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USNavy-Corrective eye surgery questions and answers
Dr. Yi-Chang Wu
2000/12/05
Corrective eye surgery questions and answers
U.S. Navy Bureau of Medicine and Surgery
Washington, DC
1) What is refractive surgery?
Corneal refractive surgical procedures change the shape of the cornea to correct myopia (near
sightedness), hyperopia (far sightedness), and some types of astigmatism (irregular curvature of the
cornea). The various types of procedures differ in how they actually change the shape of the cornea.
These procedures offer the potential to reduce or eliminate the need for glasses and contact lens. It
should be noted that in most cases these procedures do not correct presbyopia, which is the need to
wear glasses for reading after middle age.
2) What are the different types of procedures available?
Radial Keratotomy (RK) reshapes the cornea by creating linear incisions in the peripheral cornea
with a surgical knife. These incisions relax the peripheral wall of the cornea, resulting in a secondary
change which flattens the curvature of the central cornea.
Photorefractive keratectomy (PRK) is one of two FDA approved procedures for reshaping the
cornea. An excimer laser uses an ultraviolet wavelength to deliver pulses of energy that remove a
small disc shaped sliver of the central cornea. To accomplish this treatment, the surface layer of the
cornea must be also be removed, but it grows back in place within a few days after the surgery.
Laser In-situ Keratomileusis (LASIK) is a procedure almost identical to PRK, in that the same small
sliver of the central cornea is removed using the identical excimer laser. LASIK differs from PRK in
what is done with the surface layer of the cornea. Instead of removing it, a special surgical blade is
used to create a flap that can be lifted up to expose the part of the cornea that will be treated with the
laser. After the laser treatment has been performed, the flap is laid back down on the cornea, thereby
eliminating the need for the surface layer to grow back in place.
Intracorneal rings are surgical implants that can be inserted into the peripheral cornea in order to
change its shape. This procedure was just approved by the Food and Drug Administration in March
'99.
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USNavy-Corrective eye surgery questions and answers
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2000/12/05
3) Are there other types of procedures being developed?
Other types of procedures are in various stages of research and development for use in refractive
surgery. These include different types of lasers besides the excimer laser, as well as intraocular lenses
that can be surgically implanted, which appear similar to a contact lens, but are placed inside the eye.
CDR Steve Schallhorn adjusts microsurgery device during photorefractive keratectomy.
4) What are the advantages and effectiveness of these procedures?
RK: Is the oldest of the refractive surgical procedures, and has the most long-term data. It is the least
expensive of the procedures to perform, and is effective in improving the vision in people who have a
mild amount of nearsightedness without astigmatism.
PRK: Prior to FDA approval, extensive clinical studies were performed to assess PRK safety and
efficacy. Ten year follow-up data is available from some of the studies conducted. More recently, the
pool of those who may be eligible for treatment has expanded to include more severe forms of myopia,
as well as hyperopia and astigmatism.
Potentially 80-90 percent of people who require glasses for distance vision may be eligible for PRK. It
is an effective procedure, with up to 95 percent of treated patients not needing distance glasses to
achieve 20/40 vision or better. Approximately 75 percent of patients achieve 20/20 vision. The results
may not be quite as good among patients with more extreme forms of myopia, hyperopia or
astigmastism. The visual improvement appears to remain stable after healing from the surgery.
LASIK: The two primary advantages of LASIK over PRK are the quicker visual recovery time and
minimal post-operative discomfort. By creating a surgical flap at the time of the procedure instead of
actually removing the superficial layer of the cornea, the vision recovery may be instantaneous, as
opposed to days, weeks, or even months following PRK while the surface layer grows back and
smoothes itself out. Likewise, because the top layer is not actually removed, there is minimal
discomfort after the surgery.
INTRACORNEAL RINGS: The big advantage of the rings is that they can be surgically removed if
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the results are not satisfactory. Keep in mind that RK, PRK, and LASIK are irreversible. Because the
intracorneal procedure is performed on the peripheral cornea, it has the advantage of not altering the
clarity of the central cornea, which is the most important part of the cornea for vision purposes.
5) What are the disadvantages and risks associated with these procedures?
RK: The surgical incisions made in the cornea have the undesirable affect of weakening the ability of
the eye to withstand the effects of blunt trauma, making it more susceptible to severe injury. The
effects of the surgery may not remain stable over time, causing a need to return to wearing glasses,
contacts, or potentially requiring additional surgery years after the initial procedure. Also, changes in
altitude may further change the shape of the cornea, which can degrade vision. The procedure is not as
accurate as PRK or LASIK at correcting many forms of refractive error. All of these limitations make
RK an undesirable procedure for most active duty personnel today, especially in view of the
advantages offered by newer forms of refractive surgery. Therefore, applicants to the Navy and Marine
Corps that have had previous RK surgery will no longer be considered for waivers.
PRK: Active duty personnel who undergo this or other forms of refractive surgery may lose time from
work and incur possible TAD expenses associated with travel to a designated medical center
performing the procedure. As with any surgical procedure, there may be side affects and
complications. Most of these are short term, and resolve within a few weeks following the procedure.
But, some may take longer to resolve, or in a small percentage of cases, could be permanent. These
include decreased night vision, glare sensitivity, and/or worsening of the pre-operation best vision due
to scar formation and other effects of the healing process. With both PRK and LASIK, it is not
uncommon for up to 10% of patients to require retreatment with the laser to ‘fine tune’ the desired
corrective affects of the procedure. While the final visual results are indentical for PRK and LASIK,
ther is a longer recovery time following PRK. Finally, though it is not anticipated that adverse
complications will occur 10 or more years after the surgery, there is no data available to determine
what, if any, changes may devleop later in life. A patient has a corrective vision procedure performed.
LASIK: The disadvantages described for PRK are essentially the same as for LASIK. However, there
are additional risks for LASIK, including a potenially higher rate of complications. The long-term
stability of the flap created at the time of the surgery is still an operational issue. Also, studies on the
effects of changes in altitude, dimly lit operational environments, and the ramifications of minor
trauma on the eye have not yet been fully addressed. While LASIK is quickly replacing PRK as the
more common procedure performed by civilian ophthalmologists, the military must first assess its
safety and applicability in operational environments before endorsing it as a procedure that is
appropriate for active duty personnel. These studies are in progress, and preliminary results have
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2000/12/05
been favorable.
INTRACORNEAL RINGS: Although this procedure has been approved by the FDA, there is very
little long term follow-up available. The number of patients that would be suitable candidates is quite
limited at this time. The rings can only correct relatively low levels of nearsightedness without
astigmatism. While the procedure has the potential for being reversible, it may not always be possible
to return to the preoperative state. In the preliminary studies evaluated by the FDA, approximately
15% of people had to have the implants removed at some point after the surgery for various reasons.
Finally, there is no data available regarding the suitability of this procedure in military operational
environments.
6) What are the unique concerns about refractive surgery in the military? What are the
conclusions? What issues remain to be addressed?
The visual demands of personnel in the Armed Forces are often unique and more critical than day
to day requirements for most civilians. The variety of operational environments in which service
members must be capable of performing their duties requires stringent guidelines for visual function.
In many of the operational environments, the use of glasses or contacts may not be ideal or
conducive to the performance of military duties. Refractive surgery offers the distinct advantage of
enhancing the military readiness and performance capabilities of service members by eliminating the
need for glasses or contacts.
It may also enlarge the pool of potentially qualified applicants for warfare communities with
visual standards that usually limit the number of qualified applicants. However, before endorsing any
particular form of refractive surgery as being suitable for active duty personnel, it is important that
studies be conducted to evaluate its safety and efficacy in the military.
Because there is little incentive for civilian ophthalmologists to address questions pertinent to the
military environment, such as the effects of refractive surgery on variations in altitude, night vision,
target tracking, trauma, etc., the military must conduct its own studies prior to making policy
determinations.
The Navy has a very active refractive surgical investigation program and has conducted
numerous studies on refractive surgery, and PRK in particular. With more than 3000 PRK procedures
performed to date, Navy Medicine has been able to conclude that the procedure is a safe and effective
alternative to the use of contacts and glasses in the vast majority of all service members, except for
aviation personnel, where studies are still underway. LASIK is also the subject of current
investigations in a variety of non-aviation communities, with preliminary studies indicating favorable
results thus far. Other new forms of corneal refractive surgery as they develop will need to be
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2000/12/05
subjected to similar clinical evaluations prior to endorsement for use in active duty service members.
The Noptel targeting system mounted on an M-16 rifle is used to evaluate marksmanship in subjects
before and after PRK to correct nearsightedness.
7) What is the current policy for new accession candidates that have already had corneal
refractive surgery and wish to enter the service in either the Navy or Marine Corps?
Current Department of Defense regulations stipulate that any form of corneal refractive surgery is
considered disqualifying for entry into the military. However, beginning in 1997, the Navy/Marine
Corps instituted a policy that allows waivers to be granted for corneal refractive surgery, provided
certain uniform criteria are met. The purpose of requiring a waiver process is to ensure that applicants
have had successful and stable outcomes following surgery prior to being accepted into the service.
Criteria that must be met before a waiver will be considered were most recently revised in April 2000,
and include the following:
1. Surgery must have been completed at least three months prior to entry into the service.
2. Copies of all pre-operative notes, operative notes, and post-operative medical records must be
submitted as part of the waiver review process.
3. Vision following surgery must be correctable with glasses (if necessary) to meet the current visual
standards for whatever program the candidate is applying to. Visual standards may differ for
enlistment, commissioning, or appointment to a service academy or NROTC. The term
“correctable” means that glasses may be used if necessary to fine tune the visual acuity even after
surgery. If the use of glasses is still unable to correct the visual acuity to meet the specified visual
standards of a particular program, a waiver will not generally be granted.
4. The results of the surgery must be stable. In other words, the refractive error (i.e. power of glasses)
must not still be changing. In particular, the applicant must show evidence of two separate
refractions having been performed at least one month apart after surgery, and there can be no more
than 0.50 diopters difference in the measurement of sphere or cylinder.
5. There can be no complications present as a result of the surgery, such as difficulty with night
vision, glare symptoms, scars or other conditions that interfere with visual function.
6. The amount of refractive error (i.e. myopia, hyperopia, or astigmatism) that was present before
surgery can not exceed the current visual standards for entry into the service. In other words, if the
amount of nearsightedness, farsightedness or astigmatism before surgery was greater than what
Navy and Marine Corps standards allow, the applicant will still be disqualified even if the visual
acuity results after surgery are very good. The reason for this is that the risk of other diseases of
the eye associated with very high degrees of refractive error are not changed (i.e. are not reduced)
as a result of having had refractive surgery.
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2000/12/05
Although the Navy waiver policy does not specifically exclude any form of refractive surgery from
consideration, waivers for RK are no longer being considered. New forms of refractive surgery, such
as intracorneal ring implants (ICR), will not likely be waiverable until more data proving their safety
and efficacy in the military is available. Meanwhile, candidates for general accessions into
non-warfare communities will generally receive approval of waiver requests for PRK and LASIK if all
of the criteria identified above are satisfied. Candidates for accession into warfare communities may
have additional restrictions, and may require additional approval by community managers before a
candidate is accepted in those communities. Presently, PRK is waiverable for accessions into all
warfare communities, although waivers for aviation will be very limited and will require the service
member to participate in ongoing clinical studies designed to evaluate PRK’s safety and efficacy
(additional information regarding aviation requirements is addressed in section 9). LASIK is
waiverable for all warfarecommunities with the exception of aviation, SPECWARFARE and diving.
Appendix (2) contains tables that summarize PRK and LASIK policy for new accessions in both
non-warfare and warfare communities.
8) What is the current policy on corneal refractive surgery for active duty Navy and USMC
personnel in non-warfare communities?
The CNO’s NAVADMIN message of 29 Dec 99 (341/99) announced the start of the Navy’s
Corneal Refractive Surgery program. Active duty personnel, regardless of their warfare community
status, may request evaluation to determine their suitability for surgery. If the service member is
determined to be a suitable candidate, a consult requesting surgery can be submitted to one of the
Navy’s Refractive Surgery Centers (see section 10 for additional information on the process of
requesting surgery). However, because the demand for services will exceed the ability to
accommodate the interest for some time, service members will be scheduled on a prioritized basis.
Front of the line privileges will be extended at all times to those whose military duties require them to
regularly work in extreme physical environments that preclude the safe use of glasses or contact lenses.
To facilitate the screening process, unit Commanding Officers will be required to determine the
appropriate priority category, and grant permission for their personnel to have surgery performed.
While personnel in non-warfare communities are not excluded from the possibility of having surgery
performed at a Navy center, in most cases they will likely be assigned a lower priority than service
members in warfare communities. The Navy presently has laser centers in San Diego and Portsmouth,
and anticipates adding additional centers in the future. It should be noted that personnel in non-warfare
communities that are contemplating subsequent application to various warfare communities should
verify current policies governing those communities before having surgery to determine if they will
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still be eligible for consideration. Appendix (2) contains tables that summarize PRK and LASIK policy
for retention of service members in non-warfare, as well as the various warfare communities in the
Navy and Marine Corps.
Service members that do not wish to wait to have surgery performed in the Navy can elect to
have surgery performed at their own expense in the civilian sector. The Navy does not encourage this
option. Moreover, service members are required to first undergo counseling to ensure they are fully
aware of Navy/Marine Corps policies, and that they understand the responsibilities required of them
before and after surgery. Approval by the unit Commanding Officer is required before the member has
surgery in the civilian sector. Failure to comply with these requirements may result in disciplinary
action and/or loss of eligibility for disability benefits in the event of adverse outcomes following
surgery. Policy guidelines summarized in Appendix (2) are applicable regardless of whether surgery is
performed in the Navy or at the service member’s own expense in the civilian sector. See section 11
for complete details on the requirements before and after surgery in the civilian sector.
9) What is the current policy on corneal refractive surgery for active duty Navy and USMC
personnel, applying for or already designated, in warfare communities?
As noted in section 8, the CNO’s NAVADMIN message of 29 Dec 99 (341/99) announced the
start of the Navy’s Corneal Refractive Surgery program. The express intent of the program is to
provide these services to personnel in warfare communities. Front of the line privileges will be
extended at all times to those whose military duties require them to regularly work in extreme physical
environments that preclude the safe use of glasses or contact lenses. To facilitate the screening process,
unit commanding officers will be required to determine the appropriate priority category, and grant
permission for their personnel to have surgery. Warfare communities themselves are not prioritized in
such a way that any one community has preference over others. The Navy presently has laser centers
in San Diego and Portsmouth, Va., and anticipates adding additional centers in the future. See section
10 for complete details on the various steps associated with having refractive surgery performed at
Navy Refractive Surgery Centers.
Active duty service members in warfare communities, with the exception of aviation personnel,
that do not want to wait for the opportunity to have surgery performed in the Navy, may elect to have
surgery performed at their own expense in the civilian sector. DESIGNATED AVIATION
PERSONNEL MAY NOT UNDER ANY CIRCUMSTANCES HAVE SURGERY PERFORMED IN
THE CIVILIAN SECTOR. Moreover, the Navy does not encourage this option for other personnel. If
service members choose to pursue this option, they are required to first undergo counseling to ensure
they are fully aware of Navy/Marine Corps policies, and that they understand the responsibilities
required of them before and after surgery. Approval by the unit commanding officer is required before
the member has surgery. Failure to comply with these requirements may result in disciplinary action
and/or loss of eligibility for benefits in the event of adverse outcomes following surgery. See section
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11 for complete details on the requirements before and after having surgery in the civilian sector.
Service members are responsible for verifying current policies on corneal refractive surgery in
their warfare communities before surgery is performed. Policy guidelines summarized in Appendix (2)
are applicable regardless of whether surgery is performed in the Navy or at the service member’s
own expense in the civilian sector. The following additional comments reflect important current
policy:
USMC, Undersea (Submarine) and Surface Warfare: Both PRK and LASIK are authorized
corneal refractive surgery procedures. Neither PRK nor LASIK is disqualifying for retention, and no
waiver process is required. All other forms of refractive surgery (i.e. RK, intracorneal rings, etc.) are
disqualifying for retention and will not be waivered.
SPECWARFARE and Diving: PRK is the only type of refractive surgery that is authorized. PRK
is not disqualifying for retention and no waiver process is required. LASIK and all other forms of
refractive surgery (i.e. RK, intracorneal rings, etc.) are disqualifying for retention and will not be
waivered.
Aviation: All forms of refractive surgery are disqualifying for accession and retention of
personnel in Naval and Marine Corps aviation. In contrast to all other warfare communities, only PRK
will be permitted AND a waiver process is required. No other forms of refractive surgery will be
considered for a waiver. As part of the waiver process, the service member must first be accepted into
and agree to participate in a Navy sponsored clinical study. The aviation communities strongly support
Navy PRK studies and have established the following criteria for waiver consideration:
1.
New accession applicants to air warfare who have already had PRK (civilians, NROTC, and
Naval Academy, and enlisted accessions) may be waivered for aviation duty if they meet all of the
following criteria:
a. They meet the clinical criteria required to qualify, and are accepted into a Navy approved PRK
aviation clinical study protocol designed to monitor long-term follow-up.
b. Pre-PRK refractive error was less than or equal to plus or minus 5.50 (total) diopters in any
meridian with less than or equal to plus or minus 3.00 diopters of cylinder and anisometropia less
than or equal to 3.50 diopters.
c.
d.
e.
Civilian applicants must provide detailed pre-operative, operative, and post-operative PRK
follow-up records prior to acceptance into a Navy approved PRK study.
At least three months have elapsed since surgery or re-treatment and evidence of stable refractive
error is demonstrated by two separate examinations performed at least one month apart.
They meet all other applicant entrance criteria for aviation warfare, as outlined in the Manual of
the Medical Department and the Navy Aeromedical Reference and Waiver Guide.
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2.
Dr. Yi-Chang Wu
2000/12/05
For active duty personnel already designated in Navy and Marine Corps Aviation (flying class one,
flying class two and class three-designated enlisted aircrew and flight deck personnel), waiver
consideration for PRK must meet all of the following criteria.
a. The service member's request to have PRK surgery is approved by the Commanding Officer
b. The service member meets the eligibility criteria required to qualify, and is accepted into a Navy
approved PRK aviation clinical study protocol designed to monitor long-term follow-up.
c. A waiver to return to flight duties will be recommended if they meet study requirements and all
other physical standards as outlined in the Manual of the Medical Department and the Navy
Aeromedical Reference and Waiver Guide.
10) Guidelines for service members who desire to have surgery at one of the Navy's corneal
refractive surgery centers?
a. Preliminary evaluation: Corneal refractive surgery is currently available at Naval Medical Center
San Diego, Naval Medical Center Portsmouth and National Naval Medical Center Bethesda.
Regardless of where service members are stationed, they may request a screening examination be
performed by an optometrist or ophthalmologist at the medical treatment facility closest to their duty
station. These eye care providers will determine if the service member meets the minimal eligibility
criteria for surgery and address whatever questions they may have. Current inclusion and exclusion
criteria include:
Inclusion criteria:
(1) Healthy eyes.
(2) Refraction: Myopia: -1.00 to -12.00 diopters (D), spherical equivalent at the corneal
plane, with less than or equal to 4.00D of astigmatism. Hyperopia: +1.00 to +6.00,
spherical equivalent at the spectacle plane, with less than or equal to 1.00D of
astigmatism.
(3) Stability: Stable refraction as defined as less than or equal to 0.50D of change in either
the sphere or cylinder component of their refraction over the last 12 months.
(4) Age: Must be at least 21 years old.
(5) Geographic location: Service members will be eligible for surgery regardless of their
geographic location. While expenses associated with travel from certain OCONUS and
CONUS duty stations could very well limit the feasibility of some service members
ability to accept the offer to have surgery, we will not discriminate or prioritize patients
based on their current duty location as long as adequate post-op follow-up is available.
Commands will need to decide how important they believe it is for their service members
to have this treatment.
Exclusion criteria:
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(1) Keratoconus (an irregular shape of the cornea).
(2) Pregnancy or breast feeding.
(3) Autoimmune or immunodeficiency diseases.
(4) Currently taking the following medications: isotretinoin (Accutane), amiodarone
hydrochloride (Cordarone) and/or sumatripin (Imitrex).
b. Consult forms and prioritization: Consult forms have been designed specifically for the Navy’s
Corneal Refractive Surgery program. Eye care providers at military treatment facilities will use these
forms to submit requests for surgery to the Refractive Surgery Centers. In addition to the eye exam to
determine suitability for surgery, the consult form will require unit Commanding Officer input to
determine the priority category appropriate for the service member. Navy and Marine Corps policy
guidelines have been disseminated to line Commanding Officers, identifying a prioritization plan
designed to ensure that active duty warfighters whose operational effectiveness would most benefit
from PRK are given head of the line privileges. The service member's Commanding Officer shall be
required to determine the priority level merited based on operational need, probability of mission
performance enhancement and issues of personal safety in the performance of their military duties.
Priority "I" (highest priority) shall be limited to personnel whose military duties, without question,
require them to regularly work in extreme physical environments where the use of glasses or contact
lenses would be unsafe and would likely compromise mission performance. Prioritization
determinations are to be based primarily on current or likely future duty assignments. Three other
priority levels ("II-IV") shall be used to identify sequentially lower operational need / justification for
PRK. Appendix (3) is the cover letter that will be attached to each consult form, giving additional
guidance to commanding officers on considerations that should be taken into account when
completing the prioritization block on the consult form. When all required information has been
gathered and the consult form completed, the eye care provider will forward the form to the Refractive
Surgery Centers for processing.
c. What happens after the consult is received in at the Navy’s Refractive Surgery Center?: If the
information on the consult form is incomplete, the referring eye care provider will be contacted or
the form returned for whatever additional attention is needed. Completed forms will automatically
result in the service member’s name being added to the computerized database, using the date the
consult was received and the prioritization category given by the CO to determine where the
member will be on the waiting list.
d.
How will patients be contacted?: Preferably, service members will be contacted by e-mail.
E-mail addresses will be part of the information requested on the consult form. The message will
notify service members them that we wish to schedule them for surgery. They will be instructed
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to call the appropriate Refractive Surgery Center to make arrangements. If an e-mail account is
not available, the service member will be contacted by phone or by regular mail. After the patient
has been contacted and a tentative surgical date is arranged, the service member will receive (via
e-mail or regular mail) additional information from the Refractive Surgery Center that provides
details with logistics, local lodging, con leave, recommendations for deployment and instructions
for obtaining CO authorization for the dates offered.
e.
How far in advance will surgery be scheduled?: In most cases, service members will be
offered potential dates for surgery approximately 2 to 3 months in advance. It is anticipated that
this lead time shall be adequate in most cases for the service member to verify their availability,
accept or decline the offer to have the surgery scheduled, and make TAD arrangements (if
necessary). If a service member is not available within the 2-3 month window under
consideration, they will be able to keep their place in line and may have surgery scheduled at a
later date when they are available.
f.
Cancellation policy: If a service member needs to cancel a surgical date anytime prior to surgery,
they will keep their place in line. However, if they are a “no show” and fail to contact the PRK
center prior to the scheduled surgery, they will forfeit their place in line and their new consult
date becomes the date they no-showed (unless there are reasonable extenuating circumstances for
the no-show).
g.
Travel arrangements and expenses: If travel arrangements are required for the service member
to have surgery, the service member shall be responsible for arranging their own travel itineraries.
While there are no fees for the surgical procedures themselves, any expenses incurred for travel
and TAD shall be born either by the command, at the discretion of the CO, or by the individual.
Service members should expect to have to stay in the vicinity of the PRK center for 3-5 days on
average. Navy ophthalmology or optometry follow-up care will be arranged at the nearest
Military Treatment Facility to the service member's permanent duty station, thereby minimizing
time away from work.
h.
Convalescent leave: Convalescent leave recommended following corneal refractive surgery will
typically be 4 days for myopia, and 6 days for hyperopia (including the surgery day). Thereafter,
the service member may return to work and can usually perform most duties. It is the
responsibility of service member to obtain prior approval from their command for convalescent
leave.
i.
Recommended post-op follow-up schedule: Patients will typically be seen on the day after PRK
and LASIK surgery. In addition, PRK patients are usually seen every 1-2 days thereafter until the
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epithelium is healed following PRK (usually 2-3 days). Thereafter, all patients typically have
check-ups at 2 weeks, 1 month, 3 months, 6 and 12 months. However, these recommendations are
not intended to be a rigid schedule and can be tailored according to service members availability
and need for follow-up. After one year, if there are no problems that merit further follow-up, the
patient can be seen on an as needed basis.
j.
Coordinating follow-up: If the service member was referred to a Navy Refractive Surgery
Center from an eye care provider at a military treatment facility (MTF) other than one of the laser
centers, follow-up care will be arranged at the referring MTF. As part of the information to be
sent to the service member at the time surgery is scheduled, they will be instructed to contact
their local MTF well in advance of their actual surgical date. While the initial post-op visits in the
first few days after surgery will be performed at the Navy Refractive Surgery Center, the 2 week
check-up and subsequent visits will be performed at the local MTF.
k.
Return to full and unrestricted duty: This is defined as the ability to perform all duties and
suitability for deployments which may include isolated duty assignments where routine eye care
services are not readily available. After the initial few days of convalescent leave, service
members are able to return to work and perform most of their duties. However, the use of certain
types of eye drop medications and the need for follow-up will preclude the ability to return to full
and unrestricted duty until a service member has been cleared by an eye care provider managing
their post-op course. This will typically be 1 month for most myopes, but may require up to 4
months for hyperopes as well as some high myopes. It is important that the commands be aware
of the potential down time, particularly for units subject to deployment cycles, before granting
permission for the service member to have surgery. We will include this with the information sent
to patients at the time they are scheduled for surgery, and advise them to inform their command
when they seek approval for TAD and convalescent leave. Returning to full and unrestricted duty
will require documentation be made in the service member’s outpatient medical record. This
post-op medical clearance will be required regardless of whether surgery was performed in the
military or civilian health care sector. Appendix (4) are the forms required for this purpose. The
service member’s eye care provider that has been delivering follow-up care will complete the first
page and recommend when the service member is cleared for full duty. The service member’s
primary care provider shall be responsible for verifying that applicable visual standards and
policy guidelines have been complied with.
11) Guidelines for service members who, at their own expense, prefer to have corneal refractive
surgery performed by civilian practitioners.
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a. General comments: The Navy recognizes that demand for services at its own Refractive
Surgery Centers is likely to exceed the ability to keep pace with the interest, and that long
waiting times may be experienced. Moreover, with the express intent purpose of the Navy
Corneal Refractive Surgery program being to provide these services on a prioritized basis to
operational warfare personnel, other service members may have lower priority and experience
even longer waiting times. With the exception of all designated aviation personnel, there is no
policy that prohibits service members from having surgery performed in the civilian sector at
their own expense (aviation personnel are expressly prohibited from having any type of
refractive surgery in the civilian sector). However, the Navy discourages service members from
electing to pursue this option. Before having surgery performed in the civilian sector, service
members must follow certain requirements and adhere to policies governing this option.
b. Pre-op Counseling: For service members considering the option of having corneal refractive
surgery performed in the civilian sector, BUMED INST 6320.72 (21 Feb 96) entitled
‘Non-Naval Health Care, requires that they first be counseled by or in the presence of a
medical department representative. The counseling process requires the service member sign a
statement that they understanding of the significance and ramification of receiving health care
in the civilian sector at their own expense. The intent of the counseling is to ensure that service
members understand Navy policy and guidelines before they pursue surgery. The counseling
process is not intended to provide an evaluation for their suitability for surgery. Determining
such suitability is accomplished at the time the service member is examined by their eye care
provider (military or civilian). Service members must report to their primary care provider’s
military treatment facility and request counseling for corneal refractive surgery in the civilian
sector at their own expense. They will be given a hard copy of the entire "Corrective Eye
Surgery" web site, as well as a copy of Appendix (5). It is the counseling form that service
members must read, initial in the appropriate spaces, and sign in the presence of a medical
department representative. This form will be placed in the outpatient medical record for
permanent keeping. If service members have any questions after reviewing the web site
material and the counseling form, before signing the form they should address these questions
with either their primary care provider or with an optometrist or ophthalmologist at their
nearest MTF.
c. Commanding Officer approval to have surgery is required: Just as service members who
have surgery performed at Navy laser centers must have prior command approval, the same
applies to those who elect to have surgery in the civilian sector. In particular, it is the
command’s responsibility to approve requests for convalescent leave, timing of the surgery,
and the time required for post-op visits.
d. Post-op care: Service members that have surgery performed at their own expense in the
civilian sector are also expected to make arrangements for their own post-op care in the civilian
sector. Use of MTFs for this purpose will deter from delivery of eye care services to higher
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USNavy-Corrective eye surgery questions and answers
Dr. Yi-Chang Wu
2000/12/05
priority patients. Moreover, in most cases fees assessed for corneal refractive surgery in the
civilian sector include all services associated with routine post-op care. In the event of
complications that interfere with the service member’s ability to return to full and unrestricted
duty, Navy eye care providers at the nearest MTF should be contacted and assume
responsibility for determining additional treatment and disposition as indicated.
e. Return to full and unrestricted duty: The same guidelines identified in section (10k) that
outline the process for returning service members to full duty after surgery at one of the Navy’s
Corneal Refractive Surgery centers, are applicable to service members having surgery
performed in the civilian sector. Post-op medical clearance forms in Appendix (4) shall be used
regardless of whether corneal refractive surgery is performed in the Navy or in the civilian
sector. The civilian eye care provider performing the post-op care must complete the medical
clearance form and indicate when the service member can return to full duty using the
guidelines provided on the form. The service member must then return the completed form to
their primary care provider, who will verify that applicable visual standards and policies have
been complied with.
12) What is the policy on corneal refractive surgery for Reserve forces in the Navy and USMC?
a. Availability of surgery at Navy Refractive Surgery Centers: The Navy’s Corneal Refractive
Surgery program is restricted to the treatment of active duty personnel only. Reserve personnel
interested in having refractive surgery must do so at their own expense in the civilian sector.
b. Pre-op counseling and restrictions: Reserve personnel must follow the same guidelines identified
in section 11 (Guidelines for service members that prefer to have corneal refractive surgery
performed in the civilian sector at their own personal expense). Pre-op counseling is required to
ensure that service members understand Navy policy and guidelines before they pursue surgery. The
same restrictions for the types of surgical procedures authorized for active duty personnel in various
warfare communities applies to Reserve personnel in those same communities. Appendix (2)
summarizes the current authorized procedures. In particular, PRK is authorized in all communities
except for aviation, in which all forms of refractive surgery are prohibited. Waivers for PRK in
reserve personnel in aviation will not be given. LASIK is authorized in all communities except
SPECWARFARE, diving and aviation.
c. Commanding Officer approval to have surgery is required: Just as active duty service members
must obtain prior command approval to have surgery at either a Navy laser center or in the civilian
sector, the same requirement applies to reserve personnel electing to have surgery in the civilian
sector. In particular, it is the command’s responsibility to approve requests in order to plan around
the unit’s operational commitments.
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USNavy-Corrective eye surgery questions and answers
Dr. Yi-Chang Wu
2000/12/05
d. Post-op care: Reserve personnel that have surgery performed at their own expense in the civilian
sector must also make arrangements for their own post-op care in the civilian sector. Use of MTFs
for this purpose is not authorized.
e. Return to full and unrestricted duty: The same guidelines identified in section (11e) outlining the
process for returning active duty service members to full duty after surgery in the civilian sector, are
applicable to Reserve personnel having surgery performed in the civilian sector. Post-op medical
clearance forms in Appendix (4) shall be used. The civilian eye care provider performing the
post-op care must complete the medical clearance form and indicate when the service member can
return to full duty using the guidelines provided on the form. The service member must then return
the completed form to their reserve unit’s medical department representative, who will verify that
applicable visual standards and policies have been complied with.
13) Can dependents and retirees have refractive surgery performed at one of the Navy's corneal
refractive surgery centers?
No. Corneal refractive surgery is not a covered benefit or entitlement for family members or
retirees in the Military Healthcare System. Navy policy restricts corneal refractive surgical procedures
to active duty personnel only.
Appendix 1: Sample informed consent form for PRK surgery
Appendix 2: Summary tables of Navy policy on new accessions and retention on active duty for
corneal refractive surgery
Appendix 3: Cover letter for commanding officers use in determining the appropriate prioritization for
service members' requests for corneal refractive surgery
Appendix 4: Post-op medical clearance for return to full and unrestricted duty
Appendix 5: Pre-op counseling for service members considering corneal refractive surgery at their
own expense in the civilian sector
Produced by BUMED Public Affairs Office
Phone (202) 762-3223/22/18
Revised: November 29, 2000.
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