Eyeworld

EW FEATURE 48 Refractive surgery in military personnel and first responders • July 2016 by Maxine Lipner EyeWorld Senior Contributing Writer AT A GLANCE • Military study finds LASIK results are excellent, with nearly all Naval aviators willing to recommend the procedure to others. • Femtosecond LASIK has been found in Naval studies to provide better visual acuity with more reproducible flaps. • Flight vision simulators show those treated with PRK or LASIK are as good or better at detecting night vision targets as they were with glasses or contacts. Dr. Tanzer was lead investigator for a microkeratome comparison study that proved increased safety and efficacy of the femtosecond laser for creating flaps compared to 3 different mechanical microker- atomes. This study was presented but not published. "It mirrored what is in the peer-reviewed literature," he said. "It showed that the femto- second laser created a more repro- ducible flap and provided better visual acuities after LASIK than we could achieve with a mechanical microkeratome." That allowed the military to invest in femtosecond lasers for LASIK in all of its Navy refractive surgery centers. This also resulted in a significant shift from PRK to LASIK for those undergoing refractive procedures. "Prior to that, surface abla- tions were all that we were doing," Dr. Tanzer said, adding that this changed when they figured out that they were able to combine safety, efficacy, and a more rapid return to duty with femtosecond LASIK. Functional vision is key Dr. Tanzer said that functional vision is paramount for the military. "The Army is very keen on doing studies looking at functional visual acuity in their personnel. They have a sophisticated night simulator where they look at target detection and identification in a military- specific scenario at night," he said. "They're looking at the ability to detect targets and accurately identify targets in a military scenario after LASIK and PRK done in various ways." surgeries affect the performance of Navy and Marine Corps personnel doing their jobs. "We implement- ed PRK and then later LASIK in a careful and safe way," Dr. Hofmeister said. She said this was thanks to the efforts of 2 retired captains, Steven Schallhorn, MD, and Frank Butler, MD. Both were Navy ophthalmolo- gists who had firsthand experience with the operational Navy. Because of that awareness, they understood that visual outcomes are much more than 20/20 acuity alone. "They wanted to make sure that people could still see well in low-contrast situations, that they would be OK at high altitude or with low-oxygen tensions, and they wanted to make sure that the LASIK flap could not be easily dislocated in an ejection situation," she said. Dr. Tanzer likewise credits Drs. Schallhorn and Butler with starting the discussion about the pros and cons of refractive surgical procedures in the military versus wearing glasses and contact lenses in an operational environment. "Those conversations resulted in overwhelming support by the military community for refrac- tive surgery," he said. "They clearly saw the values of their fighting force not wearing glasses or contact lenses in that operational environment." They provided funding for research that was done first in the Navy and then in the Army and the Air Force to prove safety and effectiveness of refractive surgery as it transitioned from conventional ablations to more sophisticated wavefront-guid- ed ablations and LASIK as it moved from mechanical microkeratomes to femtosecond lasers, he explained. and implantable collamer lenses or phakic intraocular lenses are all refractive surgical procedures that have been studied and performed safely and effectively in military personnel." One pivotal refractive military study was a LASIK trial published in the Journal of Cataract & Refrac- tive Surgery, involving U.S. Naval aviators. 1 This showed a high level of safety and effectiveness in terms of the uncorrected visual acuity, reported Dr. Tanzer, who was the lead author. Dr. Hofmeister, who also took part in the study, views the excellent visual outcomes and high patient satisfaction as unprecedented. "Our uncorrected visual acuity was 20/20 or better in 98.3% of the patients who were treated for myopia or myopia with astigmatism and 95.7% of those who were treated for hyper- opia," she said, adding that many people gained lines of best corrected visual acuity, 95.9% said that LASIK helped their effectiveness as Naval aviators, and 99.6% would recom- mend the same treatment to other pilots. Dr. Tanzer thinks the fact that so many would be willing to recom- mend the procedure to others is par- ticularly striking. "These were anon- ymous questionnaires, so one would think that if they had any reserva- tions about the results, they would not be as likely to recommend the procedure to a fellow Naval aviator," he said. He added that in this study of 330 Naval aviators, only 1 was equivocal about recommending the procedure to a fellow aviator. The aviator in question was older and was corrected for distance visual acu- ity in both eyes, since monovision is not done in the military. "That older aviator required some reading glass- es to read up close, which is some- thing that is disclosed in informed consent," Dr. Tanzer said. "Because of that occurrence, he wasn't as like- ly to recommend the treatment to a fellow Naval aviator." This is 1 of many refractive studies that the Navy has under- taken. "The Navy's approach to refractive surgery has been highly systematic, evidence-based, and operationally focused," according to Dr. Hofmeister. She added that the idea has been to look at how such Study results on refractive surgery in the military have been pivotal in establishing acceptance for refractive surgical procedures F or those in the military, excellent vision can mean the difference between life and death, said Elizabeth Hofmeister, MD, captain, Navy Medical Center, San Diego. In her experience with those on the front lines of the Navy and Marine Corp, keen sight can be crucial. "We have pilots landing on aircraft car- riers at night, a sniper who's trying to take aim at some small, distant target, or a lookout on a ship trying to identify something on the hori- zon," Dr. Hofmeister said. "If they don't have excellent vision, they could make the wrong choice, and it could end up with someone being hurt or killed." Study results honing in on refractive surgery in the mili- tary have been pivotal in garnering acceptance for refractive surgical procedures in this population. Military studies David Tanzer, MD, chief medical officer and divisional vice president for global medical affairs, Abbott Medical Optics, Abbott Park, Illinois, who is retired from the military, said that the peer-reviewed literature is overwhelmingly favorable toward refractive surgery in the military. "There are numerous papers that have been published on refractive surgery," he said. "PRK, LASIK, Careful consideration of military refractive surgery results continued on page 50 " The Navy's approach to refractive surgery has been highly systematic, evidence-based, and operationally focused. " –Elizabeth Hofmeister, MD

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