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Contact Lens Use in Theater

Combat is a highly visual task placing Service members in a dangerous “see or be seen”, “shoot or be shot” environment. Because of this, many Service members at the front lines, as well as medical staff in the rear, feel that contact lenses afford them their highest visual acuity and are reluctant to put anything (e.g., glasses, goggles, eye protection) in front of their eyes they perceive will degrade their vision. This ultimately results in a surprising portion of our Armed Forces wearing contact lenses in theater, a risky decision and a deliberate violation of current DoD policy, DA PAM 40-506 (The Army Vision Conservation and Readiness Program) as well as the U.S. CENTCOM 021922Z (December 2011 Mod 11 to U.S. CENTCOM individual protection and individual-unit deployment policy). These policies strictly prohibit contact lens wear during basic training, field exercises, gas chamber exercises, deployments and/or combat (with exceptions for Air Force Personnel who have written authorization to wear contact lenses in combat).1 The use of contact lenses in environmentally unpredictable, austere and unhygienic environments inherently found in field conditions and combat theaters (i.e., dry, dusty, dirty), places vision health at an unnecessary risk for injury or even permanent vision loss. Among the many reasons this contact lens use policy is violated are rapid shifts during combat operations from bright outdoor light to shadowy interiors, which does not allow time to change from eye protection to glasses, as well as the misperception that staff in the rear (i.e., medical staff) are less at risk or exempt as they are not in a direct combat environment. Significant risk factors for contact lens complications include overnight wear and extended wear periods, both of which often occur in combat conditions.

The most common contact lens-associated complications include corneal ulcers, inflammation, permanent corneal scarring, ocular perforation, vision loss and in worst cases, loss of eye. These injuries may have career-changing effects resulting in substantial personal hazards as well as mission and economic consequences to the DoD including evacuation out of theater, loss to unit, cost of re-training military personnel and intense medical therapy to save sight. Review of medical records from Service members deployed to Operations Desert Shield and Desert Storm revealed reported cases of contact lens-associated corneal ulcers and inflammation, accompanied by pain, redness corneal infiltrates, light sensitivity and reduced vision.2 In a study of ocular injuries incurred during Operation Joint Endeavor in Taszar, Hungary, Bancroft and Lattimore (2001) found that 40 percent of all eye injuries in theater were associated with contact lens wear.3 Additionally, in 2006, the Army publicly reported a case of a soldier unauthorized contact lenses in theater that led to a blinding acanthamoeba keratitis infection, resulting in Hand Motion vision in that eye. This was directly attributed to an “inability to maintain proper lens hygiene.”4 As the use of Improvised Explosive Devices, chemical devices and non-conventional weapon systems increases, so does the risk of Service members obtaining ocular injuries. The use of contact lenses in these harmful environments worsens these ocular injuries.

It is important that medical personnel be aware of the high rates of contact lens use in theatre and to assess injured Service members, even those not presenting with ocular trauma, for contact lenses by direct observation and/or fluorescein stain. Assessment is critically important for those polytrauma cases in which the individual is intubated, unconscious or otherwise unable to speak; if found, lenses must be properly removed to avoid further complications from extended wear. Contact lens-associated complications must be treated aggressively, possibly requiring evacuation to ophthalmic Role 3-level facilities or medical evacuation out of theater.

Most eye injuries are preventable with proper precautions including refraining from wearing contact lenses in theater environments and wearing DoD-approved APEL eye protection. An alternative to corrective eyewear, including contact lenses and prescription glasses, is laser refractive surgery (e.g., LASIK, PRK). The DoD-funded Warfighter Refractive Eye Surgery Program (WRESP), which is available to all active duty Service members across all military branches, offers such an alternative, although not all Service members are candidates and priority is given to those that work in extreme physical environments that preclude the safe use of eye glasses or contact lenses. Additionally, each service branch has developed branch-specific refractive surgery programs to provide the highest visual acuity possible to eligible active duty Service members, which has reduced the number of Service members dependent upon prescription glasses or contact lenses. Information on WRESP is available at any military eye clinic.

1 Department of the Army, Pamphlet 40-506. Medical Services. The Army Vision Conservation and Readiness Program. Headquarters, Department of the Army 15 July 2009. Unclassified. Retrieved from USCENTCOM 021922Z DEC 11 MOD ELEVEN TO USCENTCOM INDIVIDUAL PROTECTION AND INDIVIDUAL-UNIT DEPLOYMENT POLICY

2 Heier J.S., Enzenauer, R.W., Wintermeyer, S.F., Delaney, M., & LaPiana, F.P. (1993). Ocular injuries and diseases at a combat support hospital in support of Operations Desert Shield and Desert Storm. Arch Ophthalmol, 111, 795-798.

3 Bancroft D., & Lattimore, M. (2001). Initial 67th Combat Support Hospital Optometry Services in Taszar, Hungary, during Operation Joint Endeavor. Military Medicine, 166, 71-74.

4 Bower, K.S., Donnelly, S.J., Stutzman, R.D., Ward, T.P., Weber, E.(2006). Acanthamoeba keratitis in a U.S. Army soldier after unauthorized use of contact lenses in the combat theater. Military Medicine. 2006 Sep; 171(9):833-837