Perfect vision for combat operations is not an ideal, it’s a necessity. As Lt. Col. Scott Barnes, an Army ophthalmologist at the Warfighter Refractive Eye Clinic at Fort Bragg, N.C., said, “The bottom line is that if you’re in the middle of a fight and you can’t see the enemy before they see you, you’re dead.” In a public Ophthalmic Devices Panel Meeting held on April 25, 2008, in Gaithersburg, Md., Cmdr. David J. Tanzer, M.D., program director of the U.S. Navy Refractive Surgery Program, stated that approximately 30 percent of military personnel need glasses or contact lenses. One study determined that an average of 300,000 soldiers require new vision prescriptions each year, and that each of these soldiers needs at least two sets of glasses and lens inserts for goggles and masks. The amount of extra eyeglasses substantially increases for troops deployed to combat theaters. It’s not unknown for troops to fill rucksacks and pockets with extra eyeglasses. Then there’s the age factor – vision degrades as an individual ages. For many years, this age-related loss of visual acuity in certain aviation and special operations military occupational specialties (MOS) brought otherwise rising and productive careers to a screeching halt.

For individuals in specialties that prohibited the use of corrective lenses, the rules were simple and straightforward. For instance, pilots and navigators had to have distant vision fall within the 20/70-20/20 (pilot) and 20/200-20/20 (navigator) range, and near vision had to be within the 20/30-20/20 (pilot) and 20/40-20/20 (navigator) range. When vision fell outside that range, the individual lost that qualification and could not regain it even if he or she had corrective laser refractive surgery. And up until the year 2000, a civilian with laser refractive surgery could only enlist in the military after receiving a special medical waiver. In MOS, where prescription lenses were allowed, the individual had to wear regular eyeglasses or optical inserts in goggles because contact lenses are prohibited for use in theater. This was an imperfect solution because glasses could be lost or damaged. In extreme cases, such as close proximity to a detonating improvised explosive device (IED), this damage could mean the shattering of lenses and the shards entering the eye. The Warfighter Refractive Eye Surgery Program was created to address these and other problems, and make it possible for servicemen and women to remain in their MOS where a negative change in vision would otherwise have disqualified them.

The Food and Drug Administration (FDA) approved laser eye surgery in 1989, but its acceptance in the military community was late in coming. This was hardly surprising given the groundbreaking nature of the surgery and the military’s defense mission that required any new system or procedure to be thoroughly tested before allowing its integration. In short, the military wanted to be sure the surgery really worked.

Four years after the FDA’s approval, in 1993, then-Cmdr. Steven C. Schallhorn, an ophthalmologist at the Naval Medical Center San Diego (NMCSD) who had studied the new procedures and was excited about their military application potential, opened the military’s first refractive-surgery program. Known as “the Pride of Navy Medicine,” the NMCSD is a top teaching hospital and referral center for the armed forces that has been at the forefront of military medical and humanitarian assistance care. Schallhorn’s program was developed in response to a recurring situation experienced by SEALs. SEALs who wore eyeglasses or contact lenses had chronic problems with their eyewear falling off during parachute jumps or underwater operations, and sought a solution. Schallhorn conducted preliminary studies using PRK (photorefractive keratectomy) on Navy SEALs. The other procedure, Laser-Assisted In-Situ Keratomileusis, or LASIK, did not become available until 1998. Feedback from the field from the SEALs who had the PRK procedure was overwhelmingly positive. Schallhorn soon became the Navy’s top expert in laser refractory surgery and ultimately became the first surgeon in the Department of Defense (DoD) to perform PRK, LASIK, and implant phakic intraocular lenses. For his pioneering achievements in the field, he was awarded the Legion of Merit with Gold Star, and the SEALs presented him with the rare honor of “honorary frogman.”

Schallhorn, who retired with the rank of captain in 1997, had a rare, even unique, military career. He was both an F-14 Tomcat pilot and TOPGUN instructor, and a world-class ophthalmologist. An EyeWorld magazine article stated that Schallhorn’s success in the field of laser refractive surgery “led to landmark changes in Department of Defense vision standards.” Schallhorn, who was always interested in aviation, was a senior at Colorado State University in Fort Collins and planning to continue on to medical school when he and a friend decided “on a whim” to fly, and signed on with the Navy. A qualified F-14A, A-4, and F-5 pilot, Schallhorn, whose call sign was “Legs,” logged 2,000 hours of flight time. He was rated one of the 10 best carrier pilots on board the USS Ranger, with more than 300 arrested landings, more than 100 of them at night. In 1981, he participated in the annual F-14 air-to-air combat exercise fighter derby and came away with the highest score ever recorded.

His aviation career was capped with his selection as a combat instructor at what was then the Navy Fighter Weapons School, popularly known as TOPGUN. While at Miramar, he was interviewed by Top Gun movie co-screenwriter Jack Epps, Jr., who incorporated some of Schallhorn’s anecdotes into the movie. When Schallhorn finished his tour of duty at TOPGUN, he decided that he had achieved everything he wanted to in aviation and was ready to tackle his other great love: medicine. In a 2007 interview for Cataract & Refractive Surgery Today, he said, “My decision to become an ophthalmologist, and later, a refractive surgeon, evolved naturally from my past experiences. I became interested in ophthalmology when I realized how important excellent vision is for pilots, especially in air combat situations.”

His experience as an F-14 pilot proved crucial in the development of his career as an ophthalmologist. While a med student and with the assistance of the Naval Aerospace Medical Research Laboratory at Pensacola, he instituted and directed a multi-year study to determine how well pilots visually identified incoming threats such as air-to-air missiles. That project focused his interest in ophthalmology and became, he later said, “The basis of a computer model and training programs used by TOPGUN.” By the time he retired, his pioneering program was fully embraced by all the military branches, had expanded to more than 20 refractive centers within the DoD, and in 2006 was authorized for combat aviators.

In addition to the laser refractive surgery center at the Naval Medical Center San Diego, the Navy has similar facilities at the Naval Medical Center Portsmouth, Va., the National Naval Medical Center, Bethesda, Md., and at the naval hospitals in Bremerton, Wash., Jacksonville, Fla., Camp Lejeune, N.C., and Camp Pendleton, Calif.

The U.S. Army’s first Warfighter Refractive Eye Clinic opened at Fort Bragg in 2000. Since then facilities have opened at Walter Reed Army Medical Center, Washington, D.C.; Tripler Army Medical Center, Honolulu, Hawaii; Womack Army Medical Center, Fort Bragg, N.C.; Darnall Army Community Hospital, Fort Hood, Texas; Blanchfield Army Community Hospital, Fort Campbell, Ky.; Landstuhl Regional Medical Center, Germany; Madigan Army Medical Center, Fort Lewis, Wash.; and Brooke Army Medical Center, San Antonio, Texas. The Air Force program was authorized in 2001, and centers are located at Wilford Hall Medical Center at Lackland AFB, Texas; Wright-Patterson AFB, Ohio; Air Force Academy, Colorado Springs, Colo.; Keesler, AFB, Miss., and Travis AFB, Calif.

Though each branch, and then specialties within the branch, has slightly differing criteria, in general refractive eye surgery is currently available to all active-duty and activated National Guard and Reserve personnel under the Warfighter Refractive Eye Surgery Program (WRESP). Information and forms detailing individual service requirements and application procedures are available online in each branch’s medical website. Broadly, selection priorities are allocated as follows:

• first priority to combat arms personnel whose mission involves operations at the time of battle or behind hostile lines;
• second priority to combat service support unit personnel currently assigned to a deployed unit; and
• third priority is given to all other active-duty personnel on a space available basis.

Additional criteria include:

• approval by commanding officer (rank of O-3 or above);
• minimum of 18 months remaining on active-duty roster following surgery (where applicable includes executed reenlistment action);
•  no adverse personnel actions pending;
• minimum age of 18 years old; and

• ability to attend all pre-operative and post-operative appointments.

In addition to the above mentioned, each branch has vision criteria that must be met in order for the individual to qualify. For example, SEALs require that uncorrected vision “be no worse than 20/200 in each eye” and that both eyes “must be correctable to 20/20.”

Individuals who do not qualify under WRESP are family members or retirees.

Today there are numerous types of laser surgery procedures, with additional innovative surgeries due to receive FDA approval within the next 10 years. This is important, because each procedure uses different methods to correct vision and influences what procedure can be used. For instance, up until 2006, LASIK was not prescribed for aviators. And it is prohibited for Special Forces troops or any MOS considering SCUBA or HALO school. But LASIK is permitted for those planning to have the procedure completed prior to entering Special Forces.

The program has been a huge success since its authorization. To date, more than 112,000 pairs of eyes have been treated and the waiting list, depending on the service, ranges from six months to more than a year.

While the surgeries have succeeded in retaining highly trained individuals such as aviators and special operations personnel, within their career specialties even the best of these surgeries have limitations. A typical cautionary example is offered on its Web site by the Air Force Medical Service regarding its U.S. Air Force Refractive Surgery Program:

“There is no guarantee you will have ‘perfect’ sight after undergoing any of [the] procedures. While the principle goal of all CRS [Corneal Refractive Surgery] procedures is to optimally correct your distance vision, achieving so-called ‘perfect’ distance vision is not always achieved … Further, these procedures do not alter the focusing function of your eye’s internal crystalline lens.” The document then explains how an eye “sees” and focuses and concludes by stating, “Current CRS technology does not alter the normal changes occurring in [the] internal crystalline lens. Consequently, virtually everyone will need reading glasses or a different prescription for near vision tasks whether CRS is undertaken or not at some point in their career.”

Presently, the two most popular procedures are LASIK and PRK. LASIK surgery uses a laser to reshape the cornea. This is accomplished by cutting a flap in the cornea that is pulled out of the way so that the surgeon can use a laser to reshape the exposed corneal tissue. The surgery itself usually is finished within a minute. The flap is then repositioned and allowed to heal. Because it is minimally invasive surgery that does not disturb the surface of the cornea, recovery time is fairly short. Col. William P. Madigan, who served as an ophthalmology consultant at Walter Reed and Bethesda in 2003, said that a typical LASIK patient will “Typically see 20/20 within an hour after the procedure. They’re very comfortable and do well right off the bat.”

Recovery time for patients using PRK — photorefractive keratectomy — is longer. The reason for this is because, unlike LASIK where the cornea is pulled aside enough to allow for the surgery, the cornea remains in place and the excimer laser is used to remove some of the thickness of the cornea in an area from 5 to 9 millimeters in diameter. In cases of mild to moderate myopia (nearsightedness), this thickness ranges from 5 to 10 percent of the cornea. In extreme myopia cases, this can be as much as 30 percent, or about the thickness of three human hairs. This creates a condition similar to a cornea abrasion — in other words, as if grit had scratched the eye. As a result, patients have to wear special bandage contact lenses for about four days following the operation. Madigan said, “With the PRK you don’t see real well [at first] because the [corneal] epithelium has to heal … It can be a little uncomfortable. Some people require more pain medicine than others, but the visual results are the same overall.”

Tanzer revealed at the Opthalmic Devices Panel Meeting that the DoD performed 45 studies in order to independently validate the safety and effectiveness of LASIK surgery. In one study of 480 randomly selected naval aviators, findings revealed that 94 percent of the eyes treated “attained uncorrected 20/20 or better,” that 0.5 percent experienced a “haze” that was treated with topical steroids, and that “100 percent” of patients treated had returned to flight status.

Tanzer’s comments were just the latest testimony to Schallhorn’s achievement. Speaking at Schallhorn’s 1997 retirement ceremony, Adm. Robert F. Willard, vice chief of naval operations, said that Schallhorn’s efforts “enabled thousands of men and women who may not have been able to fly to fulfill their goals and dreams.” And Schallhorn, who now serves as a consultant for the military and other government branches, as well as an advisor for 10 countries, acknowledged, “I am very proud of my contributions to the Department of Defense’s refractive surgery program.”

This article was first published in The Year in Veterans Affairs and Military Medicine: 2009-2010 Edition.