1. The Effects of Refractive Surgery on the Carrier Landing Grades of Naval Aviators Ashley Lesley, MD, LCDR MC(FS) USNR Randy Birt, OD, LCDR MSC USN Naval Hospital Lemoore and University of California Davis Eye Center The opinions and views expressed are those of the authors and do not represent official Department of Defense policy or position. This study was supported by the United States Navy. We have no other financial disclosures to report.

2. Aviation Physical Standards for new students Defined by Naval Aerospace Medical Institute Strict requirements to begin training Rigorous physical examination, many seemingly healthy candidates do not qualify Eye exam makes up fully 50% of criteria

3. NAMI Eye Exam (includes topography) Distance UCVA >20/100 OU ▫ Prior to 2006 UCDVA 20/40 or better Refractive limits No more than -1.50 in any meridian No more than +3.00 in any meridian No eso/exophoria > 6.0 PD or hyperphoria >1.5 PD All tropias disqualifying Normal color vision and stereovision IOP <22 mm Hg U.S. Navy Aeromedical Reference and Waiver Guide, Physical Standards - 5.

4. PRK Accessioning Study Internal study started in 2000 Initially 400 aviation applicants – Naval Academy students had PRK at National Naval Medical Center in Bethesda, MD – Officer candidates could obtain PRK at outside facility at their own expense Determined students post-PRK performed comparably in initial flight training (12 week initial qualifying course) History of refractive surgery remains disqualifying but waivers now granted for a history of PRK

5. PRK Waiver Guidelines Pre-op CRx -8.00 to + 3.00 D sph < 3.00 D of cyl Waiver may be submitted no earlier than – 3 months for < -6.00 SE – 6 months for > -6.00 SE – 6 months for hyperopia Must meet established aviation vision standards post-operatively U.S. Navy Aeromedical Reference and Waiver Guide, Ophthalmology, 19-23.

6. Clinical question Do aviators with uncorrected visual acuity perform better than aviators who have had refractive surgery? www.boeing.com

7. Study Design A training squadron (VFA-125) for the F/A-18C “Hornet, ” a tactical strike/fighter platform is located at NAS Lemoore, CA Carrier qualification done at the end of training syllabus 10 carrier landings during the day 6 carrier landings at night Receive Day, Night, and Total GPA Day, Night, and Total Boarding Rate (BR) Boarding rate is a percentage of successful landings Unsuccessful landing means that aircraft misses wires, must take off again, and try to land again All passes graded by panel of Landing Signals Officers (LSO) who are qualified pilots, on a standardized scale of 0.0-4.0

8. Study Design Pilots identified from Training Squadron (VFA-125) – Physical exams from NAMI’s database in Pensacola, FL reviewed – Carrier qualification scores taken from squadron Training database – Identified all students from FY 2004 to 2008 16 pilots with history of PRK prior to CQ 22 pilots required spectacle correction for CQ 79 pilots with 20/20 OU uncorrected for CQ All between ages of 25 and 32 All in excellent health without systemic illness

9. Results www.cusnc.navy.mil/images VariablePRK Group Mean With Correction Group Mean Without Correction Group Mean P-value (Noninferiority) Day Landing GPA 2.862.902.870.032 Day Boarding Rate 92.56%91.86%89.72%0.028 Night Landing GPA 2.812.852.880.033 Night Boarding Rate 83.19%87.68%85.44%0.165 Total Landing GPA 2.842.882.870.054 Total Boarding Rate 87.81%89.32%87.53%0.002

10. Conclusions Equivalence shown in Day GPA, Day Boarding, Night GPA, and Total Boarding by non-inferiority p-value Test of difference failed to showed significance in Night Boarding and Total GPA No significance shown in p-value for the same references Night Boarding and Total GPA are then equivocal No trend in our data suggests a difference in CQ performance in aviators with a history of PRK Allowing PRK has opened naval aviation to applicants who would not have met standards Has allowed the Navy wider recruiting

11. Future of Refractive Surgery LASIK Aviator Retention Study now enrolling designated personnel – Good clinical results so far in non-pilot aviators Concern about LASIK flap and ability to tolerate excessive G-forces Quicker return to full duty than with PRK Several years until applicants with LASIK arrive at the Training squadron and study can be repeated VFA-125 has been retired so must be repeated with another squadron U.S. Navy Aeromedical Reference and Waiver Guide, Ophthalmology 19-23.

12. References Cloud, David S. “Perfect Vision is Helping and Hurting Navy,” New York Times. June 20, 2006. Franklin QJ, Tanzer, DJ. Late Traumatic Flap Displacement after LASIK. Military Medicine. 2004 Apr;1969(4): 334-6. NAVAIR 00-80T-104. NATOPS Landing Signals Officer Manual. Schallhorn, SC, et al. Preliminary Results of PRK in Active Duty United States Navy Personnel. Ophthalmology. 1996 Jan;103(1): 5-22. Schallhorn, Steve. Results of PRK in Naval Aviators. Presented at Fifth International Congress on Epi-Lasik and Lasek and Advanced Surface Ablation, 2006. Stanley, PF, et al. “Laser Refractive Surgery in the United States Navy. “ Current Opinion in Ophthalmology, 2008 Jul;19(4): 321-4. United States Navy Aeromedical Reference and Waiver Guide.