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Military Health System

Corneal Collagen Cross Linking in the Military a Game Changer

Image of Corneal collagen cross-linking, known as CXL, the first and only treatment to date that is proven to stop Keratoconus, KCN, progression. Corneal collagen cross-linking, known as CXL, the first and only treatment to date that is proven to stop Keratoconus, KCN, progression.

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For years, Keratoconus has been a disqualifying condition in the military, and a reason why refractive surgery is often denied to service members.

Keratoconus (pronounced Keh·ruh·tow·kow·nuhs), or KCN, is an eye condition where the front part of the eye (cornea) gradually thins out and bulges causing irregularity and blurred vision.

KCN may result from eye rubbing. It has also been linked to sleep apnea, asthma, allergy, eczema, vernal conjunctivitis, floppy eyelid syndrome, connective tissue disorders, or a family history of KCN. Historically, the primary treatment for KCN was contact lenses when eyeglasses were not sufficient to correct the irregular astigmatism. Severe cases were treated with corneal transplantation.

Navy Capt. (Dr.) John Cason, prior ophthalmology specialty leader and refractive surgery advisor, stated that, he reviewed about 2 to 5 sailor applicants per month for possible waiver for accession into the military due to KCN.

In 2016, the Food and Drug Administration approved corneal collagen cross-linking, known as CXL. This is the first and only treatment proven to stop KCN progression.

Air Force Col. (Dr.) Matthew Caldwell, ophthalmology consultant to the Air Force Surgeon General, called CXL a "readiness game changer." He noted that "KCN is of special interest to the military as the age range of impact nearly exactly overlaps years of active-duty service." The onset can happen before or after acceptance into the military when screening is too late.

"KCN impacts the ability to deploy and can degrade vision excluding careers in aviation, Special Forces, and in severe cases, even less visually intensive administrative work," added Caldwell.

Since the FDA approval, hundreds of service members have been treated with CXL. And a majority of these have been able to retain their military careers.

Air Force Col. (Dr.) Joseph Giovannini, cornea specialist at the David-Grant USAF Medical Center at Travis Air Force Base in California stated, "I have seen several military careers saved by the procedure."

Air Force Capt. Lowell DePalma, an aviator who had bilateral CXL, backed up Giovannini, "CXL has allowed me to keep my job and helped my future eye exams to be more predictable."

Currently, ophthalmology consultants are able to recommend acceptance waivers for military candidates with early KCN as long as they are able to show stability after CXL procedure.

"CXL has offered the possibility of military service for a group of candidates with mild symptoms from KCN," stated Cason. In the past, these volunteers didn't have the option of continued service due to restrictive guidelines that did not offer any flexibility with treatment. CXL has given these people the possibility of treatment, stability, and a future military service that were previously denied."

In the future, CXL may also significantly expand the options of vision-enhancing refractive surgery. In the past, service members with abnormal corneal scans were disqualified from refractive surgery. However, over the past decade, CXL plus refractive surgery outcomes have been favorable.

"The advent of CXL has helped tremendously to retain highly trained individuals and increase the applicant pool for the armed services," explained Air Force Lt. Col. (Dr.) James Townley, refractive surgery consultant to the Surgeon General of the Air Force.

As technology continues to advance, the use of CXL and refractive surgery will help more service members remain on active duty.

All authored materials constitute the personal statements of the names listed above and are not intended to constitute an endorsement by the Unites States Air Force or any other Federal Government entity

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Last Updated: June 03, 2022
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