Eyeworld

EW SECONDARY FEATURE 92 February 2018 by Liz Hillman EyeWorld Staff Writer Relatively new procedure gives service members another refractive option A t 0800 Bruce Rivers, MD, a Colonel in the U.S. Army, and director of the Warfighter Refractive Eye Surgery Program and Re- search Center, Fort Belvoir, Virginia, spoke briefly with a small group of patients, who were members of the Army, Marine Corps, Navy, and Coast Guard, to ensure there were no additional questions since their initial preoperative counseling. Most wore standard issue, black frame glasses. By 0805, Dr. Rivers sat down at a VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany) with his first patient slated for small in- cision lenticule extraction (SMILE). Though a highly trained member of the U.S. military who said during the procedure he'd been in combat, while lying under the laser, he was nervous. The laser portion of the procedure went smoothly, but when it came time to dissect the patient's SMILE in the military Dr. Rivers docks the VisuMax femtosecond laser prior to performing SMILE. lenticule, there was tension. The patient had a hard time keeping his eye still. Dr. Rivers reassured the pa- tient ,then used a Thornton fixation ring (Beaver Visitec International, Waltham, Massachusetts) to stabi- lize the globe so he could carefully separate the upper and lower planes of the lenticule. In cases where patients are agitated, it's important to talk with them more, assuring them that they're doing well and letting them know what's going on, Dr. Rivers explained. By the time the clock struck 0900, Dr. Rivers had completed his four SMILE cases of the morning and was ready to move on to per- form PRK. In March 2017, Dr. Rivers was the first surgeon in the Department of Defense (DoD) to perform SMILE shortly after it received approval from the U.S. Food and Drug Ad- ministration (FDA). In April, John Cason, MD, a commander in the U.S. Navy, and director of the Navy Refractive Surgery Center, San Di- ego, completed his first SMILE case. "In general, we've found [SMILE] to be a nice third proce- dure that we can offer our patients. Not that it takes away from PRK or LASIK because both of those pro- cedures are very good as well," Dr. Cason said. In addition to FDA approval, the military goes through its own process to approve a new procedure for service members. Matthew Rings, MD, chief of aerospace ophthalmology, Naval Aerospace Medical Institute (NAMI), Pensacola, Florida, explained that for the flying community of the Navy and Marine Corps, for example, members of the NAMI made recommendations to the Aeromedical Advisory Council, which after being approved by a vote, were then forwarded to the Navy Bureau of Medicine and Sur- gery (BUMED). This latter group, he noted "has ultimate responsibility for all medical policy within the De- partment of the Navy." The decision to add SMILE as a LASIK variant that would not disqualify a candidate for aviation duty was granted, in addi- tion to the already approved LASIK and PRK. "This was a positive policy move forward in the aviation community as NAMI continues to recommend military standards policy based on the best available science," Dr. Rings said. Including SMILE in the policy makes it easier in the context of accepting appli- cants for military aviation as SMILE becomes more available in the civilian refractive surgery market. "Now that SMILE has been approved by policy for aviation duty as a LASIK variant, the physical exam process becomes easier and more streamlined, allowing our physical standards department at NAMI to more quickly process applications for aviation duty." The adoption of SMILE by the DoD, Dr. Cason said, "speaks to the quality of the procedure, and in the context of PRK and LASIK, it's a third great option that we're consid- ering for our service members." In terms of choosing the right procedure for the patient, Dr. Rivers said if the patient is a candidate for all three options, the decision is largely up to him or her. "It's a conversation and you lay out all of the risks and bene- fits, and as long as they qualify for the procedure, if that's what they want to have, that's what they're going to have. I talk about all three procedures, show them what the procedure entails, and I do a pros/ cons list for all three procedures," Dr. Rivers said. Dr. Cason said there are still many who come in wanting PRK, in large part because their colleagues have had it and they're familiar with the procedure. There are others who want LASIK due to the fast recovery, which enables them to "get right back in the fight as soon as possible." LASIK can often be a good option for soldiers who are due to deploy because physicians want to make sure critical phases of their recovery are complete before they go into harm's way or areas with limited resources, Dr. Cason said. "What we find is that SMILE works out nicely as a combination of [PRK and LASIK]," Dr. Cason said. "I think of it as a hybrid experience for patients because if they're con- cerned about flaps, there's no flap. … PRK is sometimes an issue be- cause the recovery is a little longer.

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