighters have new views on battlefield injuries, treatment, and rehabilitation.

“I like to think of regenerative medicine as a technology that can generate hope – hope for soldiers in the system, out of the system, thinking of becoming soldiers or veterans growing older,” Hale concluded. “The emphasis in 2005 was save lives, close wounds. Now, as we look to the long tail of the war, it is to make those lives worth living. That includes defining the burden of disease – what problems these soldiers face, day in and day out, that they would not face if not injured – then finding ways to help cure or at least solve those problems with minimal invasion.

“Regenerative medicine will take decades of continual work to make people even more functional as they age. Technologies such as face transplants are still experimental; we don’t know the long-term effects of immosuppression or even the correct amount for face transplants – how to monitor and adjust the meds so the transplant will continue to work for as long as possible. And we don’t even know how long that will be. But it is technology we are developing and learning and is available should a soldier need and want it.

“But I have had soldiers who would qualify say they would prefer to wait, to be number 50 rather than number 20. They want us to do more research and they will wait for something better. They know the military and VA are there for them, so they don’t feel they have to take whatever is immediately available that might help them. And that’s the key word – might.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.