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Military Aviation Environments and Contact Lens Use Military aviation covers a broad spectrum of activities occurring in highly diverse environments, many of them adverse with respect to contact lens wear. Fighter pilots may have to endure low atmospheric pressure at very high altitudes and substantial G-forces from acceleration. The crew of a transport aircraft may fly at lower elevations and slower speeds but for longer periods. Helicopter pilots, in turn, may not face high altitudes but are generally subject to rapid air movement and high levels of Articulates such as dust in the cockpit. Each of these scenarios presents distinct challenges for successful contact lens wear, yet, as mentioned earlier, some situations would seem to require the use of contact lenses in order to take advantage of their military potential. CONDITIONS ADVERSE TO CONTACT LENS WEAR Military aviators face a host of possible conditions that can influence the success of contact lens use in flight, some of which are described below. Reduced Pressure at Altitude Military aircraft frequently fly at altitudes, ranging from 30,000 to 40,000 ft. at which air pressures are greatly reduced from those at sea level. Air pressure at 30,000 ft is 4.36 psi, just 30 percent of the ambient pressure at sea level (14.7 psi); at 40,000 ft. air pressure is only 2.72 psi, just 18 percent of that at sea level. As the concentration of air thus decreases with altitude, so does the concentration of oxygen (measured as its partial pressure) available to crew members and their eyes. 20

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MILII:ARYAVIATION ENVIRONMENTS 21 1b offset these high altitude effects, aircraft cabins are routinely pres- surized to mimic lower altitudes. However, this ability to artificially pres- surize the cabin is limited by aircraft engine size and at high altitudes can only lessen, not eliminate, the effects of the thinning atmosphere. Generally, high-performance (fighter-attack-reconnaissance) aircraft remain unpressurized to about 8,000 ft (10.9 psi). The pressure is then held constant until the difference between cockpit pressure and outside pressure is 5 psi at about 23,000 ft. This pressure differential is main- tained as the aircraft flies higher. For example, at 30,000 ft. the cabin pressure is equivalent to an altitude of 12,000 ft; at 40,000 ft. the cabin pressure is equivalent to an altitude of about 17,000 ft (O'Neal, 1990~. In tanker-transport-bomber-type aircraft, a sea-level atmosphere can often be maintained in the cabin until the pressure difference between the cockpit and outside is about 8.6 psiat roughly 23,000 ft Again, this pressure differential is held as the craft ascends, resulting in a cabin pressure equivalent to an altitude of 3,500 ft at 30,000 It and cabin pressure equivalent to an altitude of 8,000 ft at 43,000 ft. All things considered, aircrews spend much of their hying time at pressure-equivalent altitudes of 8,000 to 16,000 ft. At these altitudes, substantially less oxygen is available relative to sea level. Since the amount of oxygen passing through a contact lens is directly related to the partial pressure of oxygen in the surrounding air, the amount of oxygen available under a contact lens will also diminish at higher altitudes. Air Force calculations suggest that at 8,000 ft the oxygen available beneath the lens may be 35 percent less than that available at sea level; at 12,000 ft. oxygen availability may be 60 percent less (O'Neal, 1990~. In addition, low cabin humidities may dehydrate soft lenses, inducing a further decrease in oxygen available beneath these lenses by as much as 15 percent. Such reductions in oxygen availability may result in hypoxia with consequent corneal edema and other stresses to ocular physiology. Low Humidity and High Air Flow Aircraft heating and air conditioning systems circulate cabin air con- stantly and remove considerable amounts of moisture from it. Relative humidity in the cabins of most military aircraft sometimes reaches 5 per- cent and is normally in the 5 to 15 percent range (O'Neal, 1990; Dennis, 1990~. These very dry conditions can lead to rapid desiccation of ocular sur- faces. There is much anecdotal evidence for humidity-induced discomfort in contact lens wearers on both commercial airliners and military aircraft (Josephson, 1990; Dennis et al., 1988~. In addition to being quite dry, cabin air may also be moving rapidly, adding to the desiccation effect. It is not uncommon for pilots to have a

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22 CONTACT LENS USE UNDER ADVERSE CONl~mONS stream of air directed at or near their faces to relieve fogging or sweat- related problems. In helicopters, especially those with doors open, there is also a great deal of air movement, with the possibility for drying effects. High Particulate Count in the Cabin All military aviation settings considered here are subject to contamina- tion with particulate matter- from dirt and sand to bits of insulationborne in the cabin air. Such particulates may be blown out by the air condition- ing unit, borne aloft when the aircraft experiences "negative Gs" during maneuvers, or blown in from outside the craft in the case of helicopters. Helicopter missions in dusty or arid locations are especially at risk from particulate contamination. Depending on the nature of the object and the type of lens worn, the presence of a foreign body beneath a lens can cause irritation, distraction, or acute pain severe enough to warrant removal of the lens or to temporarily incapacitate the contact lens wearer. In this regard, soft lenses are generally much more forgiving of particulate contamination than hard lenses. Foreign body involvement can also lead to later complications if corneal abrasion results or pathogens are introduced beneath the lens (Josephson, 1990~. Noxious Gases, Fumes, and Smoke Noxious gases from aircraft exhaust; outgassing of aircraft compo- nents, weaponry, or cargo; and mechanical discharge from heating and air conditioning systems may all contaminate the cabin environment. Organic solvent vapors, carbon monoxide and other partially combusted organic compounds, hydrazine gas from missile propellant, oil mists, ozone gas, and even carbon dioxide are just a few of many possible contaminants. If these compounds are absorbed preferentially by the contact lens and released later to the eye, they can cause ocular distress or damage. While rigid lenses will not generally absorb chemical vapors or fumes, hydrogel lenses may absorb some compounds, especially those that are water-soluble. The effect of airborne fumes or vapors on the contact lens wearer will depend on their concentration, the exposure time, the affinity of the lens for these compounds and thus the amount absorbed, the rate of release of the compounds, and their toxicity or ability to cause allergic response in the eye (Josephson, 1990~. Data on the types and concentrations of gaseous contaminants in the military cocl~it are scant in the public domain (many remain classified in- formation), but anecdotal sources and those few literature reports available indicate that a wide array of compounds is present in exhaust gas, which is

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MILITARY A ELATION ENWRONMENl S 23 commonly found in trace amounts in the cockpit. Army investigators mea- suring toxic gases in the cockpit of a standard observation helicopter found that exhaust fumes consisted of a complicated mixture of over 200 com- pounds, including paraffins, olefins, napthenes, aromatics, acids, aldehydes, alcohols, ketones, ethers, esters, chlorinated hydrocarbons, and sulfur- and nitrogen-containing compounds. Fortunately, none of these was present in high concentrations (Stroud et al., 198~, Pollard et al., 1979~. Even if tonic compounds are found to be present in fairly high concen- trations, it is hard to predict how they will interact with the lens/eye system or if they will precipitate a tome reaction, since few studies have been carried out in this area. There is some evidence to suggest that contact lenses can act as a short-term bamer to some organic solvent fumes, such as xylene and tnchloroethylene, resulting in a lower exposure than if no lens is worn (Josephson, 1990; Nilsson and Andersson, 1982~. Other evidence suggests that hydrogel lenses known to have taken up certain organic compounds do not exacerbate the eye's response to the chemicals compared with direct exposure of the eye to the compounds (Josephson, 1990; Nilsson and Andersson, 1982~. However, it should be emphasized that there is no comprehensive understanding of the short-term effects of exposure of the lens/eye system to chemical vapors, nor have any studies addressed the long-term effects of the uptake and slow release of low levels of toxic compounds by hydrogels. At a practical level, the most serious contaminant of the cabin environ- ment may be cigarette smoke. Smoking is prevalent in many cockpits, espe- cially tanker-transport-bomber-type aircraft, but also in high-performance aircraft as welt Many contact lens wearers find cigarette smoke a potent irntant. It has also been reported that ozone, which is present in increased concentrations in commercial airliner cabins and probably in military air- craft as well, acts as an irritant for both those who wear contact lenses and those who do not (Josephson, 1990~. Unhygienic Conditions for Lens Care Good hygiene practices are essential to the safe removal, disinfection, and reinsertion of contact lenses. Lenses handled in unhygienic conditions risk contamination leading to infection or other complications. This is especially true with hydrogel lenses, for which the risk of introducing and culturing infectious agents is much higher than with rigid lenses. The importance of good hygiene is further magnified with lenses worn in an extended-wear mode. While the chances for contaminating lenses are fewer, due to less frequent insertions and removals, the consequences of contamination and subsequent infection are heightened when those infrequent lens manipulations do occur.

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24 CON~4CT ~ INS USE UNDER ADVERSE CONDITIONS The question of hygiene is probably not much of a problem for fighter- attack-reconnaissance and tanker-transport-bomber personnel who have regular access to airfield facilities. However, Army and Marine helicopter pilots routinely experience prolonged missions amidst field conditions in which good lens hygiene is impossible. These pilots may live in camps without running water, electricity, or the means to adequately clean their hands to ensure a reasonably sterile lens insertion or removal. In combat situations, conditions may be worse still, as cleanliness takes a back seat to more practical survival considerations. High Acceleration As explained earlier, high G-forces experienced during rapid aircraft acceleration can influence lens placement, with possible consequences on vision. Older PMMA lenses with small diameters showed unacceptable movement downward, decentering from the pupil and affecting visual acuity. .. However, more recent trials with larger-diameter hydrogel lenses showed minimal movement up to 8 Gz (see Chapter 1~. Rapid Decompression Rapid elevation gain as experienced by the crews of high performance aircraft can give rise to decompression effects such as bubble formation under the contact lens. The quantity of gas that can remain dissolved in a solution relates directly to the atmospheric pressure it experiences. Thus, when the tear film under a contact lens experiences rapid decompression, the formation of bubbles can occur Flynn et al., 1987) as gas (nitrogen) is forced out of solution. Bubble formation has been observed beneath both rigid and hydrogel lenses. In the case of hydrogels, these bubbles formed at 6,000 ft. However, for both hydrogel and RGP lenses, bubbles dissipated without causing any apparent visual effects (see Chapter 1~. Inadequate Lens Care Systems or Regular Follow-up Care Successful contact lens use relies on a system of competent fitting and regular follow-up care by qualified specialists (i.e., optometrists or ophthalmologists), and the timely provision of lens care solutions and lens replacements. Ensuring that this system is in place and can function smoothly in wartime will be a matter of considerable logistical complexity and expense. Even in peacetime, establishing such a system is no simple taste

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MILITARY AVIATION ENVIRONMENl S 25 Currently, there is no uniformity among the services in terms of lens types employed, wear mode, lens care solutions, fitting, or follow-up care. For those with access to established military medical facilities, such as most Air Force aviators, the chances of receiving professional ophthalmic care are quite high. But for aircraft carrier-based aviators and Army units in the field, high~uality care and resupply with lens care solutions may prove a greater problem. For example, a carrier is typically responsible for maintaining the health of up to 8,000 personnel, but no dedicated eye professionals are currently assigned to carrier duty (Markovits, 1990~. Temperature Extremes Aviators especially helicopter pilotsmay experience extremes in temperature both on the ground and in the air. Arctic helicopter mis- sions may encounter temperatures of409 F. while missions occurring in desert regions may confront temperatures of 120F. Civilian clinical experi- ence to date seems to indicate that such extremes pose few special problems for contact lens wearers. In spite of the ambient temperature, the cornea and related structures seem to maintain themselves with little ill effect. Overmotivation MilitaIy aviators comprise a select and highly motivated group of individuals. The pilot's job is an esteemed one and he is generally loath to jeopardize his flying time in any way. He realizes that contact lens-related complications might well result in being grounded until the complication clears and lens wear can be resumed. Thus, he may be inclined to avoid or delay reporting minor symptoms and hope for the best. In addition, a considerable "macho" ethic surrounds the flying profession that may encourage tolerance of considerable ocular pain without complaint. For this reason, some military authorities fear that aviators may not heed early warning signs that could presage more severe complications later on. CONDITIONS REQUIRING CONTACT LENS WEAR As stated earlier, the modern military arsenal depends to an ever increasing extent upon sophisticated technology for its effectiveness. Occa- sionally, this results in the development of special equipment incompatible with spectacles. In the cockpit, there are three primary types of such equipment: electro-optical devices for aircraft piloting and weapon tar- geting, protective hoods for chemical warfare, and laser protective eye gear.

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26 CONTACT ~ INS USE UNDER ADVERSE CONDITIONS Helmet-mounted optical displays in current use in assault helicopters offer minimal relief between eye and display, effectively eliminating the option of using spectacles. For instance, the Army's AH-64 Apache attack helicopter is equipped with the Integrated Helmet and Display Sighting System (IHADSS), which provides visual input to the pilot and copilot from a closed-circuit video system. A display unit in the helmet delivers images to the right eye, along with essential instrument readings superimposed along the periphery of the display. The pilot can fly his craft using input from the right eye only, while the left eye remains free for direct viewing of the instrument panel or the scene through the windscreen. Correct placement of the display unit is essential to the proper functioning of the system, and spectacles interfere with this placement (Lattimore, 1990~. Chemical-protective hoods are also a problem for helicopter crews. Neither the Army nor the Marine hood can accommodate eyeglasses. In addition, glue-on optics mounted on the hood eyepieces have proven unworkable, leaving contact lenses as the only current option for pilots who require vision correction (Lattimore, 1990', Markovits, 1990~. The development of laser-protective eye gear usable both day and night has become a pressing concern with the increasing use of lasers on the battlefield. An all-purpose spectacle or goggle incorporating both vision correction and laser protection would be ideal, but in many ways the goals of correction and protection are incompatible. Since the vision correction cannot be ground into the laser absorptive element without compromising it, a separate lens element incorporating the correction is required. The result is a very heavy spectacle, with an increased tendency to slip under high-G loading. Moreover, the two elements can interact optically, creating additional difficulties. Use of contact lenses, by eliminating the need for a second element, would reduce the complexity and increase the effectiveness of the laser-protective spectacles (personal communication, J.B. Sheehy, 1989~. Other visual tasks and special duties would also benefit from the use of contact lenses, though spectacles are currently used. For example, looking to the side and behind the cockpit of a high-performance aircraft a procedure called "checking six" involves turning the head to the side and using extreme peripheral vision to check for other aircraft or targets. Spectacles clearly interfere with this important task with many spectacle- wearing pilots reporting their vision obstructed by the side of the frame. Among tanker-transport-bomber aircrews, a special concern is the boom operator who controls the in-flight refueling operation. This individ- ual must work face down to aim the loading boom into the fuel receptacle in the aircraft flying below. Boom operators complain that the position they must assume causes their spectacles to continually slide down.

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MlLl~RYA~4TION ENVIRONMENTS SPECIFIC MILITARY MIGHT SCENARIOS 27 For the purposes of this study, military aviation environments can be divided into three distinct categories: fighter-attack-reconnaissance (F-A-R) missions using high-perform- ance jet aircraft operating at high elevations and speeds for short times; tanker-transport-bomber (T-T-B) missions using larger aircraft op- erating at lower elevations and speeds for longer time periods; and helicopter missions, specifically attack helicopters flying at low elevations and moderate speeds in high-particulate environments, often for lengthy time periods. F-A-R Missions Although F-A-R missions generally involve the most hypoxic condi- tions, these conditions are not ordinarily experienced for prolonged time periods. Excellent night vision is critical. It should be noted that current Air Force regulations require that contact lens users carry spectacles as a backup whenever they fly. These aviators are trained to be able to remove their lenses within 45 seconds if a lens problem develops and to replace them with their backup spectacles. A mission profile involving characteristic environmental factors, visual requirements, mission length, spectacle-incompatible equipment, and other factors in a F-A-R mission is provided below. Environmental factors: high altitude/low oxygen; Articulates; low humidity; high air flow; high G-forces; noxious gases/fumes. Mission duration: usually short (2 to 4 hours) time in air, but occasionally much longer; total contact lens wear time might include considerable ground time in addition to actual flight time. Spectacle-incompatible equipment: laser protective eyewear. Visual requirements: perfect (20/20) visual acuity (for pilots, especially naval carrier- based pilots);

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28 \ CON~4CT LENS USE UNDER ADVERSE CONDITIONS excellent night vision (for pilots, especially naval carrier-based pi- lots); unimpaired peripheral vision (for ``checking SiX99). Other factors: Air Force requires that backup spectacles be carried in the flight suit; contact wearers cannot readily access their lenses due to head gear, but in an emergency can remove them within 45 see; access to qualified ophthalmic specialists for follow-up care not always available (Navy; carrier pilots). T-T-B Missions Much longer times aloft typify T-T-B missions. Although hypoxic conditions are less severe than for F-A-R missions, humidity is just as low and may become more of a factor due to increased exposure time. However, in contrast to F-A-R pilots, T-T-B aircrews can more easily adjust or remove their contact lenses or apply artificial tears if drying becomes a problem. Perfect visual acuity is not as critical among the T-T-B aircrew, except among pilots. As in the F-A-R setting, Air Force contact lens wearers must have backup spectacles in their flight suits at all times. A mission profile for T-T-B activities might typically involve: Environmental factors: high altitude/low oxygen (less severe than F-A-R); low humidity/high air flow; noxious fumes; cigarette smoke; Articulates. Mission duration: longer than F-A-R, usually 12 to 24 hours, but could extend to 36 hours; likely extended-wear mode required for contact lenses during mission. Visual requirements: among pilots, visual acuity important but not as many critical tasks requiring perfect acuity as in F-A-R; perfect visual acuity not essential for nonpilots. Other factors: backup spectacles required in flight suit;

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M7LITARYA~TION ENVIRONAfEN7S in-flight handling of lenses not a problem. Helicopter Missions 29 Helicopter missions differ considerably from both F-A-R and T-T-B missions in terms of environmental stresses encountered and mis- sion duration. Helicopter flight is all at low altitude, so hypoxia is of no concern. However, these missions take place in the most severe conditions with regard to particulate contamination and hygiene. Low altitude flight in arid and dusty climates, often with open cabins, leads to nears inevitable involvement of debris in the eye. Moreover, the nature of helicopter mis- sions dictates that they operate in the field, often for weeks at a time. During this period, the unhygienic conditions of the field prevail, marking perhaps the most critical problem with regard to contact lens wear. Finally, helicopter personnel currently face the greatest spectacle incompatibility problems of any aviators, even as they face the greatest possible stumbling blocks to the successful use of contact lenses. A typical mission profile for attack helicopters (Army and Marines) might include: Environmental factors: low-altitude, high-particulate settings (deserts, arid regions); turbulent airflow; unhygienic conditions for extended periods; temperature extremes. Mission duration: likely to encounter field conditions for 1 week or longer, possibly without opportunity to remove lenses. Spectacle-incompatible equipment (absolute incompatibility: no spectacle use possible): head gear with special optics; chemical protection masks. In summary, it is possible to characterize aviation environments for purposes of identifying the risks posed by the use of contact lenses. The remainder of the report will address these risk factors and recommendations to minimize their consequences.