Services Offering PRK and LASIK Eye Surgery to Active Duty Members
By Rudi Williams
American Forces Press Service
WASHINGTON, Jan. 14, 2003 The trend started a few years ago: throngs of professional boxers, football and basketball players, skydivers, pilots, police and firefighters flocking to get laser eye surgery -- and coming out all smiles and keen sighted.
Military eye doctors were among those paying close attention. "All these people were getting these procedures done and seeming to do their jobs safely and without any problem," Army Dr. (Col.) William P. Madigan said, one eye doctor observing the trend.
Madigan wears three hats: He's the consultant to the Army surgeon general for ophthalmology; chief of ophthalmology service here at Walter Reed Army Medical Center; and ophthalmology division chief at the Uniformed Services University of Health Sciences, Bethesda, Md.
"We talked to a lot of policemen and firefighters who said they were in such better condition to do their jobs after having LASIK," he said.
LASIK is the acronym for Laser-Assisted In-Situ Keratomileusis, which means to use a laser to reshape the cornea -- the clear covering in the front of the eye -- without invading adjacent cell layers. The surgeon cuts a flap in the cornea, leaving a hinge at one end. The flap is pulled back out of the way, and the surgeon then uses a laser to reshape the newly exposed corneal tissue. After the surgery, which takes about one minute, the flap is put back and left to heal.
"A firemen said losing his glasses going into a burning building would sometimes create a life or death situation," Madigan continued. "A policeman who loses his glasses in a scuffle could be at a disadvantage -- perhaps he can't see as well as the person he's trying to apprehend."
The same thing applies to a soldier on the battlefield, the colonel noted. "He's out there scrambling to get under cover from enemy fire, drops his glasses and can't see more than five feet in front of him," Madigan said. "Now he's no longer an asset to his unit because he can't see and needs somebody to help him get to safely. Then he needs to get to a place where he can get outfitted with glasses."
Some Persian Gulf War veterans told Madigan about difficulties they had with eyeglasses in the desert. "In the ensuing years they had refractive surgery and were deployed to Afghanistan," he said. "After returning, they said having laser eye surgery was the best thing the Army ever did to prepare them for combat missions -- the single best thing the Army ever did for them.
"It gives them confidence and good vision without optical devices, and they really benefited from it on the battlefield," the colonel said. "They say the difference between being in Desert Storm with glasses and to being in Afghanistan after laser eye surgery was like night and day."
Madigan said people who have LASIK are very comfortable because the surface of the cornea hasn't been disturbed and the reshaped tissue is protected once the flap is back in place. "They typically see 20/20 within an hour after the procedure," he said. "They're very comfortable and do well right off the bat."
The comfort level isn't the same with the refractive surgery procedure called PRK, or photorefractive keratectomy. There's no flap-cutting, but instead the laser burns right into the surface layers of the cornea. That's similar to having a corneal abrasion, the doctor explained. Consequently, patients who have PRK have to wear bandage contact lens over the cornea for about four days after the procedure.
"With the PRK you don't see real well right off the bat because the epithelium has to heal over the next few days," Madigan said. "It can be a little uncomfortable. Some people require more pain medicine than others, but the visual results are the same overall."
Although doctors have done LASIK internationally for more than 10 years, the first U.S. clinical trials started in 1995.
But the Navy started studying the effects of laser eye surgery even earlier -- in 1993. Back then, Navy then-Cmdr. Steven C. Schallhorn started a refractive surgery program at Naval Medical Center San Diego. He was doing preliminary studies on the Navy's special operations SEAL teams using PRK, Madigan noted.
Schallhorn, now a captain, found that after PRK, SEALs no longer had to worry about losing their glasses or having a contact lens float or fly away when they were in water or parachuting from an aircraft. And they could wear protective masks without a special refractive insert that limits their peripheral vision.
That was harmonious music to the ears of Madigan and other Army officials studying the possibility of using PRK/LASIK to improve readiness.
"We said, 'maybe this has some applicability to the broader military,'" Madigan recounted. "Service members are a physically active, relatively young population. They're often in remote sites that don't have optical shops if they lose their glasses or break a lens."
The Army's first PRK/LASIK site opened in May 2000 at Fort Bragg, N.C. More than 5,000 soldiers from XVIII Airborne Corps and the Special Operations Command have since been treated with outstanding results, he said.
"Our results are even better than civilian studies have quoted," Madigan noted. "I think that's because of how careful we are in our patient selection. We can just pick the patients we think it's going to be most helpful for."
The current policy among the services says that just about any active duty person can have either PRK or LASIK. Those who have had PRK can get a blanket waiver for the Special Forces Qualification, Combat Diving Qualification and Military Free Fall courses. PRK and LASIK are both waived for Airborne, Air Assault and Ranger schools.
However, those who have had LASIK must enroll in an observational study, if a slot is available, to undergo training in Special Forces qualification and aviation school. LASIK is strictly disallowed for combat divers and free-fall parachutists: Researchers want to ensure the flap does not create problems in these unique environments before granting routine waivers.
Madigan noted that the Air Force is providing PRK for certain of its personnel, but the service isn't conducting LASIK studies in its aviation community yet. But the Air Force will take people who have had PRK and allow them to enroll in a study they're doing for Air Force pilots.
Madigan emphasized that PRK and LASIK aren't part of the TRICARE program. "It's a readiness program," he noted. "It's to make soldiers better at their jobs so they can do their missions more effectively and safely. That's why it's called the Warfighter Program."
The Walter Reed Center for Refractive Surgery had its first patient in March 2002 and has since performed the procedure on more than 600 patients. The waiting list today is more than six months long.
Since PRK and LASIK are readiness issues, line commanders in the Army, Navy and Air Force prioritize the waiting list, the colonel noted. "They tell us who we're doing -- infantrymen, artillerymen, armor, special operations and Special Forces. Anybody who is going to be at the line of battle or behind the enemy's line of battle has first priority," he said.
The Army offers refractive surgery to soldiers, the Air Force to airmen, and the Navy to sailors, Marines and Coast Guardsmen.
"In May 2000, the Army was doing laser eye surgery at Fort Bragg, the Navy at San Diego, and the Air Force wasn't doing it anywhere at the time," Madigan noted. But, he said, it has since expanded:
- The Army has operating laser centers at Fort Hood, Texas; Fort Campbell, Ky.; Madigan Army Medical Center, Fort Lewis, Wash.; Tripler Army Medical Center, Hawaii; Landstuhl Regional Medical Center, Germany; Brooke Army Medical Center, San Antonio, Texas; Bragg; and Walter Reed.
- The Navy does LASIK surgery at Naval Medical Center San Diego, Calif., and National Naval Medical Center Bethesda, Md. PRK is offered at the naval hospitals in Portsmouth, Va., Bremerton, Wash., and Jacksonville, Fla.; Camp Lejeune, N.C.; and Camp Pendleton Marine Base, Calif.
- The Air Force performs PRK at Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas; Air Force Academy, Colorado Springs, Colo.; Wright-Patterson Air Force Base, Dayton, Ohio; Keesler Air Force Base, Miss.; and Travis Air Force Base, Calif. LASIK is only done at the academy and Wilford Hall.
Madigan, a U.S. Military Academy graduate and former artillery officer, expounded on the many advantages for service members not having to depend on optical devices -- eyeglasses or contact lens -- to see clearly. He remembers the difficulties he had with his glasses on maneuvers with the infantry and sleeping in the boonies wrapped up in a shelter half.
"You'd be taking off your glasses every two minutes to wipe off the raindrops so you could see," Madigan noted. "Hygiene in the field is terrible, so you're at much greater risk for corneal ulcers and other problems if you wear contact lenses."
However, he said, contact lens wearers can do physically active things rain or shine and still have better forward and peripheral vision than eyeglass wearers. He pointed out soldiers do better when they don't need glasses to use such things as binoculars or the night-vision goggles used by Apache helicopter pilots.
Preliminary studies on aviators show enhanced cockpit performance after laser treatment. Night-vision lab researchers at Fort Belvoir, Va., discovered that service members perform better, with higher marksmanship scores after PRK or LASIK, Madigan noted.
"LASIK correction is a permanent change to the cornea that should last you your lifetime," he said. "But there's an enhancement rate that runs around 10 percent. That is, about 10 percent of all the cases you do will need a second laser treatments weeks or months down the road to fine-tune the prescription."
Madigan said PRK and LASIK are best used for nearsighted people, but they also work for farsightedness and astigmatism. The procedures don't work for cataracts or diseased retinas, the doctor said.
"We just fine-tune the physical optics," he said. "We're getting 98 percent to 100 percent of our soldiers to 20/40 or better uncorrected vision (without spectacles). About 85 percent are 20/20 or better." A 20/40 correction concerns many patients -- that's the cutoff states generally use before drivers have to wear corrective lenses whenever they operate a vehicle, he remarked.
Even better results are on the horizon with a new, more sophisticated system that just arrived at Walter Reed.
"We've received the first shipment of the commercially available Ladar Wave, which delivers a more pinpoint treatment option," Madigan said. "Preliminary studies have shown an incredible increase to 20/15 and even 20/10 vision using the system -- it bounces an infrared beam into the eye and analyzes the reflection. It can analyze all the different factors that go into poor vision."
"If I were a 21-year-old artillery lieutenant in the field again, I would have had this last week," he said. "It's the best thing around. If I hadn't thought this was safe, effective and predictable, I never would have promoted it as something good for the Army."
Asked why he hasn't had LASIK to be rid of his own glasses, Madigan pointed to his age and profession. "If I were to be in the less than one-tenth of 1 percent that had a complication, I could lose my livelihood. That's a risk I don't want to take at my age," he noted.
"Maybe I'd come away with best corrected (even with glasses) 20/40 vision rather than the 20/15 I enjoy now. Well, I could drive without glasses and do most things very well -- but I couldn't do microsurgery," Madigan concluded.