PRK, LASIK Offered to US Military
AMERICAN FORCES PRESS SERVICE

by Rudi Williams

February 6, 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 smiling 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," said Army Dr. Col. William P. Madigan, 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 at Walter Reed Army Medical Center in Washington, D.C., and ophthalmology division chief at the Uniformed Services University of Health Sciences, Bethesda.

"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."

"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 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 safety. 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 said.

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 said. "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 said. "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."

“It's a readiness program," he said. "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.

"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.

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 said.
"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 treatment 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.

"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.

“If I hadn't thought this was safe,
effective and predictable,
I never would have promoted it
as something good for the Army."

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 LadarWave, [a wavefront-guided LASIK system] 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 said. "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.