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New Air Force Visual and Ophthalmological Requirements*
AIR FORCE VISUAL REQUIREMENTS COMMENT
Except for the slightly more frequent oc currence of anterior-chamber hemorrhage when the keratome incision was used—18 percent versus 12 percent—there was no sta tistical difference in the operation complica tions, postoperative course, and final vision in the two series. However, in spite of this statistical similarity, it is our general impres sion that there was a slightly greater post operative reaction in the cases in which the
3S3
keratome was used to make the section. This study gives no information which would support one or the other types of corneal section. Possibly analysis of a larger series of cases might yield some indication that one method was preferable to the other. This series, however, is sufficiently large to indicate that there is little, if any, difference in the over-all course or the final visual re sult following these two techniques. 11 East Chase Street (2).
NEW AIR FORCE VISUAL AND OPHTHALMOLOGICAL REQUIREMENTS* EARL MAXWELL, BRIG. GEN. (MC) Washington, D.C.
Recently a new regulation1, was published covering medical requirements for the vari ous flying and nonflying personnel in the U. S. Air Force. The eye requirements are considered of such interest to ophthalmolo gists that they have been tabulated and are presented herewith (table 1). In addition, tables are enclosed showing minimal accommodative power for age (table 2), and normal mean accommodative power values for age (table 3). Causes for rejection for the various ophthalmological conditions are listed as follows: 1. NONACCEPTABLE FOR ENLISTMENT
a. Lids: (1) Trichiasis; (2) complete or extensive destruction of the lids sufficient to impair protection of the eye from exposure ; (3) disfiguring cicatrices and adhesions of the lids to each other or to the eyeball; (4) chronic severe blepharitis; (5) ptosis inter fering with vision; (6) entropion, ectropion, or lagophthalmos; (7) malignant growths; (8) acute or chronic dacryocystitis. b. Conjunctiva: (1) Acute or chronic con* From the office of the Surgeon General, United States Air Force. t Refers to AFM 160-1, 1 September 1951, U. S. Government Printing Office, Washington, D.C., and changes.
U.S.A.F.
junctivitis, including vernal catarrh, if more than mild; (2) trachoma, active. c. Cornea: (1) Acute or chronic keratitis ; (2) intractable or recurrent ulcers. d. Uveal tract, retina, and optic nerve: (1) acute, chronic, or recurrent inflammation of the uveal tract; (2) retinitis; (3) neuroretinitis; (4) optic neuritis; (5) papilledema; (6) bilateral optic atrophy; (7) pigmentary degeneration of the retina. e. Lens: (1) Opacities of the lens, pre sumably progressive; (2) dislocations of a lens. f. Diseases of the eye: (1) Primary glaucoma; (2) secondary glaucoma; (3) night blindness, due to objective organic disease of the eye. (4) malignant tumor; (5) exophthalmos sufficient to interfere with proper closure of the lids and protection of the cornea; (6) diplopia, if uncorrected; (7) progressive tumors of the orbit and/or disturbance of vision or impairment of visual fields due to disease of the brain; (8) loss of one eye or anophthalmos; (9) any or ganic disease of the eye or adnexa not al ready specified, which threatens continuity of visual fields or impairment of visual func tion; (10) a heterotropia of more than 15 degrees.
20/50 O.U. Correct- Same as Class ible to 20/20 O.U. I
20/50 O.U. Correctible to 20/20 O.U.
Flying Training (Observer) Class IA
Flying (Train ing Completed) Class II
Correctible to 20/20 O.U.
Correctible to 20/20 O.U.
Correctible to 20/20 O.U.
X
20/30 O.U. Without Correction
Correctible to 20/40 and 20/70 or 20/30 and 20/100 or 20/20 and 20/400 or less, if not due to progres sive disease
Control Tower Operator
Radar Operator
Marine Diving Duty
Enlistment
X
X
X
Total +5.00 -3.00
X
Total +1.75 -0.25 Astig. ±0.75
Refractive Error Color Vision
Eso Exo Hyper
Eso Exo Kyper
Eso Exo Hyper
X
10 5 1
10 5 1.5
Eso 10 Exo 5 Hyper 1.5 Pc 70 or Less
Depth Perception Visual Fields
Night Vision*
X
Same as Class IA
Same as Class II
Same as Class I
Same as Class I
X
Same as Class II
Same as Class II
X
X
Same as Class II
Must make 4 or Same as Class I less errors on 17 Plate AOC unless makes score of 50 or better on SAM CTT
Same as Class I
Same as Class I
X
X
Same as Class II
X
Same as Class I
Same as Class II
Defects which Night Blind interfere signif ness disqual icantly w/bin ifies ocular vision disqualify
Same as Class II
15° Loss or Same as Scotoma due to Class I active process disqualifies
Same as Class [Same as I Class I
At least mini Must make 4 or Passing Score— 15° Loss in any Satisfactory mum for age less errors on 17 (Verhoeff) or 30 Meridian. Sco- score ( H o w a r d - D o l toma disquali SAM Tester (table 2) Plate AOC man) or No fies errors—(Armed Forces Vision Tester)
Accommodation
Same as Class I At least mean Same as Class I forage (table 3)
Eso 10 Exo 5 Hyper 1 Pc 70 or Less
Motility
* =Not required unless history shows evidence of defective night vision. X =No standards.
X
Correctible to 20/20 and 20/40
Same as Class III
Commission (Nonflying)
Flying (For per 20/200 O.U. Correct Correctible to sonnel not in ible to 20/20 and 20/20 and 20/30 primary control 20/30 of aircraft) Class III
Same as Class IA
20/20 O.U.
20/20 O.U.
Near Vision
Flying Training (Pilot) Class I
Distant Vision
TABLE 1 E Y E R E Q U I R E M E N T S — U . S. A I R F O R C E
X
X
Same as Class 11
Same as Class I
Same as Class I
No diplopia with in 20° of cen ter of screen in cardinal direc tions
Red Lens Test
> X w r r
> r1
AIR FORCE VISUAL REQUIREMENTS TABLE 2
2. NON ACCEPT ABLE FOR COMMISSION
a. Lids: (1) Trichiasis; (2) destruction of the lids sufficient to impair protection of the eye from exposure; (3) disfiguring ci catrices and adhesions of the lids to each other or to the eyeball; (4) blepharitis, chronic, unless it is the opinion of the ex aminer that it is sufficiently mild in degree to interfere in no way with performance of duty; (5) ptosis interfering with vision; (6) entropion or ectropion; (7) lagophthal mos; (8) growth or tumor of the eyelid other than asymptomatic, nonprogressive small benign lesions; (9) dacryocystitis, acute or chronic; (10) epiphora. b. Conjunctiva: (1) Conjunctivitis, acute, until recovered; (2) conjunctivitis, chronic, including vernal catarrh; (3) trachoma, un less healed without cicatrices; (4) xerophthalmia; (5) pterygium which encroaches on the cornea more than one millimeter or is progressive, as evidenced by marked vascularity or a thick, elevated head. c. Cornea: (1) Keratitis, acute or chronic; (2) corneal ulcer or history of re current ulcers. d. Uveal tract, retina, and optic nerve: (1) Inflammation of the uveal tract (iris, ciliary body, or choroid), acute, chronic, or recurrent; (2) neuroretinitis; (3) choroidoretinitis, unless healed, considered unlikely to recur and not interfering significantly with visual function; (4) optic neuritis; (5) papilledema; (6) optic atrophy; (7) pig mentary degeneration of the retina; (8) coloboma of the choroid or iris. e. Lens: (1) Opacities of the lens which are considered to be progressive or which interfere in any way with vision; (2) dis location of a lens. f. Diseases of the eye: (1) Glaucoma, pri mary or secondary; (2) tumor of the eye; (3) anophthalmos; (4) exophthalmos; (5) night blindness; (6) asthenopia; (7) entro pion or ectropion; (8) lagophthalmos or dacryocystitis. g. Ocular mobility: (1) Nystagmus; (2) heterotropia; (3) diplopia.
355
ACCOMMODATIVE POWER—MINIMUM FOR AGE
Age
Diopters
Age (years)
Diopters
17 18 19 20 21 22 23 24 25 26 27 28 29 30
8.8 8.6 8.4 8.1 7.9 7.7 7.5 7.2 6.9 6.7 6.5 6.2 6.0 5.7
31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
5.4 5.1 4.9 4.6 4.3 4.0 3.7 3.4 3.1 2.8 2.4 2.0 1.5 1.0 .6
(years)
TABLE 3 ACCOMMODATIVE POWER—NORMAL MEAN VALUE OF AGE
Age (years)
17 18 19 20 21 22 23 24 25 26 27 28 29 30
Diopters 11.8 11.6 11.4 11.1 10.9 10.7 10.5 10.2
9.9 9.7 9.5 9.2 9.0 8.7
Age (years)
Diopters
31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
8.4 8.1 7.9 7.6 7.3 7.0 6.7 6.4 6.1 5.8 5.4 5.0 4.5 4.0 3.6
h. Other organic diseases of the eye or adnexa: Any organic disease of the eye or adnexa not already specified, which threatens continuity of vision or impairment of visual function. 3 . NONACCEPTABLE FOR FLYING ANDlA
CLASSES I
a. History of choroidoretinitis. b. Any organic disease of the eye or ad nexa not already specified, which threatens continuity of vision or impairment of visual function and, in the opinion of the examiner, will in any way interfere with efficient per formance of flying duty or the individual's well being.
356
CONRAD BERENS AND FRANCISCO A. ROSA
4. NONACCEPTABLE
FOR
FLYING
CLASSES
I I AND I I I
a. Any organic disease of the eye or adnexa not already specified, which threatens continuity of vision or impairment of visual function and, in the opinion of the examiner, will in any way interfere with efficient per formance of flying duty or the individual's well being. b. The disqualifying conditions listed un der paragraphs 2 and 3, when found in
rated and trained personnel, will be indi vidually evaluated in regard to severity, prognosis, and importance in relationship to continued flying. SUMMARY
New visual and ophthalmological require ments for the various classes of examina tions used in the U. S. Air Force, as pre scribed in Air Force Manual (AFM) 160-1, are presented. Headquarters U. S. Air Force (25).
EVISCERATION W I T H PLASTIC INTRASCLERAL IMPLANTS* CONRAD BERENS, M.D.,
AND FRANCISCO A. ROSA,
M.D.
New York
Since Mules,1 in 1884, devised a hollow spherical glass implant, no radical changes in the technique of evisceration were pro posed up to 15 years ago, except that a cylindric implant was substituted for the sphere. Evisceration has gained more popularity in European countries than in the United States, where the preference is for enuclea tion. The preference for enucleation where evisceration is indicated is difficult to com prehend in view of the fact that the technique is simple, has proven to be safe in a large number of cases, and there is less danger of extrusion. Psychologically, a patient more readily accepts the removal of the contents of the eye rather than the removal of the globe. The cosmetic results are good, usually with less sinking of the upper eyelid, and the movement of the prosthesis more, normal because the muscles are not disturbed.' Excising the optic nerve during enuclea tion produces a potential pathway for -in* From the Department of Research, New York Eye and Ear Infirmary, and the Department of Ophthalmology, New York University Postgradu ate Medical School. Aided by grants from the Ophthalmological Foundation, Inc., and the Snyder Foundation.
fection by way of the meninges of the optic nerve to the meninges of the brain. Eviscera tion has been repeatedly advocated in cases of panophthalmitis2 to prevent meningitis. Thrombosis of the cavernous sinus has been frequently observed in reported cases of meningitis following enucleation, but it has not been determined clinically whether men ingitis was the result of bacteria invading the optic-nerve sheaths or due to surgical trauma. • Extensive research work by British oph thalmologists3 and others 4 indicates that sympathetic ophthalmia does not follow evisceration more often than enucleation. However, if an eye is potentially sympathicogenic, neither evisceration nor enucleation will always prevent sympathetic ophthalmia. The high incidence of extrusion of im plants following the Mules operation re ported by Verrey 5 and Burch6 may have been due to the fact that (1) the sphere was too large to be retained in the scleral shell, (2) hemorrhage had not been controlled, or (3) the sclera was not adequately closed with nonabsorbable sutures. In view of the poor results obtained with various types of integrated implants, it was considered that a report of experience with
Except for the slightly more frequent oc currence of anterior-chamber hemorrhage when the keratome incision was used—18 percent versus 12 percent—there was no sta tistical difference in the operation complica tions, postoperative course, and final vision in the two series. However, in spite of this statistical similarity, it is our general impres sion that there was a slightly greater post operative reaction in the cases in which the
3S3
keratome was used to make the section. This study gives no information which would support one or the other types of corneal section. Possibly analysis of a larger series of cases might yield some indication that one method was preferable to the other. This series, however, is sufficiently large to indicate that there is little, if any, difference in the over-all course or the final visual re sult following these two techniques. 11 East Chase Street (2).
NEW AIR FORCE VISUAL AND OPHTHALMOLOGICAL REQUIREMENTS* EARL MAXWELL, BRIG. GEN. (MC) Washington, D.C.
Recently a new regulation1, was published covering medical requirements for the vari ous flying and nonflying personnel in the U. S. Air Force. The eye requirements are considered of such interest to ophthalmolo gists that they have been tabulated and are presented herewith (table 1). In addition, tables are enclosed showing minimal accommodative power for age (table 2), and normal mean accommodative power values for age (table 3). Causes for rejection for the various ophthalmological conditions are listed as follows: 1. NONACCEPTABLE FOR ENLISTMENT
a. Lids: (1) Trichiasis; (2) complete or extensive destruction of the lids sufficient to impair protection of the eye from exposure ; (3) disfiguring cicatrices and adhesions of the lids to each other or to the eyeball; (4) chronic severe blepharitis; (5) ptosis inter fering with vision; (6) entropion, ectropion, or lagophthalmos; (7) malignant growths; (8) acute or chronic dacryocystitis. b. Conjunctiva: (1) Acute or chronic con* From the office of the Surgeon General, United States Air Force. t Refers to AFM 160-1, 1 September 1951, U. S. Government Printing Office, Washington, D.C., and changes.
U.S.A.F.
junctivitis, including vernal catarrh, if more than mild; (2) trachoma, active. c. Cornea: (1) Acute or chronic keratitis ; (2) intractable or recurrent ulcers. d. Uveal tract, retina, and optic nerve: (1) acute, chronic, or recurrent inflammation of the uveal tract; (2) retinitis; (3) neuroretinitis; (4) optic neuritis; (5) papilledema; (6) bilateral optic atrophy; (7) pigmentary degeneration of the retina. e. Lens: (1) Opacities of the lens, pre sumably progressive; (2) dislocations of a lens. f. Diseases of the eye: (1) Primary glaucoma; (2) secondary glaucoma; (3) night blindness, due to objective organic disease of the eye. (4) malignant tumor; (5) exophthalmos sufficient to interfere with proper closure of the lids and protection of the cornea; (6) diplopia, if uncorrected; (7) progressive tumors of the orbit and/or disturbance of vision or impairment of visual fields due to disease of the brain; (8) loss of one eye or anophthalmos; (9) any or ganic disease of the eye or adnexa not al ready specified, which threatens continuity of visual fields or impairment of visual func tion; (10) a heterotropia of more than 15 degrees.
20/50 O.U. Correct- Same as Class ible to 20/20 O.U. I
20/50 O.U. Correctible to 20/20 O.U.
Flying Training (Observer) Class IA
Flying (Train ing Completed) Class II
Correctible to 20/20 O.U.
Correctible to 20/20 O.U.
Correctible to 20/20 O.U.
X
20/30 O.U. Without Correction
Correctible to 20/40 and 20/70 or 20/30 and 20/100 or 20/20 and 20/400 or less, if not due to progres sive disease
Control Tower Operator
Radar Operator
Marine Diving Duty
Enlistment
X
X
X
Total +5.00 -3.00
X
Total +1.75 -0.25 Astig. ±0.75
Refractive Error Color Vision
Eso Exo Hyper
Eso Exo Kyper
Eso Exo Hyper
X
10 5 1
10 5 1.5
Eso 10 Exo 5 Hyper 1.5 Pc 70 or Less
Depth Perception Visual Fields
Night Vision*
X
Same as Class IA
Same as Class II
Same as Class I
Same as Class I
X
Same as Class II
Same as Class II
X
X
Same as Class II
Must make 4 or Same as Class I less errors on 17 Plate AOC unless makes score of 50 or better on SAM CTT
Same as Class I
Same as Class I
X
X
Same as Class II
X
Same as Class I
Same as Class II
Defects which Night Blind interfere signif ness disqual icantly w/bin ifies ocular vision disqualify
Same as Class II
15° Loss or Same as Scotoma due to Class I active process disqualifies
Same as Class [Same as I Class I
At least mini Must make 4 or Passing Score— 15° Loss in any Satisfactory mum for age less errors on 17 (Verhoeff) or 30 Meridian. Sco- score ( H o w a r d - D o l toma disquali SAM Tester (table 2) Plate AOC man) or No fies errors—(Armed Forces Vision Tester)
Accommodation
Same as Class I At least mean Same as Class I forage (table 3)
Eso 10 Exo 5 Hyper 1 Pc 70 or Less
Motility
* =Not required unless history shows evidence of defective night vision. X =No standards.
X
Correctible to 20/20 and 20/40
Same as Class III
Commission (Nonflying)
Flying (For per 20/200 O.U. Correct Correctible to sonnel not in ible to 20/20 and 20/20 and 20/30 primary control 20/30 of aircraft) Class III
Same as Class IA
20/20 O.U.
20/20 O.U.
Near Vision
Flying Training (Pilot) Class I
Distant Vision
TABLE 1 E Y E R E Q U I R E M E N T S — U . S. A I R F O R C E
X
X
Same as Class 11
Same as Class I
Same as Class I
No diplopia with in 20° of cen ter of screen in cardinal direc tions
Red Lens Test
> X w r r
> r1
AIR FORCE VISUAL REQUIREMENTS TABLE 2
2. NON ACCEPT ABLE FOR COMMISSION
a. Lids: (1) Trichiasis; (2) destruction of the lids sufficient to impair protection of the eye from exposure; (3) disfiguring ci catrices and adhesions of the lids to each other or to the eyeball; (4) blepharitis, chronic, unless it is the opinion of the ex aminer that it is sufficiently mild in degree to interfere in no way with performance of duty; (5) ptosis interfering with vision; (6) entropion or ectropion; (7) lagophthal mos; (8) growth or tumor of the eyelid other than asymptomatic, nonprogressive small benign lesions; (9) dacryocystitis, acute or chronic; (10) epiphora. b. Conjunctiva: (1) Conjunctivitis, acute, until recovered; (2) conjunctivitis, chronic, including vernal catarrh; (3) trachoma, un less healed without cicatrices; (4) xerophthalmia; (5) pterygium which encroaches on the cornea more than one millimeter or is progressive, as evidenced by marked vascularity or a thick, elevated head. c. Cornea: (1) Keratitis, acute or chronic; (2) corneal ulcer or history of re current ulcers. d. Uveal tract, retina, and optic nerve: (1) Inflammation of the uveal tract (iris, ciliary body, or choroid), acute, chronic, or recurrent; (2) neuroretinitis; (3) choroidoretinitis, unless healed, considered unlikely to recur and not interfering significantly with visual function; (4) optic neuritis; (5) papilledema; (6) optic atrophy; (7) pig mentary degeneration of the retina; (8) coloboma of the choroid or iris. e. Lens: (1) Opacities of the lens which are considered to be progressive or which interfere in any way with vision; (2) dis location of a lens. f. Diseases of the eye: (1) Glaucoma, pri mary or secondary; (2) tumor of the eye; (3) anophthalmos; (4) exophthalmos; (5) night blindness; (6) asthenopia; (7) entro pion or ectropion; (8) lagophthalmos or dacryocystitis. g. Ocular mobility: (1) Nystagmus; (2) heterotropia; (3) diplopia.
355
ACCOMMODATIVE POWER—MINIMUM FOR AGE
Age
Diopters
Age (years)
Diopters
17 18 19 20 21 22 23 24 25 26 27 28 29 30
8.8 8.6 8.4 8.1 7.9 7.7 7.5 7.2 6.9 6.7 6.5 6.2 6.0 5.7
31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
5.4 5.1 4.9 4.6 4.3 4.0 3.7 3.4 3.1 2.8 2.4 2.0 1.5 1.0 .6
(years)
TABLE 3 ACCOMMODATIVE POWER—NORMAL MEAN VALUE OF AGE
Age (years)
17 18 19 20 21 22 23 24 25 26 27 28 29 30
Diopters 11.8 11.6 11.4 11.1 10.9 10.7 10.5 10.2
9.9 9.7 9.5 9.2 9.0 8.7
Age (years)
Diopters
31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
8.4 8.1 7.9 7.6 7.3 7.0 6.7 6.4 6.1 5.8 5.4 5.0 4.5 4.0 3.6
h. Other organic diseases of the eye or adnexa: Any organic disease of the eye or adnexa not already specified, which threatens continuity of vision or impairment of visual function. 3 . NONACCEPTABLE FOR FLYING ANDlA
CLASSES I
a. History of choroidoretinitis. b. Any organic disease of the eye or ad nexa not already specified, which threatens continuity of vision or impairment of visual function and, in the opinion of the examiner, will in any way interfere with efficient per formance of flying duty or the individual's well being.
356
CONRAD BERENS AND FRANCISCO A. ROSA
4. NONACCEPTABLE
FOR
FLYING
CLASSES
I I AND I I I
a. Any organic disease of the eye or adnexa not already specified, which threatens continuity of vision or impairment of visual function and, in the opinion of the examiner, will in any way interfere with efficient per formance of flying duty or the individual's well being. b. The disqualifying conditions listed un der paragraphs 2 and 3, when found in
rated and trained personnel, will be indi vidually evaluated in regard to severity, prognosis, and importance in relationship to continued flying. SUMMARY
New visual and ophthalmological require ments for the various classes of examina tions used in the U. S. Air Force, as pre scribed in Air Force Manual (AFM) 160-1, are presented. Headquarters U. S. Air Force (25).
EVISCERATION W I T H PLASTIC INTRASCLERAL IMPLANTS* CONRAD BERENS, M.D.,
AND FRANCISCO A. ROSA,
M.D.
New York
Since Mules,1 in 1884, devised a hollow spherical glass implant, no radical changes in the technique of evisceration were pro posed up to 15 years ago, except that a cylindric implant was substituted for the sphere. Evisceration has gained more popularity in European countries than in the United States, where the preference is for enuclea tion. The preference for enucleation where evisceration is indicated is difficult to com prehend in view of the fact that the technique is simple, has proven to be safe in a large number of cases, and there is less danger of extrusion. Psychologically, a patient more readily accepts the removal of the contents of the eye rather than the removal of the globe. The cosmetic results are good, usually with less sinking of the upper eyelid, and the movement of the prosthesis more, normal because the muscles are not disturbed.' Excising the optic nerve during enuclea tion produces a potential pathway for -in* From the Department of Research, New York Eye and Ear Infirmary, and the Department of Ophthalmology, New York University Postgradu ate Medical School. Aided by grants from the Ophthalmological Foundation, Inc., and the Snyder Foundation.
fection by way of the meninges of the optic nerve to the meninges of the brain. Eviscera tion has been repeatedly advocated in cases of panophthalmitis2 to prevent meningitis. Thrombosis of the cavernous sinus has been frequently observed in reported cases of meningitis following enucleation, but it has not been determined clinically whether men ingitis was the result of bacteria invading the optic-nerve sheaths or due to surgical trauma. • Extensive research work by British oph thalmologists3 and others 4 indicates that sympathetic ophthalmia does not follow evisceration more often than enucleation. However, if an eye is potentially sympathicogenic, neither evisceration nor enucleation will always prevent sympathetic ophthalmia. The high incidence of extrusion of im plants following the Mules operation re ported by Verrey 5 and Burch6 may have been due to the fact that (1) the sphere was too large to be retained in the scleral shell, (2) hemorrhage had not been controlled, or (3) the sclera was not adequately closed with nonabsorbable sutures. In view of the poor results obtained with various types of integrated implants, it was considered that a report of experience with