Disclosure Statement Ken Whitwell, Chris DeAngelis, and all others involved in the planning, development and presentation of this CME activity provide the following Disclosure information:   "Nothing to disclose"

“To Waive or Not to Waive…” Ken Whitwell, OD, MBA, FAAO CDR/MSC/USN NAMI Eye Clinic Kenneth.Whitwell@med.navy.mil

“To Waive or Not to Waive…” Most common eye conditions that may or may not require a waiver base on clinical presentation, add’l testing, other factors Always error on side of caution and safety of flight When in doubt contact NAMI Eye Dept staff or submit a waiver

“To Waive or Not to Waive…” Preglaucoma, Lens / Corneal Opacities, Pterygium Sec 2.1 Waivers of Physical Standards Pt has a condition or receives a diagnosis that does not meet physical stds = CD Aircrew personnel and applicants who do not meet physical standards may be considered for a waiver of standards. Waivers may be granted on the need of the service, consistent with training, experience, performance, and proven safety of the aircrew personnel. In addition, waivers are also based upon risk management and how it is applied to the following nine criteria: cannot jeopardize the successful completion of a mission must be resolved or stable at the time of the waiver If the possibility of progression or recurrence exists, the first signs or symptoms must be easily detectable and cannot constitute an undue hazard to the individual or to others.

“To Waive or Not to Waive…” Clinical mindset and Aeromedical decision-making Waivers ~ “guaranteed follow-up exam” Preglaucoma, Lens / Corneal Opacities, Pterygium Why increase in waivers with these eye conditions? More aviators with glaucoma and opacities? AHLTA Advancements in skill and technology

“To Waive or Not to Waive…” Preglaucoma – MANMED 15-34(8) Misc defects and disorders WG definition Glauc / OHTN = VF loss and/or >22mmHg Risk factors for Glaucoma: Age, sex, race, family Hx, IOP, optic disc asymmetry, optic disc cupping Often used as “placeholder” Dx in AHLTA Justify add’l testing – OCT, auto VF, serial IOP, pach, fundus photos Prove do not have condition

“To Waive or Not to Waive…” If all tests negative, no risk factors = NCD (Large # younger aviation population) If all tests negative, one risk factor = NCD or CD/WR? Work with eye provider – do have enough factors to be at risk to develop glaucoma? If yes, apply for waiver. Make a clear note in record

“To Waive or Not to Waive…” Images from Kanski, J. Clinical Ophthalmology: A Systemic Approach, 5th ed. 2003

“To Waive or Not to Waive…” Opacities MANMED 15-34(3) Cornea MANMED 15-34(6) Lens WG only discusses Cataracts, but get many submissions for waivers for lens and corneal opacities Why? higher skills, better tech first time facility documented in AHLTA and paired w/ procedure code, generates a waiver application

“To Waive or Not to Waive…” Alternative approach, go back to eyecare provider and discuss further: size - <1-2mm location – central (within pupil margin) or peripheral origin – congenital or aqcuired visual significance – subj or obj (Brightness Acuity Test) Small, likely congenital, peripheral, no reduction in VA’s w/ BAT = NCD Ultimately FS decision, but utilize better info

“To Waive or Not to Waive…” Pinguecula and Pterygium Pinguecula – asymptomatic, less 4 gtts/day art tears = NCD Pterygium - <= 1mm onto cornea, asymptomatic = NCD Concerns excessive astigmatism, ref error not corr to 20/20m, interference with peripheral vision Surgery option, but not always best option More likely waived in designated personnel vs. applicant Images from Kanski, J. Clinical Ophthalmology: A Systemic Approach, 5th ed. 2003

Waiver Guide Update Chris DeAngelis, OD, FAAO LCDR/MSC/USN Department Head, NAMI Eye Clinic Christopher.DeAngelis@med.navy.mil

Waiver Guide Update Optic Disc Drusen Central Serous Retinopathy Pigment Dispersion Syndrome Corneal Refractive Surgery Disclaimer: Aviation Advisory Council (AAC) has met and approved waiver guide entry for Optic Drusen and Refractive Surgery. Information for CSR and PDS is based on the most current research at NAMI and is currently being prepared for approval.

Optic Disc Drusen Background and Aeromedical Concern: - Cacified proteinaceous bodies within the optic nerve, causing visual field defects. Usually a bilateral presentation - Visual acuity, color vision, night vision also can be affected 1% of the population Patients are usually asymptomatic No treatment available Slowly progressive condition that may lead to a larger, debilitating VF defect

Optic Disc Drusen Information Required (initial): Ophthalmology consult to confirm Dx Complete Aeromedical Hx (incl. systemic Hx and FHx of drusen) Complete ocular exam (slit lamp, funduscopic exam, color vision, refraction to best VA with Goodlite letters, Amsler Grid) Optic Disc photographs for baseline/monitoring Visual Field (Humphrey 30-2 preferred) B-scan ultrasound examination Retinal nerve fiber layer analysis using Ocular Coherence Tomography is desirable but not required. Annual Evaluation: Must include comprehensive eye exam by eye care professional. All of the initial testing, with exception of B scan and OCT required for annual submission

Optic Disc Drusen

Optic Disc Drusen

Central Serous Retinopathy Background and Aeromedical Concern: - Localized detachment of the retina at the macular region - Decreased vision, metamorphopsia, micropsia (image minification), color desaturation - Unknown etiology Affects males (10:1), 20-50 years of age, and has been associated with ‘Type-A’ personalities, and stress Usually self limiting in first 3-4 months with continuing improvement over the course of 2 years Some cases require Laser intervention or intravitreal injections - no effect on final VA or incidence of recurrence

Central Serous Retinopathy Information Required (initial): Eye Exams every 4-8 weeks until condition resolves Vision must meet class standard Dilated fundus exam including slit lamp to examine macula Amsler Grid, Unilateral color vision testing (PIP) Retinal photographs (macula) for baseline/monitoring Visual Field (Humphrey 10-2 preferred) Ocular Coherence Tomography upon Dx and resolution Flourescein Angiography optional Annual Submission: - Comprehensive exam by an eye provider required for waiver - DFE, Amsler Grid required with submission

Central Serous Retinopathy

Central Serous Retinopathy Photo credit: http://retinalinks.tripod.com/photogallery.html

Central Serous Retinopathy Ocular Coherence Tomography

Pigment Dispersion Syndrome Background and Aeromedical Concern: Liberation of pigment granules from the posterior iris - Iris epithelium rubbing against crystalline lens zonules Disposition occurs on corneal endothelium (Krukenburg Spindle) and in the Trabecular Meshwork Iris Transillumination defects present Occurs in young adult (20-45), Caucasian, males (2:1) with myopia and a concave iris posture 1-2% of the Caucasian population Typically bilateral presentation - Patient is asymptomatic

Pigment Dispersion Syndrome Triad of PDS Trabecular Meshwork Hyperpigmentation Krukenberg spindle Iris Transillumination Defect Images from Kanski, J. Clinical Ophthalmology: A Systemic Approach, 5th ed. 2003

Pigment Dispersion Syndrome Information Required: Annual eye exam by Navy OD, OMD IOP measurement (using Goldmann Applanation Tonometry) Slit Lamp examination, noting anterior segment findings Gonioscopy (to evaluate anterior chamber angle) Optic nerve evaluation with comment on health of neuro-retinal rim - OCT and Optic nerve photos recommended, if available Visual Field (Humphrey 30-2 preferred) Treatment: Not required if IOP < 22mmHg

Corneal Refractive Surgery LASIK in Accession Study still enrolling Class I/II patients LASIK and PRK both acceptable for designated aviators Custom ‘All LASER’ wavefront guided LASIK is preferred - Less complications vs. PRK (haze) Designated Class I personnel must go to DON Refractive Surgery Centers, Keesler AFB, or Tripler Army Medical Center Designated Class II personnel may go to any DoD facility Routine submission of waivers for designated personnel Post operative Cycloplegic refraction required for SG1 aviators Waiver may be submitted at 2 weeks for myopic LASIK (vs. 3mo PRK) and 4 weeks for hyperopic LASIK (vs. 6mo PRK) - Local board of flight surgeons for 90 day up-chit

Waiver Requirements for Corneal Refractive Surgery

Common Refractive Surgery Op Reports

Not Required for submission

Not Required for submission Corneal Topography– OrbScan, Humphrey , PentaCam

Not Required for submission IntraLase – Laser Flap creation report