July 2016




Refractive surgery in military personnel and first responders

Refractive surgery in the military changed the lives of troops

by Liz Hillman EyeWorld Staff Writer


LASIK surgery
The U.S. Air Force changed its policy to allow LASIK surgery for its aviators in 2007.

Source: U.S. Air Force/Senior Airman Brian Ferguson

Refractive surgery

David Tanzer, MD, then a captain in the U.S. Navy and director of the refractive surgery program at the Naval Medical Center, performs PRK in 2010.

Source: U.S. Navy/Mass Communication Specialist 2nd Class Chad Bascom

Laser vision correction has opened the door for a new pool of candidates, improved safety and performance

Steven Schallhorn, MD, in private practice, San Diego, intended to go to medical school, but when he graduated with an undergraduate degree from Colorado State University, he and a friend decided on a whim to enter the U.S. Navy with the goal of joining its aviation program. That was 1977. But the friend with whom Dr. Schallhorn applied for military service found he couldnt be a Navy pilot. Back then, you had to have 20/20 uncorrected vision, said Dr. Schallhorn, who retired from the Navy as a captain. You could not miss 1 letter on the 20/20 line or you could not be a pilot. This friend was slightly nearsighted in 1 eye. More than a decade later, after training and teaching at the United States Navy Fighter Weapons School (known more popularly as Topgun), Dr. Schallhorn was involved with conducting laser vision correction procedures and studies that would allow applicants like his friend to serve in some of the militarys most dynamic roles after successful refractive surgery. About 12 years ago, this same friend received laser vision correction thanks to the work pioneered by Dr. Schallhorn. We went full circle. He ended up getting the kind of surgery that would have enabled him to be a Navy pilot, had the clock been moved forward 20 years, Dr. Schallhorn said. In the decades since its approval for military personnel, refractive surgery has transformed the lives of thousands of men and women who would otherwise have been excluded from or removed from certain occupations due to impaired vision. Refractive surgery has been wonderful for the military, said Charles Chaz Reilly, MD, Rashid, Rice, Flynn & Reilly Eye Associates, San Antonio, former chief of U.S. Air Force Ophthalmology, who retired from the military as a lieutenant colonel. In aviation in particular, it has had a large impact. Fully 25% of Air Force personnel entering pilot training have undergone refractive surgery, and they graduate pilot training at a higher rate than those who have not had to undergo refractive surgery. The U.S. Navy has also seen a large increase in its midshipmen from the Naval Academy seeking aviation training because of refractive surgery.

Laser vision correction approval

Wearing glasses can impede and restrict the use of certain headgear. Contact lens hygiene in the field can be virtually non-existent, creating an environment ripe for vision-threatening complications. Some duties, based on their physical demands and stresses, are not suited for glasses or contacts as a whole. Theres also the issue of otherwise highly qualified candidates being passed over only because of their refractive error. The military wants the very best and brightest to serve and often that is someone who needs glasses or contact lenses, Dr. Schallhorn said. Thus entered the possibility of refractive surgery. Prior to laser surgery, the most common refractive surgery was radial keratotomy. But this was not suited for all military personnel, for example, a Navy SEAL diver. Frank Butler, MD, Navy Hospital of Pensacola, Florida, a retired Navy SEAL captain, described the case of a SEAL who had RK and later suffered a ruptured globe after blunt trauma. It was Dr. Butlers job to evaluate this SEAL for diving afterward. In doing so he made these 3 recommendations to the Navy Bureau of Medicine and Surgery: 1) that RK remain a disqualifying condition for military divers; 2) that the SEAL in question be an exception since he was such a high value to the military; Dr. Butler noted that this SEAL never suffered other RK complications even after he returned to diving; and 3) that the Navy research the benefits of photorefractive keratectomy (PRK), an investigational procedure not yet approved by the U.S. Food and Drug Administration at the time, as an alternative refractive procedure for some of its personnel. RK at the time was also known to have the possibility of significant refractive changes at altitude, among other complications, such as halo, glare, progressive hyperopia, irregular corneal curvature, and more, according to Dr. Butler, leading to the desire for other surgical options. As the director of the Naval Special Warfare Command Biomedical Research Program at the time, Dr. Butler piqued the interest of leadership about PRK and was connected in 1993 with Dr. Schallhorn to conduct the first studies using an excimer laser for the procedure on active-duty U.S. Navy personnel.1 The research published in Ophthalmology in 1996 found that PRK reduced myopia and improved visual acuity in all 30 patients who were followed for 12 months postop. The FDA approved PRK to correct myopia in 1995. Following this study, Dr. Schallhorn said the Navy purchased its first laser and began to conduct many other studies looking at a host of issues such as visual recovery, quality of vision, extreme environmental conditions, and the impact of PRK on marksmanship ability.

Dr. Schallhorn said there were 2 studies pivotal in changing policies for refractive surgery for Naval aviators, called the Retention and Accessioning projects. According to a paper published in Current Opinion in Ophthalmology in 2008 discussing this research, the Retention of Naval Aviators PRK Study, there were 785 aviators who had received PRK and 90% were able to fly without vision correction 6 weeks postop.2 Whats more, 87% reported experiencing better vision for carrier landings after the surgery. PRK was able to return all of the treated aviators to the highest visual classification for a Naval aviator, and there were more than 47,051 flight hours accumulated and 2,979 aircraft carrier landings by PRK-treated aviators, the authors of this paper wrote. The Accessioning study was designed to determine any issues that post-PRK patients entering flight training might experience. More than 300 post-PRK students were admitted to flight training and were compared to more than 5,000 controls.

In no case did the PRK students perform worse than controls, the authors wrote. This was the first study that enabled a myope, who since the inception of Naval aviation could never have been a carrier pilot, to now enter flight training in the Navy. That was the study that allowed people who always knew they couldnt be a Navy pilot to do so if they had a successful PRK procedure, Dr. Schallhorn said. Not only did these studies lead to monumental change in the military, but they then led to changes for first responders and others in visually demanding, dynamic jobs as well. As LASIK came onto the scene, many military studies were conducted, including the evaluation of LASIK flap stability, improved ablation profiles, and the use of femtosecond lasers. These eventually led to the procedure being approved for U.S. military personnel as well. Still, Dr. Schallhorn said the majority of refractive procedures performed on military personnel today are PRK. This is due to the long history of successful surface ablation procedures making it a preferred procedure for surgeons and patients. However, he thinks that as the military continues to research newer technologies it will serve to improve options and outcomes for service men and women.

Refractive surgery changed the military

It is life-saving and performance enhancing. These are the 2 benefits a Navy admiral cited when he told Dr. Schallhorn that he would accept the risk of PRK presented to him, leading to his approval of the surgery for SEALs. Time and further research would lead other branches of the military to accept it for various roles as well. At this point, the standard for military members to enter as a post-refractive patient or receive surgery while in service varies depending on the branch and his or her occupation, Dr. Reilly said, adding that while it might require some administrative hoops, the procedure is very popular. Dr. Reilly, who was also chair of the Department of Ophthalmology at the Wilford Hall Air Force Center and consultant to the Air Force Surgeon General for Refractive Surgery, emphasized that an active-duty patient must have his or her commanders approval prior to surgery.

Refractive surgery in the military was a paradigm shift. Military medicine has always been predicated on the principle that you take injured soldiers, sailors, airmen, and make them better, return them to health, Dr. Schallhorn said. Refractive surgery takes healthy individuals and helps them do their jobs better with a significant safety benefitand as a byproduct, theres a huge quality of life benefit, too. In addition, refractive surgery has eliminated many of the barriers that prevented men and women from assuming certain occupations in the Navy, Air Force, and Army, provided they are good candidates for the corrective surgery in the first place. There are no restrictions now, Dr. Schallhorn said. It used to be that 70% of all people who could not be a Navy pilot were rejected because of myopia in the pastnow thats gone. Refractive Surgery article summary


1. Schallhorn SC, et al. Preliminary results of photorefractive keratectomy in active-duty United States Navy personnel. Ophthalmology. 1996;103:522.

2. Stanley PF, et al. Laser refractive surgery in the United States Navy. Curr Opin Ophthalmol. 2008;19:321324.

Editors note: Drs. Schallhorn, Reilly, and Butler have no financial interests related to their comments. The views expressed by the sources of this article are their own, not those of the Department of Defense.

Contact information

Reilly: cdreillymd@gmail.com
Schallhorn: scschallhorn@yahoo.com

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

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