Andrew_Doan
Ophthalmology, Aerospace Medicine, Eye Pathology
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20+ Year Member
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William P. Madigan MD and Kraig S. Bower MD
http://www.sciencedirect.com/scienc...d=440026&md5=4c8d056b7f834b53d2353f60b34eb717
We have seen extensive media coverage of the remarkable young men and women who go in harm's way in service to our country. It is estimated that up to one third of the 1 million active duty Army, Navy, and Air Force service members require corrective lenses. Operational demands in the military present distinct disadvantages to the soldier, sailor, or airman wearing corrective lenses. Glasses can get broken, lost, and clouded by sand, dust, rain, or mist, and are often incompatible with sophisticated helmet-mounted targeting devices, night vision goggles (NVGs), and other combat gear. Although contact lenses offer a potential advantage over glasses, they have problems of their own, particularly the inability to maintain proper lens hygiene. Despite a Department of Defense policy prohibiting contact lenses in combat and field environments such as Kuwait and Iraq, soldiers, marines and airmen continue to wear them in the field. As a result, more than 60 service members developed contact lens?related corneal ulcers/infiltrates in Iraq between April and September 2003 (Madigan, unpublished data).
The applicant pool for military aviation programs has decreased to dangerous levels in recent years. Refractive error is the most common disqualifier for potential applicants who fail to meet flight medical standards. Because of a mean myopic shift of approximately 1 diopter (D) from freshman to senior year, documented in the mid-1980s at the Air Force Academy[1] and at West Point, [2] a young man or woman may enroll at one of the military academies or the Reserve Officer Training Corps hoping for a career in aviation, only to fall outside the proscribed refractive range by graduation. A safe and effective refractive procedure would clearly present a valuable option.
Before refractive surgery was accepted as an organizational policy in the Armed Forces, it had to demonstrate appropriate levels of efficacy, predictability, and safety. Radial keratotomy was never an approved alternative to corrective lenses in the Armed Forces due to concerns over structural integrity and fluctuating vision at altitude.[3 and 4] No branch of service, with rare exception, accepts applicants who have had radial keratotomy.
The excimer laser offered much greater promise, and in 1993 preliminary investigations demonstrated the safety and efficacy of photorefractive keratectomy (PRK) in the Navy's elite special operations branch, known commonly as SEALS.[5] Work since then has offered additional insight into the role of refractive surgery in the military operational environment. [6 and 7] Although refractive surgery may allow high-contrast target discrimination in daylight conditions, loss of contrast sensitivity resulting from the procedure may make targets difficult to see through NVGs. Evaluating patients 3 months after PRK under a full range of night-sky conditions using NVGs, Subramanian et al demonstrated that postoperative visual performance without correction equaled or exceeded preoperative spectacle-corrected abilities. [7] In a study now under way, this visual improvement seems to translate to enhanced performance on the night firing range with standard metal sights at simulated dusk and through NVGs at starlight (Bower, unpublished data). In 2000, the Army began observational studies of soldiers enrolled in Ranger and Airborne (Parachute) School after LASIK. Benefits anecdotally reported in professional athletes, firemen, and policemen seemed to hold true when studied in our unique population. Soldiers continued to perform safely, and well, without complications after refractive surgery and, importantly, without the need for corrective lenses (Madigan, unpublished data).
In late 2000, recognizing the tremendous potential for refractive surgery to enhance military readiness, a new policy was adopted allowing enlistment after laser refractive surgery, and the Warfighter Refractive Eye Surgery Program was launched. This is an ambitious program with the objective of enhancing battlefield effectiveness and increasing individual safety and survivability in our front-line combat soldiers through refractive surgery. To date, the military has established 19 Warfighter Refractive Eye Surgery Program centers worldwide and treated approximately 35 000 service members. Because regulations prohibit enlistment of myopes over -8.00 D, the majority of treatments are for low and moderate myopia. To date, about two thirds have been surface ablations (primarily PRK) and one third LASIK. In fiscal year 2003, the Army treated 15 401 eyes of 8449 soldiers. Uncorrected visual acuity (VA) is 20/40 or better in 98.1%, 20/25 or better in 91.8%, and 20/20 or better in 85.6%. Less than 10 lost more than one line of best spectacle-corrected VA (BSCVA), and no soldier has required medical separation due to loss of BSCVA.
Although emphasis is placed on the benefits of reducing the need for corrective lenses, this is not to say that the military aims to eliminate eyewear altogether. Casualties in modern warfare frequently have serious globe injuries, usually caused by small fragmentation projectiles.[8 and 9] Although the eyes represent only 2% of the body surface area, 16% of military injuries involve the eye or ocular adnexa. Several factors are responsible for the disproportionate number of ocular injuries in the combat setting. Visual target-seeking behavior directs our eyes toward the source of danger. Terrorists make use of this when they precede the large blast with a small noise to attract the victim towards the awaiting bomb, thereby inflicting greater damage. More importantly, as body armor (flak jacket and helmet) has become standard issue, explosions that would have resulted in fatal chest or abdominal wounds in the past are now survived. However, these new survivors have more injuries to the relatively unprotected extremities, face, neck, and eyes. Between April and September 2003, the 286th Eye Surgical Team in Iraq treated 97 serious ocular and adnexal injuries, including over 40 ruptured globes. [10] Most of these injuries would have been prevented by the appropriate use of protective eyewear.
Wraparound polycarbonate lenses designed to block the force of a 22-caliber bullet from 20 feet have been developed by and for the Armed Forces. This eye armor is now a standard supply item thanks to the pioneering vision and hard work of Col Francis LaPiana, MD, FACS (Ret), and others.[11 and 12] We recommend that all combat soldiers wear eye armor along with their body armor, and every soldier is issued a pair when they leave a Warfighter Refractive Eye Surgery Program center after refractive surgery.
Exciting research continues to define the contribution of refractive surgery to our individual and force readiness. The ability of wavefront-guided ablations to reduce postoperative higher order aberrations has opened up a whole new field for investigation. The potential to achieve better than 20/20 vision while simultaneously improving night vision in warfighters is an exciting possibility. We look forward to working with our colleagues to advance our knowledge in this field and apply it not only to civilians but also to the men and women of the Armed Forces as they serve in defense of our nation.
http://www.sciencedirect.com/scienc...d=440026&md5=4c8d056b7f834b53d2353f60b34eb717
We have seen extensive media coverage of the remarkable young men and women who go in harm's way in service to our country. It is estimated that up to one third of the 1 million active duty Army, Navy, and Air Force service members require corrective lenses. Operational demands in the military present distinct disadvantages to the soldier, sailor, or airman wearing corrective lenses. Glasses can get broken, lost, and clouded by sand, dust, rain, or mist, and are often incompatible with sophisticated helmet-mounted targeting devices, night vision goggles (NVGs), and other combat gear. Although contact lenses offer a potential advantage over glasses, they have problems of their own, particularly the inability to maintain proper lens hygiene. Despite a Department of Defense policy prohibiting contact lenses in combat and field environments such as Kuwait and Iraq, soldiers, marines and airmen continue to wear them in the field. As a result, more than 60 service members developed contact lens?related corneal ulcers/infiltrates in Iraq between April and September 2003 (Madigan, unpublished data).
The applicant pool for military aviation programs has decreased to dangerous levels in recent years. Refractive error is the most common disqualifier for potential applicants who fail to meet flight medical standards. Because of a mean myopic shift of approximately 1 diopter (D) from freshman to senior year, documented in the mid-1980s at the Air Force Academy[1] and at West Point, [2] a young man or woman may enroll at one of the military academies or the Reserve Officer Training Corps hoping for a career in aviation, only to fall outside the proscribed refractive range by graduation. A safe and effective refractive procedure would clearly present a valuable option.
Before refractive surgery was accepted as an organizational policy in the Armed Forces, it had to demonstrate appropriate levels of efficacy, predictability, and safety. Radial keratotomy was never an approved alternative to corrective lenses in the Armed Forces due to concerns over structural integrity and fluctuating vision at altitude.[3 and 4] No branch of service, with rare exception, accepts applicants who have had radial keratotomy.
The excimer laser offered much greater promise, and in 1993 preliminary investigations demonstrated the safety and efficacy of photorefractive keratectomy (PRK) in the Navy's elite special operations branch, known commonly as SEALS.[5] Work since then has offered additional insight into the role of refractive surgery in the military operational environment. [6 and 7] Although refractive surgery may allow high-contrast target discrimination in daylight conditions, loss of contrast sensitivity resulting from the procedure may make targets difficult to see through NVGs. Evaluating patients 3 months after PRK under a full range of night-sky conditions using NVGs, Subramanian et al demonstrated that postoperative visual performance without correction equaled or exceeded preoperative spectacle-corrected abilities. [7] In a study now under way, this visual improvement seems to translate to enhanced performance on the night firing range with standard metal sights at simulated dusk and through NVGs at starlight (Bower, unpublished data). In 2000, the Army began observational studies of soldiers enrolled in Ranger and Airborne (Parachute) School after LASIK. Benefits anecdotally reported in professional athletes, firemen, and policemen seemed to hold true when studied in our unique population. Soldiers continued to perform safely, and well, without complications after refractive surgery and, importantly, without the need for corrective lenses (Madigan, unpublished data).
In late 2000, recognizing the tremendous potential for refractive surgery to enhance military readiness, a new policy was adopted allowing enlistment after laser refractive surgery, and the Warfighter Refractive Eye Surgery Program was launched. This is an ambitious program with the objective of enhancing battlefield effectiveness and increasing individual safety and survivability in our front-line combat soldiers through refractive surgery. To date, the military has established 19 Warfighter Refractive Eye Surgery Program centers worldwide and treated approximately 35 000 service members. Because regulations prohibit enlistment of myopes over -8.00 D, the majority of treatments are for low and moderate myopia. To date, about two thirds have been surface ablations (primarily PRK) and one third LASIK. In fiscal year 2003, the Army treated 15 401 eyes of 8449 soldiers. Uncorrected visual acuity (VA) is 20/40 or better in 98.1%, 20/25 or better in 91.8%, and 20/20 or better in 85.6%. Less than 10 lost more than one line of best spectacle-corrected VA (BSCVA), and no soldier has required medical separation due to loss of BSCVA.
Although emphasis is placed on the benefits of reducing the need for corrective lenses, this is not to say that the military aims to eliminate eyewear altogether. Casualties in modern warfare frequently have serious globe injuries, usually caused by small fragmentation projectiles.[8 and 9] Although the eyes represent only 2% of the body surface area, 16% of military injuries involve the eye or ocular adnexa. Several factors are responsible for the disproportionate number of ocular injuries in the combat setting. Visual target-seeking behavior directs our eyes toward the source of danger. Terrorists make use of this when they precede the large blast with a small noise to attract the victim towards the awaiting bomb, thereby inflicting greater damage. More importantly, as body armor (flak jacket and helmet) has become standard issue, explosions that would have resulted in fatal chest or abdominal wounds in the past are now survived. However, these new survivors have more injuries to the relatively unprotected extremities, face, neck, and eyes. Between April and September 2003, the 286th Eye Surgical Team in Iraq treated 97 serious ocular and adnexal injuries, including over 40 ruptured globes. [10] Most of these injuries would have been prevented by the appropriate use of protective eyewear.
Wraparound polycarbonate lenses designed to block the force of a 22-caliber bullet from 20 feet have been developed by and for the Armed Forces. This eye armor is now a standard supply item thanks to the pioneering vision and hard work of Col Francis LaPiana, MD, FACS (Ret), and others.[11 and 12] We recommend that all combat soldiers wear eye armor along with their body armor, and every soldier is issued a pair when they leave a Warfighter Refractive Eye Surgery Program center after refractive surgery.
Exciting research continues to define the contribution of refractive surgery to our individual and force readiness. The ability of wavefront-guided ablations to reduce postoperative higher order aberrations has opened up a whole new field for investigation. The potential to achieve better than 20/20 vision while simultaneously improving night vision in warfighters is an exciting possibility. We look forward to working with our colleagues to advance our knowledge in this field and apply it not only to civilians but also to the men and women of the Armed Forces as they serve in defense of our nation.
