July 2016

 

COVER FEATURE

 

Refractive surgery in military personnel and first responders

Refractive surgery and patient selection in the military


by Ellen Stodola EyeWorld Senior Staff Writer

 
   

Additional considerations are needed for military refractive surgery patients

Refractive surgery requires careful patient selection, and refractive surgery in the military requires extra considerations, as there are particular concerns and procedures for performing these surgeries in the different branches of the military. Colonel Matthew Caldwell, MD, San Antonio, and Lt. Cmdr. Hunter Stolldorf, MD, department head, ophthalmology and refractive surgery, Naval Hospital Camp Lejeune, Jacksonville, North Carolina, weighed in on possible concerns for refractive surgery in the military and other considerations that should be noted.

LASIK in those at risk for ocular trauma

There certainly is a concern about the potential risk of trauma in LASIK patients, especially due to the fact that these patients can potentially incur the injuries while deployed in austere locations distant from an ophthalmologist, Dr. Caldwell said. Fortunately, the actual incidence has been very low. However, he noted that this is something that is closely followed. Of the tens of thousands of femtosecond LASIK flaps, there have only been about 5 or 6 cases in the Department of Defense of trauma to a post-LASIK eye where a flap actually came up. These were generally in cases of trauma that would have damaged the eye regardless of the history of refractive surgery, Dr. Caldwell added.

Dr. Stolldorf said that, in his experience at the Naval Hospital Camp Lejeune, femtosecond LASIK is used often. Integration of LASIK in the Navy was delayed in the past because of fears of flap dislocation, he said. Mechanical microkeratomes are not used in the military precisely because [the flaps] are feared to be less stable in a stressful environment, such as an explosion or ejection from a fighter jet. Although mechanical microkeratome flaps require a waiver for military service, Dr. Stolldorf said that it is preferred that applicants and active duty service members have either PRK or LASIK with a femtosecond flap.

Prevalence of PRK and LASIK in the separate branches

The ratio of PRK vs. LASIK can vary. This is different not only among branches of the military, but also from center to center in each branch based on the needs of the patient population at each base as well as on individual surgeon preferences, Dr. Caldwell said. In general, the Navy has tended to do a higher percentage of LASIK than the Army and Air Force, he said.

Dr. Stolldorf stressed the prevalence of PRK vs. LASIK among Naval hospitals. These hospitals serve the Navy and Marine Corps bases, he said. Most centers do more PRK than LASIK, he said, but in 2 hospitals, Naval Medical Center San Diego and Naval Hospital Camp Pendleton, LASIK cases outnumber PRK cases.

Phakic IOLs

Dr. Caldwell said that phakic IOLs, specifically ICLs, are used in the Army and Navy for patients with high myopic refractive errors who would not otherwise be good candidates for corneal refractive surgery. However, ICLs are not currently approved in the Air Force, he added. These cases make up a smaller percentage of the total refractive surgery performed in the Department of Defense, however, these are frequently the patients most debilitated by refractive error and the patients who benefit the most, Dr. Caldwell said. Dr. Stolldorf said these options are used sparingly. We tend to use this technology in patients with significant refractive errors who are not candidates for PRK or LASIK, he said. This technology is not approved for certain warfare communities, such as aviation. Dr. Stolldorf said that if he puts an ICL in a person who flies for the Navy or Marine Corps aviation, they will no longer be able to fly professionally, even if they see 20/20.

Eligibility

Today, eligibility for refractive surgery in the military is based mostly on whether or not patients are good medical and surgical candidates for the procedure, Dr. Caldwell said. In the past, there were a number of occupational restrictions in the military, but as studies and experience have demonstrated safety and stability even in extreme environmental situations, most of these restrictions have been lifted, he said. LASIK, for example, was restricted for certain aviators in the Air Force until we were able to demonstrate in altitude chamber studies that vision was stable up to 35,000 feet. Dr. Caldwell noted that there are still occupational considerations, but for LASIK and PRK most of the restrictions have been lifted. For ICLs, he said, where there is less history, there are still restrictions for some fields such as aviation, and it is disqualifying for patients who had the surgery before deciding to join the military. To be eligible for refractive surgery in the Navy, personnel must meet standard, conservative corneal/medical criteria, such as normal topography scans along with a stable refraction, Dr. Stolldorf said. A person also needs to have greater than 1 year on his or her contract with the Navy, he added. We want to prioritize the surgery for sailors and marines who will use the surgery to perform better in harms way while in uniform, he said. Dr. Stolldorf added that the Navy performs LASIK and PRK on about 10,000 to 15,000 eyes annually.

Are pilots allowed to undergo refractive surgery?

Pilots and other aviators are authorized to undergo both PRK and LASIK. However, Dr. Caldwell said, they lose their flying status at the time of surgery and then have to undergo a thorough waiver process to demonstrate that their vision is adequate prior to their return to flying. There are specific requirements regarding where pilots can have surgery, what exactly can be done, and who can do it, he said. They also have specific requirements in their pre- and postoperative evaluations, such as 5% low contrast testing. It is very important that aviators are treated at Department of Defense facilities familiar with these requirements, he added.

Additional informationRefractive surgery article summary

Dr. Caldwell said that except for a small community of closely monitored aviators, contact lenses are strictly forbidden in the deployed setting due to the very significant risk of corneal infections. A patient with a 8 D refractive error wearing glasses or special lens inserts will have a hard time using essential equipment like gas masks/chemical gear, night vision goggles, heads up displays, and even the blast suites that the explosive ordinance disposal people have to wear, he said. When these people lose their glasses after an explosion or fire fight, they are immediately incapacitated, essentially blind without glasses. Not only are their own lives at risk, Dr. Caldwell said, but they become a liability to the team that now has to make sure they get to safety. In cases like this, having had refractive surgery can be the difference between life and death, he said. Refractive surgery can literally be a life-saving surgery, and this is clearly a big deal to our patients, he said.

Editors note: Drs. Caldwell and Stolldorf have no financial interests related to their comments.

Contact information

Caldwell
: matthew.c.caldwell.mil@mail.mil
Stolldorf: hunter.s.stolldorf.mil@mail.mil

Related articles:

Reflections on refractive surgery in the military by Eric Donnenfeld, MD, EyeWorld chief medical editor

Refractive surgery in the military changed the lives of troops by Liz Hillman EyeWorld Staff Writer

Careful consideration of military refractive surgery results by Maxine Lipner EyeWorld Senior Contributing Writer

Refractive surgery in military personnel and first responders Poll size: 122

Tools for post-refractive surgery eyes by Louise Gagnon EyeWorld Contributing Writer

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