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Refractive Surgery In the Military

Refractive Surgery In the Military. LTC Jeff Rabin, OD, PhD. Center for Refractive Surgery Walter Reed Health Care System Washington, DC. In the past we had…. Radial Keratotomy (RK). Deep spoke-like incisions Central cornea flattens For mild to moderate myopia Good results

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Refractive Surgery In the Military

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  1. Refractive Surgery In the Military LTC Jeff Rabin, OD, PhD Center for Refractive Surgery Walter Reed Health Care System Washington, DC

  2. In the past we had…

  3. Radial Keratotomy (RK) • Deep spoke-like incisions • Central cornea flattens • For mild to moderate myopia • Good results • Weakens cornea

  4. Now we have…

  5. Laser Procedures • PRK • LASIK

  6. Photorefractive Keratectomy (PRK) • Excimer laser reshapes cornea • Very precise • For myopia, hyperopia, astigmatism • Good results & safety

  7. LASIK • Microkeratome flap • Excimer laser removes precise amount corneal tissue • For myopia, astigmatism and hyperopia • Rapid popularity worldwide

  8. LASIK

  9. Center for Refractive Surgery PRK vs. LASIK • PRK • Day one: “Oowww!” • Less surgical risk • Slower recovery • 80% 20/20 • Haze possible • No flap LASIK • Day one: “Wow!” • Greater surgical risk • Quicker recovery • 80% 20/20 • No haze • Flap

  10. Do we need refractive surgery in the military…

  11. OPERATIONAL VISION CORRECTION • Over 1/2 million soldiers, sailors and airmen • 40% require optical correction • Annual cost of optical corrective devices…vast

  12. OPERATIONAL VISION CORRECTION

  13. GLASSES • Traditional way to correct all forms of refractive error • Relatively inexpensive • Few complications • Very precise

  14. GLASSES • Disadvantages:

  15. GLASSES • Disadvantages:

  16. GLASSES • Disadvantages: • Limit range of vision • Fogging, scratched • Broken or lost • Compatibility problems-- with night vision goggles, protective mask inserts, etc.

  17. CONTACT LENSES • Advantages: • Cosmesis • Increased FOV • Less minification—better vision in myopia

  18. CONTACT LENSES • Disadvantages: • Difficult to clean in field environment • May lead to infection • Problematic in chemical environments • Dislodge with G-forces

  19. REFRACTIVE SURGERY • All-weather24/7correction • Compatible with equipment • Increased soldier confidence(no broken or fogged glasses) • Increased survivability(lost glasses = casualty) • Improved quality of life---higher retention

  20. ARMY POLICY • AR 40-501 prohibits entry with history of refractive surgery, but… • Waiver policy (OTSG May 2000)allows for PRK or LASIK if--- • At least 6 months since surgery • Meet AR 40-501 vision standards

  21. ARMY POLICY • No visual side effects affecting daily activities • Refractive error stability • Post-LASIK: excluded from HALO, Flight, Diving and SF training • Post-PRK: excluded from Aviation

  22. Center for Refractive Surgery WRESP Warfighter Refractive Eye Surgery Program • WRESP -- limited resource available to commanders to enhance mission readiness

  23. Center for Refractive Surgery WRESP Warfighter Refractive Eye Surgery Program • WRESP -- limited resource available to commanders to enhance mission readiness • MEDCOM establishing WRESP Laser Eye Centers in MTFs designated by the DCSOPS

  24. Center for Refractive Surgery WRESP Warfighter Refractive Eye Surgery Program • WRESP -- limited resource available to commanders to enhance mission readiness • MEDCOM establishing WRESP Laser Eye Centers in MTFs designated by the DCSOPS • WRESP Centers: Operational -- Ft. Bragg Planned -- Ft Campbell, Ft Hood, Tripler AMC, Landstuhl RMC

  25. Center for Refractive Surgery WRESP Warfighter Refractive Eye Surgery Program • WRESP -- limited resource available to commanders to enhance mission readiness • MEDCOM establishing WRESP Laser Eye Centers in MTFs designated by the DCSOPS • WRESP Centers: Operational -- Ft. Bragg Planned -- Ft Campbell, Ft Hood, Tripler AMC, Landstuhl RMC, • DHS allocates appointments to supported units

  26. Center for Refractive Surgery WRESP Warfighter Refractive Eye Surgery Program • WRESP -- limited resource available to commanders to enhance mission readiness • MEDCOM establishing WRESP Laser Eye Centers in MTFs designated by the DCSOPS • WRESP Centers: Operational -- Ft. Bragg Planned -- Ft Campbell, Ft Hood, Tripler AMC, Landstuhl RMC, • DHS allocates appointments to supported units • Unit commands maintain by-name 3-month list

  27. Center for Refractive Surgery WRESP Soldier Selection Criteria Warfighter Refractive Eye Surgery Program • Assigned to unit with mission atline-of-battleorbehind hostile lines

  28. Center for Refractive Surgery WRESP Soldier Selection Criteria Warfighter Refractive Eye Surgery Program • Assigned to unit with mission atline-of-battleorbehind hostile lines • 1st priority-- SOC; Infantry, Armor, Field Artillery

  29. Center for Refractive Surgery WRESP Soldier Selection Criteria Warfighter Refractive Eye Surgery Program • Assigned to unit with mission atline-of-battleorbehind hostile lines • 1st priority-- SOC; Infantry, Armor, Field Artillery • 2nd priority-- CSS assigned to Division or SeparateBrigade

  30. Center for Refractive Surgery WRESP Soldier Selection Criteria Warfighter Refractive Eye Surgery Program • Assigned to unit with mission atline-of-battle or behind hostile lines • 1st priority-- SOC; Infantry, Armor, Field Artillery • 2nd priority-- CSS assigned to Division or SeparateBrigade • Other service members-- space available

  31. Center for Refractive Surgery WRESP Soldier Selection Criteria Warfighter Refractive Eye Surgery Program • Assigned to unit with mission atline-of-battle or behind hostile lines • 1st priority-- SOC; Infantry, Armor, Field Artillery • 2nd priority-- CSS assigned to Division or Separate Brigade • Other service members-- space available • At least 18 mo remaining on AD or with reenlistment

  32. Center for Refractive Surgery WRESP Soldier Selection Criteria Warfighter Refractive Eye Surgery Program • Assigned to unit with mission atline-of-battle or behind hostile lines • 1st priority-- SOC; Infantry, Armor, Field Artillery • 2nd priority-- CSS assigned to Division or Separate Brigade • Other service members-- space available • At least 18 mo remaining on AD or with reenlistment • At least 12 mo remaining with same/similar unit

  33. Center for Refractive Surgery WRESP Soldier Selection Criteria Warfighter Refractive Eye Surgery Program • Assigned to unit with mission atline-of-battle or behind hostile lines • 1st priority-- SOC; Infantry, Armor, Field Artillery • 2nd priority-- CSS assigned to Division or Separate Brigade • Other service members-- space available • At least 18 mo remaining on AD or with reenlistment • At least 12 mo remaining with same/similar unit • Must return for follow-up as specified

  34. Center for Refractive Surgery Womack Army Medical Center Warfighter Refractive Eye Surgery Program • AD Army, Navy and Marines at Ft Bragg • To benefit Warfighter(USASOC, 18th Airborne) • 1500 pts/year (3000 procedures); 125/month • USASOC—PRK only • All others—LASIK or PRK • LASIK disqualifying for SOC schools(HALO, scuba, SFQC, SERE) • Aviators—not eligible

  35. NAVY POLICY • Similar to ARMY for PRK • Excludes LASIK unless in research protocol • WRESP Centers at San Diego, Portsmouth, Bethesda • Four others planned

  36. AIR FORCE POLICY • Waiver for PRK only • Aviation and special duty • Includes 200 rated aviators and 100 student aviators per year • WRESP Center at Wilford Hall; planned for AF Academy and Wright-Patterson

  37. Center for Refractive Surgery Completed Navy Research Initial Evaluation of PRK Bottom line… • 80% -- 20/20 UCVA • 60% -- 20/16 UCVA • >90% --20/20 on re-treatment • Overall-- safe and effective

  38. Center for Refractive Surgery Completed Navy Research Visual Recovery in PRK Bottom Line… • How long before 20/20 uncorrected VA?- 40% at 1 week- 81% at 4 weeks- 81% at 12 weeks • Prolonged recovery, transient CS loss • Stable refraction in 6 weeks to 3 months • Extended recovery period in PRK

  39. Center for Refractive Surgery Completed Navy Research Pupil Size, Glare and Halos In PRK Bottom line… • No correlation: pupil size & symptoms • No correlation: pupil size & pre- / post-op visual performance differences • Symptomscorrelated withdegree of myopia

  40. Center for Refractive Surgery Completed Navy Research Psychiatric Factors and Patient Satisfaction After PRK Bottom line… • Overall:92% happy with outcome • The greater the depression before PRK-- less happy and more regret after PRK • Older patients: less happy, more regret

  41. Center for Refractive Surgery Completed Navy Research NVG Performance and PRK Bottom line… • Slight VA and CS decrease at 2 weeks • Returned to normal at 4 weeks • Transient loss of NVG performance

  42. Center for Refractive Surgery Completed Navy Research Quality of Vision & Prolonged Exposure to Altitude Bottom line… • RK, PRK, LASIK groups • All: slight corneal swelling (12-34 microns) • Hyperopic shift large in RK, slight in PRK/LASIK (0.2 – 0.3 D) • Slightdecreaseinuncorrected and best correctedvision

  43. Center for Refractive Surgery Completed Navy Research Night Driving Simulation After PRK Bottom line… • Distance for detection of road signs • Detection distances decreased in symptomatic eyes & those with greater light scatter • Promising functional approach

  44. Center for Refractive Surgery Completed Navy Research Vector Analysis Outcome of Astigmatic PRK Bottom line… • 20/20 UCVA in 73% • Slight undercorrectionof astigmatism common • Induced cylinder—rare

  45. Center for Refractive Surgery Completed Navy Research Initial Evaluation of LASIK In Navy Bottom line… • 92% -- 20/20 UCVA at 12 months • 70% -- 20/16 UCVA • Slight decrease in CS, resolved 3 months • 1 displaced flap at I day post-op • Rapid return to duty

  46. Center for Refractive Surgery Ongoing/Future Naval Research • Visual performance after PRK and LASIK • Initial evaluation of (INTACS) • Hyperopic PRK • Normative values for contrast sensitivity • Wavefront sensing • Cyclogyl vs tropicamide in refractive surgery • NEI refractive surgery questionnaire • PRK to retain ametropic Naval aviators

  47. Center for Refractive Surgery USAF PRK Study • 80 non-aviators, 20 controls; 30 months • Comprehensive ophthalmological baseline • Unique operational testing • Contrast sensitivity, color vision, NVGs, glare disability, corneal haze detection • Subsets:PRK at altitude PRK under high Gz loads PRK and cockpit visual simulation

  48. Center for Refractive Surgery Ongoing Air Force Research Evaluation of PRK In Air Force Bottom line… • Nearly 100 subjects; all myopic • Safe and effective thus far • Mean values at 6 months:UCVA 20/16BSCVA 20/14BSC SLCT 1.21 • Loss BSCVA and CS in some

  49. Center for Refractive Surgery Ongoing Air Force Research High & Low Contrast Vision In PRK Bottom line… • Pre-op BSC vs post-op UC • Decrease on each chart—high contrast VA – 2 letterslow contrast VA –5 lettersSLCT –11 letters • 24% require Rx for 20/20 in one eye

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