More than 312,000 laser refractive procedures performed in the U.S. Air
Force, Army and Navy have provided invaluable insight about laser refractive
surgery to both military and civilian communities.
Since the first military laser study began in 1993 and the U.S.
Department of Defense adopted laser refractive surgery in 2000, military laser
refractive cases have demonstrated safety, efficacy and excellent visual
results when performed in appropriate patients.
Military refractive cases have also provided accurate and large sample
data that can be extrapolated to the general population.
The studies that we perform here at the Naval Medical Center San
Diego are viewed by civilian ophthalmologists all over the world as a benchmark
of refractive surgery research because the studies are unbiased, theyre
fair, theyre balanced, U.S. Navy Capt. David J. Tanzer, MD, said.
Were looking at safety and efficacy of [military] war fighters, so
we want to ensure that these procedures are safe.
The extrapolation of
the data that we accumulate here influences how civilian surgeons perform
refractive surgery all over the world.
|U.S. Navy Capt. David J. Tanzer, MD,
performing LASIK on a patient, says that unbiased military studies of the
procedure are a benchmark of refractive surgery research.
Image: MC2 Chad Bascom
Known as a force enhancer or force extender in
military parlance, refractive surgery is considered a life-saving procedure in
all branches of the U.S. military. It has also helped to alter the paradigm of
military medicine, according to Steven C. Schallhorn, MD.
Refractive surgery has been revolutionary in the military,
Dr. Schallhorn said. Nothing short of revolutionary, as far as what it
can offer active duty members. Put simply, it can enhance battlefield safety
and improve the performance of our military personnel.
Refractive surgery in military
When laser refractive surgery was approved by the U.S. Food and Drug
Administration, it was not permitted for enlisting military service members,
but a system of waivers now allows for the procedure. The Air Force was the
first military branch to waive both PRK and LASIK for all personnel, including
LASIK for aviators.
The Navy and Marines Corps waive PRK and LASIK for military personnel,
but not for aviators. However, those on active naval flight duty can have
successful PRK procedures waived, and LASIK can be performed if service members
enroll in the ongoing LASIK aviator study at the Naval Medical Center San
In the Army, both PRK and LASIK are waived for most service personnel.
LASIK is performed in the Army; however, surface ablation, such as PRK and
LASEK, is the preferred procedure to be performed on combat-bound soldiers and
others in special operations.
Laser refractive surgery for active military personnel is now supported
by the Department of Defense and top military commanders. There are six active
laser refractive centers in the Air Force, 10 such centers in the Army and
seven in the Navy.
Military laser refractive surgery is voluntary and based on FDA
guidelines for patient selection. Patients are carefully screened and provided
a detailed informed consent before refractive surgery, the same as with
All branches of the military adhere to specific standardized clinical
guidelines for screening, examining and performing refractive surgery and
following patients postoperatively. Outcomes of numerous clinical trials
conducted in the military have served to hone this process to improve the
outcomes of treatment performed on military members.
The most common laser procedure performed in all branches of the
military is PRK, while LASIK has been gaining in popularity in recent years. In
some Army laser refractive centers, up to 30% of procedures are LASIK, and at
the Naval Medical Center San Diego, more LASIK procedures are performed than
PRK, at a rate of 2-to-1, according to Dr. Tanzer.
Benefits for Navy
In many ways, refractive surgery is a perfect fit for the military, Dr.
Schallhorn said. A retired Navy captain and founder of the Department of
Defenses refractive surgery program, he was the first principal
investigator to examine refractive surgery in the military, starting with a
study of PRK on 30 Navy personnel in 1993.
Steven C. Schallhorn
He was inspired to investigate laser refractive surgery in the military
based on his own experiences as a Navy Top Gun pilot and instructor. He has
observed firsthand how eyesight is vital to military personnel, especially
When Dr. Schallhorn entered the Navy in 1977, the aviator vision
requirement was 20/20 uncorrected in both eyes. The vision requirement now
allows for vision correction by refractive surgery, he said.
Refractive surgery has made fields of service in all branches of the
military accessible to individuals whose vision would have previously
restricted them from entering.
It opened the world up to a lot of people, Dr. Schallhorn
said. Ive had many folks e-mail me and thank me for allowing them
to get in or allowing their sons or daughters to get into flight training when
prior they could never have done so because of their nearsightedness.
Dr. Tanzer said refractive surgery has also improved vision in demanding
environments, including underwater and in the air. For example, he performed
PRK on the first F-18 pilot to have refractive surgery and then land on board
an aircraft carrier. Subsequently, he was a passenger in a plane piloted by
that patient to assess results of the surgery.
The pilot successfully landed the plane on an aircraft carrier for a
night re-qualifying run with his surgeon in the backseat.
As we were flying to the ship that night, he related to me that he
had never seen the carrier or the landing lights better, Dr. Tanzer said.
You can well imagine that vision is the critical sense when it comes to
landing aircraft, let alone landing an aircraft on a pitching deck of an
Benefits for Army
In the Army, use of spectacles and contact lenses can be problematic for
soldiers, U.S. Army Col. Scott D. Barnes, MD, said. Contact lenses, prone to
infection in many austere military conditions, are prohibited for use overseas
deployments and in combat zones.
For decades, soldiers have been putting extra eyeglasses in their
pockets and rucksacks in case they lost or damaged a pair, he said. Replacement
glasses can take days to arrive by supply lines.
They know that if those glasses come off and theyre in the
middle of a firefight and someone is shooting at them, they cant raise
their hand and say, Would you mind stopping for a minute, let me climb
over this hill and get my glasses so I can see you, Dr. Barnes
said. They know that they can no longer take care of themselves or their
team members around them.
They might have to make a difficult decision
in the middle of the heat.
Do I shoot that moving object and hope
its not my buddy or an innocent civilian, or do I just sit here and hope
its a good guy that doesnt plan to shoot me?
If captured as a prisoner of war, glasses are often the first item taken
from captured soldiers, Dr. Barnes said, because soldiers without glasses
cannot see to escape. Vision can become one of the most debilitating senses in
Not only does laser refractive surgery provide better job performance
and safety capabilities for military personnel, it also is a cost-benefit to
the military over time. As of December 2009, there were more than 1.42 million
active duty U.S. personnel in all military branches. Of those, approximately
40% require optical correction.
After refractive surgery, gas masks, chemical protection and other
special Army gear do not have to be specially fitted for spectacle correction.
Benefits for Air Force
In the Air Force, clarity of night vision is essential for pilots,
according to U.S. Air Force Lt. Col. Charles D. Reilly, MD. Dr. Reilly, who was
theater ophthalmologist in support of Operation Enduring Freedom in Afghanistan
in 2007 and 2008, said he saw the significant impact of refractive surgery on
Air Force personnel.
Many Air Force operations occur at night, making good night vision
vital, he said.
Some of the life-support equipment that our personnel are required
to wear when youre flying a high-performance jet aircraft like an F-15 or
F-16, using night vision goggles or using a very big heavy helmet, with a big
mask over the helmet, if your glasses slip down or if your contact lenses have
an issue, youre at a real disadvantage, he said.
Key study results
Quality of vision after refractive surgery was one of the most important
factors first examined by military studies, Dr. Schallhorn said. Military
research has studied thousands of patients and found excellent results even
among large subject sets.
At the Naval Medical Center San Diego alone, more than 45 studies have
been conducted, 15 of those with investigational device exemption from the FDA.
An ongoing study there is examining 300 aviators on active flight duty
including 100 pilots who are undergoing wavefront-guided LASIK with a
femtosecond laser. So far, 175 aviators have undergone refractive surgery, Dr.
Tanzer said, and approximately 50 of those are in control of an aircraft.
The study is examining the safety and efficacy of the procedure for
potential approval in naval aviators, he said.
Results have shown that at 2 weeks, all aviators have 20/20 or better
uncorrected vision. Of those, 96% are 20/16 and 75% are 20/12.
The data that we have received thus far from this study is
unbelievably good. Its the best that Ive ever seen reported or
presented anywhere in the world, Dr. Tanzer said. Our nearsighted
aviators are eligible to return to flight status by 2 weeks following
refractive surgery now.
Military studies have investigated topics such as patient-reported
outcomes after surgery, contrast sensitivity, high-altitude conditions and
LASIK flap exposure in high wind blasts. Studies that have investigated
different laser platforms and technology without bias have also improved
outcomes, Dr. Schallhorn said.
The extensive military refractive surgical experience has shown that
patient selection is key to best outcomes, Dr. Reilly said. Rigorous preop
screening is vital.
In addition, best postoperative results are achieved if patients use eye
drops and sunglasses as directed, he said.
The majority of the military does a lot of surface ablation, and
the problems with corneal haze can really be significant if our patients
arent educated well about how to avoid haze formation, Dr. Reilly
Military results, civilian populations
Military refractive surgery demonstrates how military medicine has
helped contribute to the civilian population. Dr. Reilly noted that military
medicine developed the yellow fever vaccine, addressed anti-malarial and
parasitic infections, and now, with refractive surgery, has changed vision
Scott D. Barnes
In the world of refractive surgery, weve been really trying
to help advance the science and help the whole ophthalmic community understand
better whats the role of refractive surgery and whats possible with
refractive surgery, he said. It really is a very synergistic
relationship between the military and the civilian community when it comes to
Dr. Barnes said that even though PRK is considered a more painful
procedure than LASIK, Army personnel have rated pain from the procedure on a
scale of 0 to 10 as a 2 at 1 day after surgery. Service members do
not have a higher threshold for pain than civilians, Dr. Barnes said, and will
tell physicians when they are unhappy with surgical results.
Soldiers are like a slice of the civilian community as that is
where they come from; there are tough people who wouldnt complain at
anything and there are others who seem not to tolerate almost any
irritant, he said.
In addition, almost uniformly, most military patients consider their
postoperative refractive results outstanding. While there are those who
occasionally complain, he said, we have not had to discharge anybody from
the Army due to a poor result or complication of refractive surgery.
The nonmilitary community has sought out military commentary on
refractive surgery. In 2008, Dr. Tanzer and Dr. Barnes spoke at an FDA
Ophthalmic Device Panel meeting that examined the use of LASIK. The panel
reviewed topics such as procedure safety and patient satisfaction after there
were syndicated reports of patient depression and suicide after LASIK.
Dr. Tanzer presented Navy results and the military perspective on laser
refractive surgery, while Dr. Barnes, who had PRK in the military before he
became an ophthalmologist, spoke about LASIK and excellent patient satisfaction
results. He also presented studies in military populations that have shown
refractive surgery is a safe and effective procedure.
We [military ophthalmologists] make no money if we do no laser
cases at all, if we do a thousand laser cases; we make the exact same amount of
money. It is of zero dollar interest to us. In fact, our life would be easier
for us if we didnt do it. Wed have less work to do. But our
population is so clearly in favor of this, so happy with this and wants this,
and says its a need for them, Dr. Barnes said. Its
pretty strong, being able to say things from that perspective.
Although the Army mainly performs PRK, he said he appealed to the FDA to
not discontinue the use of LASIK for military personnel because of the growing
number of LASIK done in their centers.
These soldiers, these sailors, these marines, these airmen, they
are doing jobs that are now more secure, he said. This changes
their lives. In some cases, its a difference between life and
death. by Erin L. Boyle
What are practical
applications to civilian refractive surgery from extensive military refractive
results, and how could civilian surgeons incorporate those applications into
- Hammond MD, Madigan WP Jr, Bower KS. Refractive surgery in the
United States Army, 2000-2003. Ophthalmology. 2005;112(2):184-190.
- Rabin J. Refractive surgery in the military. Tri-Service Vision
Conservation and Readiness Program Web site.
Accessed Feb. 24, 2009.
- Schallhorn SC, Blanton CL, Kaupp SE, et al. Preliminary results of
photorefractive keratectomy in active-duty United States Navy personnel.
- Col. Scott D. Barnes, MD, is stationed at Womack Army Medical
Center, Fort Bragg, NC 28310. He can be reached at COL Scott Barnes, Dept. of
Ophthalmology-WAMC, Fort Bragg, NC 28310; 910-907-7921; e-mail:
- Lt. Col. Charles D. Reilly, MD, can be reached at 59 SSS/SGO2E,
Wilford Hall USAF Medical Center, Lackland AFB, 2200 Bergquest Drive, Suite 1,
San Antonio, TX 78236-5300; 210-292-2010; fax: 210-292-2313; e-mail:
- Steven C. Schallhorn, MD, can be reached at
- Capt. David J. Tanzer, MD, can be reached at Naval Medical Center
San Diego, 34800 Bob Wilson Drive, San Diego, CA 92135; 619-532-6700; e-mail: