Back to Top Skip to main content Skip to sub-navigation

Brief Report: Refractive Surgery Trends at Tri-Service Refractive Surgery Centers and the Impact of the COVID-19 Pandemic, Fiscal Years 2000–2020

Image of Cadet Saverio Macrina, U.S. Military Academy West Point, receives corneal cross-linking procedure at Fort Belvoir Community Hospital, Va., Nov. 21, 2016. (DoD photo by Reese Brown). Cadet Saverio Macrina, U.S. Military Academy West Point, receives corneal cross-linking procedure at Fort Belvoir Community Hospital, Va., Nov. 21, 2016. (DOD photo by Reese Brown)

Recommended Content:

Medical Surveillance Monthly Report

Background

Since the official introduction of laser refractive surgery into clinical practice throughout the Military Health System (MHS) in fiscal year 2000, these techniques have been heavily implemented in the tri-service community to better equip and improve the readiness of the U.S. military force. Military studies of refractive surgery date back to 1993, but prior to full military utilization of laser refractive surgery, spectacles or contact lenses were the mainstay to correct refractive error among military personnel.1,2 Studies on the prevalence of refractive error, including myopia, hyperopia, and astigmatism, have shown that these conditions are quite common among active component service members.3,4 Reversing such error through refractive surgery has been documented to improve military readiness, operational capability, and the quality of life of U.S. service members.5

There are 26 Department of Defense (DOD) Warfighter Refractive Surgery Centers that offer a combination of vision-correcting procedures such as photorefractive keratectomy (PRK), laser assisted in situ keratomileusis (LASIK), laser epithelial keratomileusis (LASEK), small incision lenticule extraction (SMILE), implantable collamer lens (ICL), and refractive lens exchange (RLE).6–8 The capability to readily perform surgery with laser technology using the latest refractive surgery platforms highlights the importance of optimized vision to the DOD.

The COVID-19 pandemic introduced numerous obstacles which contributed to the reduction in the number of procedures performed. These obstacles included the closure of surgical centers and lack of temporary duty travel (TDY) patients. The pandemic also resulted in a shift to pre-operative testing for COVID-19 and virtual pre-operative briefings which could potentially result in delayed or cancelled refractive surgeries.

The objective of this report was to describe trends in total numbers of refractive surgeries over the last 21 fiscal years and to demonstrate how the early COVID-19 pandemic affected military refractive surgery trends.

Methods

Data on all refractive surgery cases performed at 26 DOD Warfighter Refractive Surgery Centers were compiled by the U.S. Navy refractive surgery program manager and presented at the 2021 virtual Military Refractive Surgery Safety and Standards Symposium annual meeting.6–8 These data are summarized in this report.

The surveillance period was from 1 October 1999 through 30 September 2020 (fiscal years 2000–2020). The surveillance population included active duty service members (active component and activated Reserve/Guard members) who met eligibility criteria for refractive eye surgery. Criteria for qualifying for refractive surgery may have differed among the services, but in general, service members had to have had at least 18 months left in their service commitments, a commander's authorization letter, and no adverse personnel actions. In addition, 3 Air Force locations performed refractive surgery on a small number of non-service member beneficiaries of the Military Health System as part of a research protocol (accounting for <0.03% of Air Force refractive surgical cases for fiscal year 2020).

Results

For fiscal years 2000–2020, a total of 746,950 refractive surgeries were reported from the 26 Warfighter Tri-Service Refractive Surgery Centers. The number of surgeries performed each fiscal year ranged from a low of 4,381 refractive surgeries in 2000 to a peak of 50,690 surgeries in 2005 (Figure 1) with an average of 35,569 surgeries per year. In fiscal year 2020, 20,270 refractive surgeries were performed which represents a 38.6% decrease from the number of cases performed in 2019 (n=33,039).

During the surveillance period, there were 363,058 surgeries performed at Army refractive centers, 216,568 at Navy refractive centers, and 167,324 at Air Force refractive centers. The number of surgeries for all services declined from fiscal year 2019 to fiscal year 2020 (Army, 39.8% decrease; Navy, 34.6% decrease; Air Force, 41.0% decrease) (Figure 1).

In 2020, the types of refractive surgery approximately consisted of 65.1% PRK (n=13,201), 27.6% LASIK/LASEK (n=5,585), 4.5% SMILE (n=920), 2.7% ICL (n=540), and 0.1% RLE (n=24) (Figure 2). The percentage distributions of type of refractive surgery were similar among all the services in 2020.

Editorial Comment

This report describes trends in the numbers of refractive surgeries performed during the 21 year surveillance period, including the COVID-19 pandemic. Since fiscal year 2000, the tri-service ophthalmology community conducted 746,950 vision corrective surgeries at 26 DOD Warfighter Refractive Surgery Centers. The large number of refractive cases reported and the amount of refractive surgery centers present in the DOD speaks to the valued importance of optimal vision in U.S. military members. In addition to the warfighter's improvement in quality of life, vision corrective surgeries are used frequently in the U.S. military due to the need and for improved preparedness and performance in operational tasks.3–5 An Air Force study from 2020 reported the prevalence of myopia in 767 Air Force Basic Military Trainees. Among the trainees, 45% were found to have myopia classified as greater than -0.5 D, and 2% of trainees were found to have high myopia classified as greater than -6.0 D.In 2019, Reynolds et al. reported that 51.1% of ocular care for service members during fiscal year 2018 was dedicated to refractive error-related disorders.9 A study published in 2017 demonstrated the excellent and comparable vision outcomes of Wave-Front Guided and Wave-Front Optimized PRK on military members in regard to marksmanship, visual performance, threshold target identification, and contrast sensitivity.10 These studies shed light on the importance of refractive surgery offered by the DOD.

When analyzing the effect of the COVID-19 pandemic, a decrease in the number of refractive surgery cases performed in the tri-service community was reported. Specifically, the total number of surgeries during fiscal year 2020 was comparable to the number of surgeries in fiscal year 2002, shortly after the procedures were first introduced. The pronounced decrease in the number of surgeries performed was undoubtedly due to factors related to the SARS-CoV-2 pandemic: shutdown of DOD Warfighter Refractive Surgery Centers, unavailability of TDY patients, pre-operative SARS-CoV-2 testing, difficulty with pre-operative virtual briefings, availability of N-95 masks, properly scheduling post-operative follow-up, and limitations on family members helping with patients after surgery. The reduced number of procedures observed in fiscal year 2020 is consistent with many published reports of reduced health care utilization during the COVID-19 pandemic.11 One such report demonstrated initial reduced demand for refractive surgery which subsequently rebounded in 2021.12

In fiscal year 2020, the majority of cases were PRK followed by LASIK/LASEK and SMILE, respectively. A trend toward PRK surgery in the military has been prevalent for years; however, there has been a shift towards LASIK especially among Navy surgery centers.13,14 Various reasons exist for the preference of PRK, which include surgeon's comfort with performing PRK over LASIK, previous military policies that prohibited LASIK for special forces, and the risk of traumatic corneal flap lifting following LASIK that cannot be attended to in an environment that is not readily equipped with an ophthalmologist (e.g., deployment, training, austere environments).15 With the introduction of SMILE in 2016 after the U.S. Food and Drug Administration approval, it has been increasingly implemented in the DOD.16 SMILE has shown promise with comparable, if not better, visual outcomes than PRK and more predictable outcomes and similar corneal biomechanical stability when compared to LASIK.17,18 The emergence of new refractive surgery techniques will continue to provide opportunity for advancement in military refractive surgery.

Limitations of this study include potential bias in data retrieval and documentation. Data were individually reported from each center and were not verified with medical coding. Additionally, refractive surgeries performed outside of Warfighter Refractive Surgery Centers were not captured in this analysis.

In summary, this report demonstrates the trend in refractive surgeries at the DOD Refractive Surgery Centers and reveals the decrease in refractive surgeries during the COVID-19 pandemic. Because of the instrumental role refractive surgery plays in gaining a strategic advantage for the U.S. military warfighter, surgical procedures still continued during this period and will most likely increase to pre-pandemic numbers as the COVID-related restrictions are lifted or conditions to handle COVID-related spread are improved. Future implications from the lessons learned during the COVID-19 pandemic will provide a framework on how to troubleshoot barriers to performing refractive surgery in the future.

Author affiliations: United States Air Force, Medical College of Georgia at Augusta University (2d Lt Brandon Sellers, BS); United States Air Force, Air Force Refractive Surgery Consultant, Joint Base Elmendorf-Richardson, Anchorage, AK (Lt Col J. Richard Townley, MD); United States Navy, Prior Navy Refractive Surgery Program Manager, Camp Lejeune, Jacksonville, NC (CAPT Corby Ropp, DO); United States Army, Army Refractive Surgery Program Manager, Defense Health Agency Refractive Surgery Board Chair, Brooke Army Medical Center, Ft. Sam Houston, TX (LTC Gary Legault, MD). Dr. Corby Ropp died during the creation of this manuscript but was instrumental in compiling the data.

Disclaimer: The contents, views, or opin­ions expressed in this publication are those of the author(s) and do not necessarily reflect the official policy or position of the Defense Health Agency, Department of Defense, or the U.S. Government.

References

1. Lattimore MR, Jr., Schrimsher RH. Refractive error distribution and incidence among U.S. Army aviators. Mil Med. 1993;158(8):553–556.

2. Hammond MD, Madigan WP, Jr., Bower KS. Refractive surgery in the United States Army, 2000-2003. Ophthalmology. 2005;112(2):184–190.

3. Reynolds ME, Taubman SB, Stahlman S. Incidence and prevalence of selected refractive errors, active component, U.S. Armed Forces, 2001-2018. MSMR. 2019;26(9):26–30.

4. Reed DS, Ferris LM, Santamaria J, et al. Prevalence of myopia in newly enlisted airmen at Joint Base San Antonio. Clin Ophthalmol. 2020;14:133–137.

5. Sia RK, Ryan DS, Rivers BA, et al. Vision-related quality of life and perception of military readiness and capabilities following refractive surgery among active duty U.S. Military service members. J Refract Surg. 2018;34(9):597–603.

6. Legault, GL. Army refractive surgery update. Military Refractive Surgery Safety and Standards Symposium, virtual. 1 January 2021.

7. Townley, JR. Air Force refractive surgery update. Military Refractive Surgery Safety and Standards Symposium, virtual. 1 January 2021.

8. Ropp, C. Navy refractive surgery update. Military Refractive Surgery Safety and Standards Symposium, virtual. 1 January 2021.

9. Reynolds ME, Williams VF, Taubman SB, Stahlman S. Absolute and relative morbidity burdens attributable to ocular and vision-related conditions, active component, U.S. Armed Forces, 2018. MSMR. 2019;26(9):4–11.

10. Ryan DS, Sia RK, Stutzman RD, et al. Wavefront-guided versus wavefront-optimized photorefractive keratectomy: Visual and military task performance. Mil Med. 2017;182(1):e1636–e1644.

11. Moynihan R, Sanders S, Michaleff ZA, et al. Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review. BMJ Open. 2021;11(3):e045343. 

12. Bickford M, Rocha K. Impact of the COVID-19 pandemic on refractive surgery. Curr Ophthalmol Rep. 2021:1–6.

13. Stanley PF, Tanzer DJ, Schallhorn SC. Laser refractive surgery in the United States Navy. Curr Opin Ophthalmol. 2008 Jul;19(4)321–324.

14. Gao H, Miles TP, Troche R, et al. Quality of vision following LASIK and PRK-MMC for treatment of myopia. Mil Med. 2021;usab071. 

15. Shih LY, Peng KL, Chen JL. Traumatic displacement of laser in situ keratomileusis flaps: an integrated clinical case presentation. BMC Ophthalmol. 2021;21(1):177.

16. Dishler JG, Slade S, Seifert S, Schallhorn SC. Small-incision lenticule extraction (SMILE) for the correction of myopia with astigmatism: Outcomes of the United States Food and Drug Administration Premarket Approval Clinical Trial. Ophthalmology. 2020;127(8):1020–1034.

17. Sia RK, Ryan DS, Beydoun H, et al. Visual outcomes after SMILE from the first-year experience at a U.S. military refractive surgery center and comparison with PRK and LASIK outcomes. J Cataract Refract Surg. 2020;46(7):995–1002.

18. Cao K, Liu L, Yu T, Chen F, Bai J, Liu T. Changes in corneal biomechanics during small-incision lenticule extraction (SMILE) and femtosecond-assisted laser in situ keratomileusis (FS-LASIK). Lasers Med Sci. 2020;35(3):599–609.

FIGURE 1. Number of refractive surgery cases, by service from a Tri-Service Refractive Surgery Center, fiscal years 2000–2020

FIGURE 2. Refractive surgery cases, by service and type of procedure performed at a Tri- Service Refraction Surgery Center, fiscal year 2020

You also may be interested in...

Update: Exertional Rhabdomyolysis, Active Component, U.S. Armed Forces, 2016–2020

Article
4/1/2021
Marine Corps Recruit Depot, San Diego  Recruits with Bravo Company, 1st Recruit Training Battalion, hydrate after a physical training session

Recommended Content:

Medical Surveillance Monthly Report

Update: Heat Illness, Active Component, U.S. Armed Forces, 2020

Article
4/1/2021
Fort Jackson, SC. A trainee with 2nd Battalion, 60th Infantry Regiment puts his arms in an arm immersion cooling tank during training. The tanks allow Soldiers to rapidly cool by putting their forearms into a tank of ice water. (Photo by Saskia Gabriel)

Recommended Content:

Medical Surveillance Monthly Report

Disparities in COVID-19 Vaccine Initiation and Completion Among Active Component Service Members and Health Care Personnel, 11 December 2020–12 March 2021

Article
4/1/2021
Capt. Shamira Conerly, 149th Medical Group, gives Staff Sgt. Timmy Sanders, 149th Maintenance Squadron, his first dose of COVID-19 vaccine

Recommended Content:

Medical Surveillance Monthly Report

Update: Exertional Hyponatremia, Active Component, U.S. Armed Forces, 2005–2020

Article
4/1/2021
Tech. Sgt. Kimberly Weaver, 606th Air Control Squadron noncommissioned officer in charge of medical readiness, measures an Airman’s blood pressure at Aviano Air Base, Italy, May 10, 2021.

Recommended Content:

Medical Surveillance Monthly Report

A Retrospective Cohort Study of Blood Lead Levels Among Special Operations Forces Soldiers Exposed to Lead at a Firing Range in Germany

Article
3/1/2021
A soldier fires a pistol during small arms training

Recommended Content:

Medical Surveillance Monthly Report

Update: Sexually Transmitted Infections, Active Component, U.S. Armed Forces, 2012–2020

Article
3/1/2021
Magnified photomicrograph of a Gram-stained urethral discharge specimen

Update: Sexually Transmitted Infections, Active Component, U.S. Armed Forces, 2012–2020

Recommended Content:

Medical Surveillance Monthly Report

Influenza Surveillance Trends and Influenza Vaccine Effectiveness Among Department of Defense Beneficiaries During the 2019–2020 Influenza Season

Article
3/1/2021
Captured in 2011, this transmission electron microscopic (TEM) image depicts some of the ultrastructural details displayed by H3N2 influenza virions, responsible for causing illness in Indiana and Pennsylvania in 2011. See PHIL 13469, for the diagrammatic representation of how this Swine Flu stain came to be, through the “reassortment” of two different Influenza viruses.  Credit: CDC/ Dr. Michael Shaw; Doug Jordan, M.A.

Influenza Surveillance Trends and Influenza Vaccine Effectiveness Among Department of Defense Beneficiaries During the 2019–2020 Influenza Season

Recommended Content:

Medical Surveillance Monthly Report

Influenza Outbreak During Exercise Talisman Sabre, Queensland, Australia, July 2019

Article
3/1/2021
Flight Lt. Michael Campion, an aviation medical officer from No. 3 Aeromedical Evacuation Squadron prepares a medical patient leaving Exercise Talisman Sabre to be transferred to a C-27J Spartan aircraft July 18, 2019 at Rockhampton Airport. No. 3 Aeromedical Evacuation Squadron is providing medical support to troops participating in Talisman Sabre 2019, a bilateral combined Australian and United States exercise designed to train respective military services in planning and conducting Combined and Joint Task Force operations, and improve the combat readiness and interoperability between Australian and US forces. (U.S. Army photo by Sgt. 1st Class John Etheridge)

Influenza Outbreak During Exercise Talisman Sabre, Queensland, Australia, July 2019

Recommended Content:

Medical Surveillance Monthly Report

Update: Malaria, U.S. Armed Forces, 2020

Article
2/1/2021
Preventive medicine specialists check an insect trap

Recommended Content:

Medical Surveillance Monthly Report

Surveillance for Vector-borne Diseases Among Active and Reserve Component Service Members, U.S. Armed Forces, 2016–2020

Article
2/1/2021
Dorsal view of a female lone star tick

Recommended Content:

Medical Surveillance Monthly Report

Historical Perspective: The Evolution of Post-exposure Prophylaxis for Vivax Malaria Since the Korean War

Article
2/1/2021
An Aedes aegypti mosquito

Recommended Content:

Medical Surveillance Monthly Report

Attrition Rates and Incidence of Mental Health Disorders in an Attention-Deficit/Hyperactivity Disorder (ADHD) Cohort, Active Component, U.S. Armed Forces, 2014–2018

Article
1/1/2021
Capt. Michelle Tsai, the behavioral health officer for the 4th Brigade, 2nd Infantry Division, reviews medical information in her office at the Joint Readiness Training Center June 17. Tsai, an Alexandria, Va., native, is here with the Raider Brigade in support of training operations for the unit's upcoming deployment to Iraq. (Photo by Pfc. Luke Rollins)

Recommended Content:

Medical Surveillance Monthly Report

The Prevalence of Attention-Deficit/Hyperactivity Disorder (ADHD) and ADHD Medication Treatment in Active Component Service Members, U.S. Armed Forces, 2014–2018

Article
1/1/2021
New Recruits are screened after arriving at Depot

Recommended Content:

Medical Surveillance Monthly Report

Exertional Rhabdomyolysis and Sickle Cell Trait Status in the U.S. Air Force, January 2009–December 2018

Article
1/1/2021
Master Sgt. Daniel Bedford prepares to pump up a gold medal lift in the bench press during the United States Powerlifting Association 2020 Texas State Bench Press Championship

Exertional Rhabdomyolysis and Sickle Cell Trait Status in the U.S. Air Force, January 2009–December 2018

Recommended Content:

Medical Surveillance Monthly Report

Cases of Coronavirus Disease 2019 and Comorbidities Among Military Health System Beneficiaries, 1 January 2020 through 30 September 2020

Article
12/1/2020
A U.S. Army nurse paratrooper provides patient care in support of preventative efforts against COVID-19

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 61 - 75 Page 5 of 12
Refine your search
Last Updated: May 23, 2022

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.