Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.

com

From beach lifeguard to astronaut: occupational

vision standards and the implications of refractive
surgery
Gerry Clare, John A Pitts, Ken Edgington, et al.

Br J Ophthalmol published online May 21, 2009

doi: 10.1136/bjo.2008.156323

Updated information and services can be found at:

http://bjo.bmj.com/content/early/2009/05/21/bjo.2008.156323

These include:
P<P Published online May 21, 2009 in advance of the print journal.

Email alerting Receive free email alerts when new articles cite this article. Sign up in the box at
service the top right corner of the online article.

Notes

Advance online articles have been peer reviewed and accepted for publication but have not yet
appeared in the paper journal (edited, typeset versions may be posted when available prior to
final publication). Advance online articles are citable and establish publication priority; they are
indexed by PubMed from initial publication. Citations to Advance online articles must include the
digital object identifier (DOIs) and date of initial publication.

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://journals.bmj.com/cgi/ep
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com
BJO Online First, published on May 21, 2009 as 10.1136/bjo.2008.156323

From beach lifeguard to astronaut: occupational

vision standards and the implications of refractive
surgery
G Clare1, J Pitts2, K Edgington3, BD Allan4
Corresponding author:
Gerry Clare
Consultant Ophthalmologist, British Army
University of Nottingham
Queen’s Medical Centre
Division of Ophthalmology and Visual Sciences
Nottingham, NG7 2UH
Email: msxgc@nottingham.ac.uk
Telephone: 0115 924 9924 extension 62025
Fax: 0115 970 9963

John A Pitts
Consultant Ophthalmologist, Bayview Hospital, Barbados
Consultant Ophthalmologist to the UK Civil Aviation Authority

Ken Edgington
Consultant in Aviation and Occupational Medicine
Airport Medical Services Ltd
Horley, UK

Bruce D Allan
Consultant Ophthalmic Surgeon
Moorfields Eye Hospital
London, UK

Keywords: Vision; Diagnostic tests/Investigation; Treatment Surgery; Psychophysics

Word count: 3,000

Copyright Article author (or their employer) 2009. Produced by BMJ Publishing Group Ltd under licence.
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

Minimum vision standards for employees are used in manufacturing,[1]transport

industries,[2, 3]the emergency[4] and armed services1.[5]Traditionally, these have
applied to colour vision, visual acuity and refractive error, with the later addition of
visual fields for driving.[6]Vision standards are often historic and differ between
countries, and their validity may be questioned as technological advances obviate
some visual tasks.[7]Furthermore, entry standards applied to uncorrected acuity are
being bypassed by advances in refractive surgery. This is of special significance in
the armed services, where operational constraints must be taken into account. Our
understanding of the interplay between visual demands at work and the effects of
refractive surgery is evolving. Vision standards and official policies on refractive
surgery should be understood in relation to the work environment, by both surgeons
and patients. Performance-based and parametric tests are helping to define vision
standards in a variety of occupations. Surgical correction of refractive errors can in
many cases allow previously ineligible candidates to pursue their chosen occupation.

The rationale for visual standards

Visual standards are commonly based on concepts of public safety, selection for
training, and competition. The public safety angle invokes a balance between the
individual’s right to work and the right of society to expect a safe level of health, for
example in its public transport workers. Selection reduces the cost of training by
precluding unsuitable individuals who, if selected, would go on to fail. High standards
of performance permit the competitive selection of highly able personnel.
Organizations frequently have separate vision standards for entry and retention,
accommodating personnel whose vision has changed since joining. In accordance
with modern precepts of equality of opportunity (e.g. Disability Discrimination Act
2005), exclusion requires justification based on evidence,[8]and if organizations lean
too far towards very high standards, high-quality applicants may be denied
employment. Thus, vision standards should serve both the individual worker and
society at large.
Comprehensive vision standards for a variety of professions such as the armed
forces and the police, as well as for motor sports and the offshore oil and gas
industry are helpfully provided by the Association of Optometrists on their website,
www.aop.org.uk. Abridged, updated versions are presented here (Table 1).

Police Fire Officer Army soldi er Ordinary Professional Motor Seafarer Bridge

Officer driver driver sports (Merchant watchkeeper

Navy) (Royal Navy)

UCVA 1st 6/18 3/60 6/60 6/24

eye

UCVA 2nd 6/24 3/60 6/60 6/36

eye

UCVA 6/36

binocular

BCVA 1st 6/12 6/12 6/6 to 6/12 6/12 6/9 6/6 6/6

eye (ri ght eye)*

BCVA 2nd 6/12 6/12 6/36 6/12 6/12 6/9

eye

2
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

BCVA 6/6 6/9 6/6

binocular

Maxi mum +3.00D -7.00D to -2.50 to

spherical +8.00D +3.00D

error

Minimum Dichromacy Anomalous * Pass l antern Pass lantern

colour trichromacy test test (low

vision brightness)

Visual Full Full Full

fields

Table 1 Visual acuity and refractive error standards for a variety of UK occupations. Empty
spaces represent unspecified standards.*Precise standard depends on trade, regiment or
corps. Military ophthalmologists make final decisions on fitness to serve in borderline cases.
Please refer to www.aop.org.uk for more detailed information. (UCVA: uncorrected visual
acuity; BCVA: best corrected visual acuity)

Some of the most exacting and widely recognized visual standards are set for
military pilots (Table 2). Vision standards for fighter pilots are based on distance and
reading visual acuity, refractive error, colour vision, muscle balance, convergence,
accommodation and stereopsis, but not contrast sensitivity or visual performance
with night vision goggles (NVG). Current weapons systems requiring split visual
tasks (e.g. Apache helicopter helmets) place further demands on pilots. Extended
testing in these areas may help to define performance advantages relevant to
modern combat flying such as target awareness in the peripheral visual field.[9]
Arguments against introducing new functional tests for pilots include the relative lack
of normative data and the possibility that pilots with contrast sensitivity at the low end
of the scale may have neuro-adaptive mechanisms giving them unimpaired
performance. Whilst new technology can assume tasks formerly reliant on human
vision, such as monitoring targets, superior visual ability is still considered to be an
essential survival advantage, and demanding entry standards for fighter pilots are
likely to remain. The focus of debate moving forwards is likely to be determined by
the extent to which refractive surgery can widen the pool of potential recruits.

Visual acuity Refractive error

UCVA each BSCVA 1st BSCVA BSCVA binocular Spheri cal error Cyli ndrical error

eye eye 2nd

eye

Pilot, Royal Navy, 6/12 6/6 -0.75D to +1.75D +0.75D

Army

Pilot, Royal Air Force 6/6 0D - +1. 75D +0.75D

Commercial pilot, 6/9 6/9 6/6 -6.00D to +5.00D ±2.00D

JAR (entry)

Private pilot, JAR 6/12 6/12 6/6 -8.00D to +5.00D ±3.00D

Pilot astronaut, 20/200 20/20 20/20

NASA*

Canadian Forces 6/12;6/18 6/6 6/9 -5.00D to +5.00D

Pilot†

Group 1 Aviator, US 20/100 20/20 20/20 No limits

Navy

3
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

Table 2 Visual acuity and refractive error minimum standards for military and civilian pilots.
(JAR, Joint Aviation requirements; NASA, National Aeronautics and Space Administration).
*From www.nasa.gov; †Department of National Defence, Canada (from Kumagai JK,
Williams S, Kline D. Visual standards for aircrew: visual acuity for pilots. Contract Report
2005-142, Defence Research and Development Canada, Toronto, March 2005)

The history of visual standards

Historically, visual standards have been derived arbitrarily or intuitively. In 1917, a
committee was appointed by the Council of the Ophthalmological Society to consider
“The standards of vision desirable for the performance of different duties in the
British Army”. Chaired by Edward Treacher Collins, the committee stated that “as
late as 1837, ability to detect a person at ten paces was considered adequate in one
continental army”.[10]However, it is the visual perception of colour, not form, which
may first have been assessed against occupational requirements in a medical
context.
The late industrial revolution heralded the introduction of colour vision standards in
the rail and maritime industries as coloured signal lights came into use to prevent
collisions.[11]Defects in colour vision had been recognized since the late eighteenth
century, with one of the earliest descriptions provided by the English chemist John
Dalton. He described his own colour deficiency, later discovered to be deuteranopia
by DNA analysis of his preserved eyes in 1995.[12]
A contemporary of Dalton’s, Thomas Young postulated that normal colour vision
depended on the presence of three photoreceptors, a theory developed by von
Helmholtz in the mid-nineteenth century[13, 14]and confirmed by
microspectrophotometry in 1983.[15] In 1855 Professor George Wilson of Edinburgh
discovered the prevalence of colour defects to be relatively common.[11]He
highlighted the dangers associated with defective red-green colour vision and
advocated excluding colour defective sailors and railwaymen from certain jobs.
These ideas were echoed by Frans Cornelis Donders in Holland, and other industrial
nations followed suit.
Colour blindness was implicated in a train accident in Lagerlunda, Sweden, by
Professor Holmgren of the University of Uppsala in 1877.[16]After a well-publicized
enquiry, the Swedish State Railways introduced a requirement for normal colour
vision, a criterion adopted for officers of the Swedish Navy. Holmgren developed the
first standardized occupational test for colour blindness, based on the Young-
Helmholtz theory of trichromatic vision, using skeins of coloured wool. Also in 1877
Donders described a lantern test for railroad workers, and the British Board of Trade
introduced colour vision testing for officers in the Merchant Navy, eventually using
coloured glass lanterns illuminated by oil lamps.[17]Electric lanterns followed in due
course.
In 1862, the systematic testing of visual acuity was made possible by the invention of
a chart consisting of capital letters designed to subtend an angle of five minutes of
arc at a given distance.[18]This advance, made in Utrecht by Herman Snellen, would
form the basis of all future visual acuity. Snellen’s optotypes were first presented by

4
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

Donders at the 2nd International Congress of Ophthalmology in 1862.[18]Donders

first understood the basis of refractive errors[19] and is reported to have been the
first to introduce an occupational visual acuity standard, for Dutch Railroad workers
in 1877.[11]
It is difficult to date the introduction of vision standards relating to refractive error, but
the Treacher Collins’ 1917 committee recommended visual acuity for general Army
service should be “at least 6/24 with either right or left eye without glasses, and at
least 6/12 with the right eye, aided, if necessary, by glasses” and that “in the case of
sphericals refractive error should not exceed 8 dioptres. Simple cylindricals should
not exceed 4 dioptres, and of the highest meridian in combined sphero-cylindricals
should not exceed 8 dioptres”.[10]How this was arrived at is unknown. In contrast to
other European armies, the British Army had previously not “taken into account”[10]
men with glasses but had been forced to do so by the sheer demand for front line
troops. The question of vision standards vexed the committee, which concluded that
further investigation and consultation with the War Office were necessary to
determine vision standards of the many occupations within the army. At around the
same time, it was recognized that visual standards in military aviation would have to
be higher than that of “the ordinary soldier” (better eye 6/12, 6/6 with correction,
worse eye 6/18, 6/12 with correction).[20]
Significant strides were made in the Industrial Revolution and the First World War
concerning vision standards, which have continued to evolve to the present day.

Current Testing of Visual Performance

Task-based visual tests
Vision standards using high-contrast photopic acuity criteria may miss more subtle
anomalies of peripheral vision, stereopsis and contrast acuity. Testing of these
aspects of vision by conventional methods (e.g. Pelli-Robson chart, stereoacuity
tests) may not be sensitive enough to detect potentially adverse effects on ability to
function. Visual tests devised to document eye disease may not be the best
indicators of visual performance in health, although screening tests such as the
Keystone visual-skills test can pick up deficiencies. Moreover, it is difficult to specify
what the minimum level of visual acuity should be in order to shoot a rifle, fly a plane
safely or perform retinal surgery. In-depth observational and questionnaire-based
analyses of the various requirements of a particular occupation, such as fire
fighting[21]and policing,[22]have emphasized these areas of uncertainty. This has
led to a trend to develop visual task-based tests with specific functional relevance.
Simulators test higher skills which rely on visual performance. They include night
driving with and without glare, the tasks being to detect and identify road
hazards.[23]In ophthalmic surgery, virtual reality simulation of complex procedures is
becoming increasingly popular. Correlations between performance on surgical
simulators, performance in tests of visual function including stereopsis, and later
surgical performance will form an important area for future research.

5
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

Computerized tasks associated with occupational performance include tests of the

ability to detect and identify peripheral stimuli. The useful field of view test attempts
to analyze attention span within the visual field, and may be a better predictor of
driving performance than conventional screening tests.[24]Similarly, the contrast
acuity assessment, designed for pilots who have undergone refractive surgery,
assesses the ability to detect contrast changes within the minimum spatial vision
requirements.[25]
Empirical task-based tests simulate working conditions to determine minimum vision
requirements. The ability of air traffic controllers to carry out safety-critical tasks
requiring colour discrimination can be tested in simulated control-room scenarios,
excluding some anomalous trichromats.[26]One study of police applicants showed
that the uncorrected visual acuity (UCVA) required to identify a weapon in a room
and to find dislodged glasses was at least 20/125.[27]For train crews viewing slide-
projected images to identify a hazardous scene at 285 feet, a best corrected visual
acuity (BCVA) of 20/20 was needed.[28]In a study of the visual requirements of
beach lifeguards, the angle subtended by a human head at 300m was calculated to
be 6/17.[29]However, the BCVA standard, determined by incremental blurring with
spherical lenses, was at least 6/9 in one eye and 6/18 in the other, because of the
additional requirements to search for and identify the visual target.
Occupational colour vision testing has been subjected to scrutiny recently. In 2002, a
colour defective pilot who crashed in Tallahassee airport was found to have had
difficulty distinguishing the Precision Approach Path Indicator lights despite having
passed a Farnsworth lantern test.[30]The Optec 900, said to be more stringent than
the Farnsworth test, has since come into use.[31]Lantern tests are secondary colour
vision tests which do not exclude all anomalous trichromats,[32]but pick up
difficulties in colour signal light recognition better than clinical tests such as the
Nagel anomaloscope.[33]The Holmes-Wright Lantern, devised in the UK in 1974, is
no longer produced and is being superseded by the improved Fletcher-Evans CAM
Lantern Test (www.evansinstruments.co.uk). There is some variability between the
lantern tests used in different European countries to meet Joint Aviation
Requirements[34]as well as inconsistency of the pass criteria;[35]moreover, these
tests do not identify individuals with superior colour discrimination.

Tests of visual parameters

Although not dependent upon task performance, other objective tests of the limits of
human vision continue to provide more information and may make the
characterization of occupational visual standards more comprehensive.
Near vision is dependent on accommodative power as well as distance acuity and
therefore cannot easily be expressed as an angle. In terms of occupational testing, it
is useful to know whether tasks requiring excellent near vision, such as cartographic
drawing or searching for cracks in a metal fuselage, can be performed. Backlit
Landolt C optotypes can be used for extra-fine acuity measurements.[36]
The Snellen chart measures uneven increments in visual acuity, and is less reliable
and reproducible test than standardized logarithmic visual acuity charts,[37]casting
6
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

doubt over its suitability for measuring vision standards. Contrast sensitivity function
(CSF) has been demonstrated to be a better predictor of target detection in low-
contrast conditions.[38]The Small Letter Contrast Test offered an improvement over
standard tests by picking up more subtle visual defects, and was promoted for use in
evaluating visual performance after refractive surgery and in the selection of military
aviators.[39-41]However, the contrast of the letters faded with time. Photopic and
mesopic contrast acuity can be measured with backlit charts using linear sine-wave
gratings and image-processing software;[42]this test is now preferred by U.S. military
ophthalmologists.[43]
In addition to testing in the contrast domain, aberrometry[44, 45]and sophisticated
measures of intraocular light scatter[46, 47]are evolving which could in future help
determine the suitability of candidates for occupations with specific, task related
demands on visual performance.

The impact of refractive surgery

Modern refractive surgery has blurred the boundaries of occupational vision
standards, with many candidates previously excluded from a job now able to
undergo a corrective procedure in order to qualify. However, the effects of refractive
surgery on vision in low contrast or low luminance have not yet been fully defined.
Peripheral vision may be adversely affected by some procedures.[48] Low contrast
logMAR charts and CSF measurements at mesopic luminance levels may help to
improve our understanding.
Open-minded policies on refractive surgery have a number of advantages. A
prohibitive stance may deter candidates from disclosing a history of refractive
surgery (surgery-induced changes can be detected by imaging techniques), or may
lead recruits to choose the wrong procedure. For example, radial keratotomy may
result in unstable refraction, making it unsuitable for military and other
occupations.[49, 50]The availability of refractive surgery expands the pool of
potential recruits, which may be especially significant in countries with a high
prevalence of myopia.
The United States Military has identified benefits associated with refractive surgery
including cost, military readiness and improved morale.[23, 51, 52]Wearing of
glasses is problematic functionally for the military (and other occupations) because
of incompatibility with equipment and the inherent risk of loss, breakage, fogging and
glare. Contact lenses are prohibited on operations because of hygiene difficulties
and serious infection risks.[53]The potential to enhance military capability by
refractive surgery has been recognized since the safety of photorefractive
keratectomy (PRK) was demonstrated in a cohort of special operations personnel in
1993.[54]The launch of the Warfighter Refractive Eye Surgery Program in 2000 has
resulted in treatment centres being established worldwide, with over one hundred
thousand personnel receiving treatment.

Current and future areas of research

7
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

Initially, PRK was considered the gold standard in the U.S. Navy,[55]but LASIK has
since gained favour and is increasingly advocated for naval personnel.[23]The U.S.
Army, in contrast, has retained a preference for surface treatments because of the
risk of traumatic LASIK flap dislocations during combat.[51]If sustained on
operations, this rare complication would severely debilitate a soldier and require
repatriation. Conversely, late corneal haze has been observed in troops serving in
the Middle East, due to fibrosis following surface treatment (pers. comm., Captain
Steven Schallhorn, US Navy (retired), 2008).
While PRK has been found to be safe following aircraft ejection,[56]it has been
argued that the high gravitational forces sustained could dislodge a LASIK flap.
Extensive animal tests using a rabbit model found the corneal flap to be stable
during ejection[57]and windblast.[58]The effects of changes in ocular biomechanical
properties following refractive surgery, such as reduced corneal hysteresis,[59]are
not fully understood in the context of physiological extremes.
The view that LASIK and fast jets were not mutually incompatible was reinforced by
an Israeli Air Force pilot who had an uneventful return to full duties 2 weeks after
refractive surgery.[60]Refraction in post-LASIK eyes has been found to be stable in
conditions of prolonged exposure to altitude and hypoxia, and LASIK is now
considered suitable for U.S. Air Force and Navy pilots and National Aeronautics and
Space Administration (NASA) astronauts (Table 3).[23]

Refractive procedures permitted Pre-operative refractive error

LASI K Surface Intracorneal Radial Phaki c Maximum Minimum

treatment ring segments keratotomy IOL spherical postoperative

equival ent probation

British Army (entry)   ±6.00D 6-12 months

Royal Air Force aircrew     

(entry)

Royal Air Force aircrew  6-12 months

(retenti on)

Joint Avi ati on  -6.00D to +5.00D 3 months

Requirement s (LASI K)

US naval avi ator (trained) *  3-6 months

Police (UK)  6 weeks

Fire Brigade  12 months

NASA 
Republic of Singapore Air   -5.00D (-2.00 cyl)

Force ( pil ot applicants)

Table 3 Refractive surgery waivers, armed and emergency services UK, US Navy and
NASA, and Republic of Singapore Air Force. Empty spaces are either unspecified or waivers
determined on a case-by-case basis. *LASIK waiverable only as part of LASIK in Designated
Aviators Study. Minimum postoperative period assumed no complications and is generally
lower for surface treatment.

Recent refinements to refractive techniques include advanced surface ablation and

sub-Bowman’s keratomileusis. Comparing the two, Schallhorn et al found no
8
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

difference in visual acuity and photopic contrast sensitivity at one year.[23]Haloes,

glare disability and loss of contrast sensitivity may affect vision, particularly in the
early postoperative period.[61, 62]Recent evidence suggests that wavefront-guided
(aberrometry based) laser retreatment is effective in treating persistent night vision
symptoms, principally by reducing spherical aberration.[63]Wavefront-guided primary
laser treatments produce fewer higher order aberrations than conventional
techniques, with improved night vision and higher levels of patient satisfaction.[64]
The use of NVGs, so essential to the military, has prompted a number of studies to
ascertain the visual performance in NVGs after refractive surgery. High-contrast
visual acuity through NVGs was found to be equal or better three months after
PRK.[65]Night firing range performance, with and without NVGs, was demonstrated
to improve following both PRK and LASIK.[66]Another study compared one group of
U.S. Army helicopter pilots who had undergone LASIK to another who had
PRK.[41]LASIK patients had an advantage at one week, in terms of overall visual
performance, but this was no longer present at 1 or 6 months postoperatively. Post-
surgical flight performance was assessed in a Black Hawk simulator under night and
NVG flight conditions. Overall, flight performance was stable or improved.
For patients in the presbyopic age group, monovision is an increasingly popular
option.[67]Monovision relies on binocular blur suppression to provide an enhanced
range of focus with emmetropia in one eye and low myopia in the other. Reduced
spectacle dependence is achieved at the price of reduced stereopsis and reduced
suppression of blur in high-contrast mesopic conditions (for example, driving at
night).[68]The optimal monovisual correction, in one study using contact lenses in
emmetropic presbyopes, was determined to be 1.5D.[69]Monovision correction is
currently disallowed by Joint Aviation Requirements (Class 1), but the arguments
against monovision for pilots are poorly defined. In the event of loss of vision in the
distance-corrected eye, a commercial or private pilot may still be able to land a plane
with myopia between 1 and 1.5D using cockpit instruments. Conversely, the inability
to read cockpit instruments clearly may impair flying ability in presbyopic
emmetropes who lose their reading correction whilst flying.
Compromises in the quality of vision of associated with multifocal lens implants and
their impact on flying ability have also not yet been fully evaluated. Problems with
haloes are more common than with monofocal implants. Again, however, the
advantages of an improved range of focus may be useful functionally, and the impact
of visual side effects on flying ability may be determined by interindividual differences
in neural adaptation.[70]

Conclusions
Military and other organizations around the world are recognizing the value of
refractive surgery in recruiting, suitably employing and thus retaining personnel.
Often, individuals with relatively poor eyesight need no longer be excluded from their
dream jobs. Advice given in practice by the independent clinician should reflect the
changing trends. In all cases, the official standards should be consulted. A regularly
updated website could provide all the relevant information. The principle of
understanding the work environment, engendered by Bernardino Ramazzini in 1700,
9
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

remains as valid today,[71]and research should continue to challenge and refine

occupational visual standards.
1
The definitive source of occupational vision standards for the Services is Joint
Service Publication 346 for general guidance and the individual service manning
authority documents which have more detail by trade.

Acknowledgements: Ms. Chetna Lakhanpal, Lt Col Andrew Jacks RAMC, Wg Cdr Malcolm
Woodcock RAF, Cdr Elizabeth Hofmeister USN, Lt Col Gerard Nah RSAF, Lt Col Mark
Adams RAMC, Lt Col Fiona Foulkes RAMC, Capt Steven Schallhorn USN (retired).

"The Corresponding Author has the right to grant on behalf of all authors and does grant on
behalf of all authors, an exclusive licence (or non-exclusive for government employees) on a
worldwide basis to the BMJ Publishing Group Ltd and its Licensees to permit this article to
be published in British Journal of Ophthalmology editions and any other BMJPGL products
to exploit all subsidiary rights, as set out in our licence
http://bjo.bmjjournals.com/ifora/licence.pdf "

Competing Interest: None declared.

10
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

Reference List

1 Good GW, Weaver JL, and Augsburger AR. Determination and application of vision
standards in industry. Am J Ind Med. 1996;30:633-640.

2 Charman WN. Visual standards for driving. Ophthalmic Physiol Opt. 1985;5:211-220.

3 Oliver PO. Statutory vision standards for the Merchant Navy. J Soc Occup Med.
1978;28:64-66.

4 Easterbrook M, Brown JJ, Casson EJ et al. Vision standards in the Royal Canadian
Mounted Police: are they reasonable and fair? Can J Ophthalmol. 1997;32:153-157.

5 Buzzelli AR, Trowell-Harris I, and Protsko R. The measurement of visual efficiency

standards for pilots in the United States Air Force. Mil Med. 1989;154:345-347.

6 Kotecha A, Spratt A, and Viswanathan A. Visual function and fitness to drive. Br Med
Bull. 2008;87:163-174.

7 Vingrys AJ, Cole BL. Are colour vision standards justified for the transport industry?
Ophthalmic Physiol Opt. 1988;8:257-274.

8 Cole BL. The handicap of abnormal colour vision. Clin Exp Optom. 2004;87:258-275.

9 Grimson JM, Schallhorn SC, and Kaupp SE. Contrast sensitivity: establishing
normative data for use in screening prospective naval pilots. Aviat Space Environ Med.
2002;73:28-35.

10 Anon. The War Office and the Ophthalmological Society. Br J Ophthalmol. 1918;2:35-
40.

11 Vingrys AJ, Cole BL. Origins of colour vision standards within the transport industry.
Ophthalmic Physiol Opt. 1986;6:369-375.

12 Hunt DM, Dulai KS, Bowmaker JK et al. The chemistry of John Dalton's color
blindness. Science. 1995;267:984-988.

13 Berry GA. A DIFFICULTY IN ACCEPTING THE YOUNG-HELMHOLTZ THEORY. Br J

Ophthalmol. 1920;4:537-546.

14 Dock W. THE LURE OF MEDICAL HISTORY: YOUNG AND HELMHOLTZ: The

Master Minds of Medicine. Cal West Med. 1928;29:182-184.
11
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

15 Dartnall HJ, Bowmaker JK, and Mollon JD. Human visual pigments:
microspectrophotometric results from the eyes of seven persons. Proc R Soc Lond B
Biol Sci. 1983;220:115-130.

16 Frey FG. [A railway accident a hundred years ago as reason for systematic testing of
colour vision (author's transl)]. Klin Monatsbl Augenheilkd. 1975;167:125-127.

17 TOPLEY H. Sight testing for the merchant navy. Br J Physiol Opt. 1959;16:36-47.

18 Linksz A. The development of visual standards: Snellen, Jaeger, and Giraud-Teulon.

Bull N Y Acad Med. 1975;51:277-285.

19 Blodi FC. The Tenth Frederick H. Verhoeff lecture. What else did 1864 contribute to
ophthalmology? Trans Am Ophthalmol Soc. 1989;87:213-300.

20 Anon. The visual requirements of military aviators. Br J Ophthalmol. 1917;1:498-499.

21 Sheedy JE. Fire fighter vision standards. J Am Optom Assoc. 1984;55:365-374.

22 Sheedy JE, Keller JT, Pitts D et al. Recommended vision standards for police officers.
J Am Optom Assoc. 1983;54:925-928.

23 Stanley PF, Tanzer DJ, and Schallhorn SC. Laser refractive surgery in the United
States Navy. Curr Opin Ophthalmol. 2008;19:321-324.

24 Ball K, Owsley C. The useful field of view test: a new technique for evaluating age-
related declines in visual function. J Am Optom Assoc. 1993;64:71-79.

25 Chisholm CM, Evans AD, Harlow JA et al. New test to assess pilot's vision following
refractive surgery. Aviat Space Environ Med. 2003;74:551-559.

26 Mertens HW, Milburn NJ, and Collins WE. Practical color vision tests for air traffic
control applicants: en route center and terminal facilities. Aviat Space Environ Med.
2000;71:1210-1217.

27 Good GW, Maisel SC, and Kriska SD. Setting an uncorrected visual acuity standard
for police officer applicants. J Appl Psychol. 1998;83:817-824.

28 Schwartz SH, Swanson WH. Empiric determination of corrected visual acuity

standards for train crews. Optom Vis Sci. 2005;82:774-778.

12
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

29 Tipton M, Reilly T, Scarpello E et al. Visual acuity standards for beach lifeguards. Br J
Ophthalmol. 2007;91:1570-1571.

30 Cole BL, Maddocks JD. Color vision testing by Farnsworth lantern and ability to
identify approach-path signal colors. Aviat Space Environ Med. 2008;79:585-590.

31 Cole BL, Lian KY, and Lakkis C. Color vision assessment: fail rates of two versions of
the Farnsworth lantern test. Aviat Space Environ Med. 2006;77:624-630.

32 Birch J. Pass rates for the Farnsworth D15 colour vision test. Ophthalmic Physiol Opt.
2008;28:259-264.

33 Cole BL, Vingrys AJ. Who fails lantern tests? Doc Ophthalmol. 1983;55:157-175.

34 Squire TJ, Rodriguez-Carmona M, Evans AD et al. Color vision tests for aviation:
comparison of the anomaloscope and three lantern types. Aviat Space Environ Med.
2005;76:421-429.

35 Birch J. Performance of colour-deficient people on the Holmes-Wright lantern (type A):

consistency of occupational colour vision standards in aviation. Ophthalmic Physiol
Opt. 2008;28:253-258.

36 Vos JJ, Padmos P, and Boogaard J. Occupational testing of near vision. Ophthalmic
Physiol Opt. 1994;14:413-418.

37 Hussain B, Saleh GM, Sivaprasad S et al. Changing from Snellen to LogMAR: debate
or delay? Clin Experiment Ophthalmol. 2006;34:6-8.

38 Ginsburg AP, Evans DW, Sekule R et al. Contrast sensitivity predicts pilots'
performance in aircraft simulators. Am J Optom Physiol Opt. 1982;59:105-109.

39 Grimson JM, Schallhorn SC, and Kaupp SE. Contrast sensitivity: establishing
normative data for use in screening prospective naval pilots. Aviat Space Environ Med.
2002;73:28-35.

40 Rabin J, Wicks J. Measuring resolution in the contrast domain: the small letter contrast
test. Optom Vis Sci. 1996;73:398-403.

41 Van de Pol C, Greig JL, Estrada A et al. Visual and flight performance recovery after
PRK or LASIK in helicopter pilots. Aviat Space Environ Med. 2007;78:547-553.

13
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

42 Ginsburg AP. Contrast sensitivity: determining the visual quality and function of
cataract, intraocular lenses and refractive surgery. Curr Opin Ophthalmol. 2006;17:19-
26.

43 Vignal R, Tanzer D, Brunstetter T et al. [Scattered light and glare sensitivity after
wavefront-guided photorefractive keratectomy (WFG-PRK) and laser in situ
keratomileusis (WFG-LASIK)]. J Fr Ophtalmol. 2008;31:489-493.

44 Applegate RA. Glenn Fry award lecture 2002: wavefront sensing, ideal corrections,
and visual performance. Optom Vis Sci. 2004;81:167-177.

45 Villa C, Gutiérrez R, Jiménez JR et al. Night vision disturbances after successful

LASIK surgery. Br J Ophthalmol. 2007;91:1031-1037.

46 Bueno JM, De Brouwere D., Ginis H et al. Purkinje imaging system to measure
anterior segment scattering in the human eye. Opt Lett. 2007;32:3447-3449.

47 Díaz-Doutón F, Benito A, Pujol J et al. Comparison of the retinal image quality with a
Hartmann-Shack wavefront sensor and a double-pass instrument. Invest Ophthalmol
Vis Sci. 2006;47:1710-1716.

48 Montés-Micó R, Charman WN. Image quality and visual performance in the peripheral
visual field following photorefractive keratectomy. J Refract Surg. 2002;18:14-22.

49 Bullimore MA, Sheedy JE, and Owen D. Diurnal visual changes in radial keratotomy:
implications for visual standards. Refractive Surgery Study Group. Optom Vis Sci.
1994;71:516-521.

50 Mader TH, Blanton CL, Gilbert BN et al. Refractive changes during 72-hour exposure
to high altitude after refractive surgery. Ophthalmology. 1996;103:1188-1195.

51 Hammond MD, Madigan WP, Jr., and Bower KS. Refractive surgery in the United
States Army, 2000-2003. Ophthalmology. 2005;112:184-190.

52 Madigan WP, Bower KS. Refractive surgery and protective eyewear in the military.
Ophthalmology. 2004;111:855-856.

53 Bower KS, Donnelly SJ, Stutzman RD et al. Acanthamoeba keratitis in a U.S. Army
soldier after unauthorized use of contact lenses in the combat theater. Mil Med.
2006;171:833-837.

14
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

54 Schallhorn SC, Blanton CL, Kaupp SE et al. Preliminary results of photorefractive

keratectomy in active-duty United States Navy personnel. Ophthalmology. 1996;103:5-
22.

55 Schallhorn S. Photorefractive surgery in the Navy. Navy Med. 1994;85:27-32.

56 Tanzer DJ, Schallhorn SC, and Brown MC. Ejection from an aircraft following
photorefractive keratectomy: a case report. Aviat Space Environ Med. 2000;71:1057-
1059.

57 Goodman RL, Johnson DA, Dillon H et al. Laser in situ keratomileusis flap stability
during simulated aircraft ejection in a rabbit model. Cornea. 2003;22:142-145.

58 Laurent JM, Schallhorn SC, Spigelmire JR et al. Stability of the laser in situ
keratomileusis corneal flap in rabbit eyes. J Cataract Refract Surg. 2006;32:1046-
1051.

59 Kirwan C, O'Keefe M. Corneal hysteresis using the Reichert ocular response analyser:
findings pre- and post-LASIK and LASEK. Acta Ophthalmol. 2008;86:215-218.

60 Levy Y, Zadok D, and Barenboim E. Laser in situ keratomileusis in a combat jet

aircraft pilot. J Cataract Refract Surg. 2003;29:1239-1241.

61 Klyce SD. Night vision disturbances after refractive surgery: haloes are not just for
angels. Br J Ophthalmol. 2007;91:992-993.

62 Fan-Paul NI, Li J, Miller JS et al. Night vision disturbances after corneal refractive
surgery. Surv Ophthalmol. 2002;47:533-546.

63 Alió JL, Pinero D, and Muftuoglu O. Corneal wavefront-guided retreatments for

significant night vision symptoms after myopic laser refractive surgery. Am J
Ophthalmol. 2008;145:65-74.

64 Schallhorn SC, Farjo AA, Huang D et al. Wavefront-guided LASIK for the correction of
primary myopia and astigmatism a report by the American Academy of Ophthalmology.
Ophthalmology. 2008;115:1249-1261.

65 Subramanian PS, O'Kane B, Stefanik R et al. Visual performance with night vision
goggles after photorefractive keratectomy for myopia. Ophthalmology. 2003;110:525-
530.

15
 Downloaded from bjo.bmj.com on October 18, 2010 - Published by group.bmj.com

66 Bower KS, Burka JM, Subramanian PS et al. Night firing range performance following
photorefractive keratectomy and laser in situ keratomileusis. Mil Med. 2006;171:468-
471.

67 Braun EH, Lee J, and Steinert RF. Monovision in LASIK. Ophthalmology.

2008;115:1196-1202.

68 Schor C, Landsman L, and Erickson P. Ocular dominance and the interocular

suppression of blur in monovision. Am J Optom Physiol Opt. 1987;64:723-730.

69 Durrie DS. The effect of different monovision contact lens powers on the visual
function of emmetropic presbyopic patients (an American Ophthalmological Society
thesis). Trans Am Ophthalmol Soc. 2006;104:366-401.

70 Montés-Micó R, Alió JL. Distance and near contrast sensitivity function after multifocal
intraocular lens implantation. J Cataract Refract Surg. 2003;29:703-711.

71 Johnston RV and Pitts J. Vision and eye disorders. In: Palmer KCRBI Fitness for Work:
the Medical Aspects. Oxford: Oxford University Press 2007:189-210.

16