2. 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"

3. “To Waive or Not to Waive…”
Ken Whitwell, OD, MBA, FAAO
CDR/MSC/USN
NAMI Eye Clinic

4. “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

5. “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.

6. “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

7. “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

8. “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

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

10. “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

11. “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

12. “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

13. Waiver Guide Update Chris DeAngelis, OD, FAAO LCDR/MSC/USN
Department Head, NAMI Eye Clinic

14. 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.

15. 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

17. 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

18. Optic Disc Drusen

19. Optic Disc Drusen

20. 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), 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

22. 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

23. Central Serous Retinopathy

24. Central Serous Retinopathy
Photo credit:

25. Central Serous Retinopathy
Ocular Coherence Tomography

26. 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

27. 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

29. 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

30. 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

31. Waiver Requirements for Corneal Refractive Surgery

32. Common Refractive Surgery Op Reports

33. Not Required for submission

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

35. Not Required for submission
IntraLase – Laser Flap creation report