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Military refractive surgery enhances ophthalmic knowledge, service members’ readiness
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I became interested in laser corneal refractive surgery in 1985. I sent my then-fellow Ralph Zabel, MD, to England to work with Prof. John Marshall for a year. Ralph, while initially skeptical, became a believer after about 6 months and co-authored the first publication on excimer laser PRK in the rabbit, describing the healing response that included subepithelial fibrosis with corneal haze and compensatory epithelial hyperplasia. He returned to Minnesota for a second year of fellowship, and we decided to get an excimer laser at the Phillips Eye Institute in Minneapolis, starting with Taunton Technologies, which later merged with Visx. It took 8 years of clinical trials to achieve FDA approval for the Summit excimer laser in 1995 and Visx excimer laser in 1996.
Most of us busy refractive surgeons had been doing automated lamellar keratoplasty for high myopia for several years and immediately favored LASIK over PRK even though this procedure was off label. In the first year after FDA approval, approximately 100,000 procedures were performed in the U.S. Five years later that number rose to 1.4 million, which remains the high-water mark for annual number of excimer laser corneal refractive procedures in the U.S.
My friend, Steve Schallhorn, MD, a former Top Gun Navy pilot, was leading the ophthalmology division at the Navy Medical Center in San Diego when PRK received FDA approval. He immediately recognized the potential benefit the correction of refractive error, especially myopia and astigmatism, might have on his Navy colleagues. While one could not become a Navy jet fighter plane pilot with vision less than 20/20, many well-trained, highly experienced pilots became myopic during their careers. The cost to train a naval aviator who can land a jet fighter on an aircraft carrier at night approaches $6 million each. To ground these well-trained pilots because they developed myopia was unthinkable, but glasses and contact lens correction were less than ideal. The same was true for other highly valued personnel including Navy SEALs.
Dr. Schallhorn prepared a grant to study PRK in naval aviators and went to Washington to secure funding. Fortunately, a former pilot friend at the Pentagon came to his assistance, and the now world-famous U.S. military Warfighter Refractive Eye Surgery Program (WRESP) was born. The early work was done in the Navy, but leading surgeons in the Army, notably Scott Barnes, MD, at Fort Bragg, North Carolina, and Charles Reilly, MD, at Wilford Hall Air Force Center in San Antonio, were fast followers. To date more than 350,000 military personnel have undergone refractive surgery, significantly enhancing their ability to safely and effectively perform their duties, often while in harm’s way. More than 50 peer-reviewed publications from military authors, including the recent landmark PROWL-1 study led by Malvina Eydelman, MD, of the FDA and Elizabeth Hofmeister, MD, of the Navy, have added significantly to our knowledge.
As a program chair for the International Society of Refractive Surgery of the American Academy of Ophthalmology, the Hawaiian Eye meeting and OSN New York, I have regularly invited these pioneering and deadly honest military surgeons to share their knowledge and experience with their private practice colleagues. They have done so willingly and admirably.
A decade ago I was honored with an invitation from Dr. Schallhorn to a Navy program in San Diego that includes a fly out to a nuclear aircraft carrier for a 3-day visit. During my memorable trip to the USS John C. Stennis, I was extremely impressed with the quality of the military personnel serving our country. I also had the opportunity to see many active duty personnel perform after laser corneal refractive surgery, including the ship commander and many pilots. They all stated that their ability to perform their dangerous and demanding duties had been significantly enhanced by their corneal refractive surgery. Everything done in the military is graded, and objective performance evaluations also confirmed that LASIK and PRK enhanced individual performance. The admiral stated that in his opinion the greatest strategic advantages of the U.S. military are superior training, superior equipment and superior visual performance. While this ability to see better than the enemy includes superior equipment for night vision performance and the like, he also credited the WRESP as being a meaningful U.S. military strategic performance advantage.
While corneal refractive surgery has struggled with a mixed perception in the general public, it is alive, well and greatly appreciated in the U.S. military and utilized by every branch, as well as NASA and its valuable highly trained astronauts. I look forward to further quality military studies into the comparative safety and efficacy of SMILE as it launches in the U.S. I congratulate my military colleague refractive surgeons for enhancing our nation’s military readiness and also significantly advancing our knowledge.