Benefits of regular comprehensive eye exams reinforced in analysis of military exams

A policy of periodic comprehensive eye examinations for all service members (SMs), as opposed to basic visual acuity screenings, would benefit military readiness and outweigh any cost concerns, a new report finds. 

Published in November by the RAND National Security Research Division, Cost-Benefit Analysis of Comprehensive Military Eye Examination Policies, finds that baseline and regular comprehensive eye exams for all SMs are cost-effective, relative to current basic acuity screenings, with more frequent exams providing greater benefit than less frequent ones. The 72-page analysis demonstrates that comprehensive eye exams’ benefits exceed costs through the early diagnosis and timely intervention of ocular and visual dysfunctions (OVDs) that otherwise would go undiagnosed, affecting productivity or actively harming military strength. 

“Despite the increase in total costs of administering periodic comprehensive eye exams to all SMs, our [cost-benefit analysis] reveals that the reduction in visual readiness costs from early diagnosis outweighed these additional expenses, making the implementation of periodic comprehensive eye exam policy among current SMs cost beneficial,” the report concludes. 

“We recommend the introduction of periodic comprehensive eye exams, especially for SMs for whom the negative impacts of undiagnosed OVDs on contributions to the force are high,” the report continues. 

Current military policy calls for a visual acuity screening as part of accession and SMs’ annual health assessment, where failure prompts further determination of refractive status. But basic acuity screenings are only intended to detect refractive errors. 

Referring to the AOA’s Comprehensive Adult Eye and Vision Examination evidence-based clinical practice guideline, the RAND report emphasizes that comprehensive eye exams go beyond simple detection of refractive error and are designed to diagnose a wide range of OVDs that may go undetected by acuity screenings, including: 

• Traumatic brain injury (TBI)-related OVDs 
• Corneal dystrophies 
• Retinal dystrophies 
• Dry eye 
• Keratoconus 
• Glaucoma 

The RAND report notes that current vision screening policies fail to detect many SMs with OVDs that may render them not visually ready, and further, that nearly half of SMs have never received a comprehensive eye exam. 

Such is the case, RAND created a model to demonstrate the cost-benefit of comprehensive eye exams at SMs’ accession, three, five and eight years—frequencies selected based on the timing of cognitive screenings for occupational specialties.  

For the scenario based on enlisted pay, the three-year exam model found net monetary benefit (NMB) per 1,000 SMs of: 

• Over $200 per SM given severe impact of OVDs on readiness. 
• $125 per SM given moderate impact of OVDs on readiness. 
• $75 per SM given the least impact of OVDs on readiness. 

In the case of officer pay, the three-year exam model found even higher net benefits. Additionally, the model demonstrated that more frequent—every three years—comprehensive eye exams were more cost-effective than less frequent exams. 

"Military vision readiness is essential to ensure that service members have the visual fitness required to perform their mission successfully, maintain deployability and serve without duty limitations,” notes Capt. Todd Lauby, O.D., chief of the Defense Health Agency’s Vision Center of Excellence (DHA VCE) and a subject matter expert for the report. 

“Optimizing vision is critical to the survivability of the warfighter and the lethality they project,” he adds. Alternatively, visual dysfunctions may significantly affect readiness, performance and overall well-being considering military personnel face disproportionately higher exposure to risk factors that cause visual dysfunctions, including after TBI. 

Dr. Lauby notes that a gap analysis conducted by the DHA VCE found that many service members would go their entire military career—boot camp to retirement—without seeing an eye doctor due to the current policy. In comparison, service members are required to see a dentist each year. Lacking that regular eye health and vision care could lead to issue, such as: 

• A lack of early diagnosis of vision-related disorders that cannot be diagnosed with screening alone; therefore, lack of preventive care.
• A lack of a baseline comprehensive vision exam that prohibits understanding if the visual disorder was previously present and has gotten worse or if it is a newly diagnosed eye condition.
• The inability to perform quality research aimed at improving clinical outcomes for service members due to a lack of baseline information on the visual system. 

"The RAND study found that service members who have an undiagnosed visual dysfunction, on average, are less productive, and this diminishes their visual readiness value they add to the force,” Dr. Lauby says. 

Echoing Dr. Lauby’s concern, Lindsay Wright, O.D., executive director of the Armed Forces and Federal Optometric Services, says it’s unfortunate that service members may go an entire career without receiving a comprehensive eye exam. Further, simple vision screenings at Military Entrance Processing Stations and during periodic health assessments are not sufficient to ensure peak visual performance and quality eye health. 

“The RAND report objectively and clearly shows that baseline and routine comprehensive eye exams by a doctor of optometry provide cost savings to the Department of Defense,” Dr. Wright says. “We would also argue that a policy requiring periodic comprehensive eye examinations is the morally right thing to do by our military members.” 

AOA’s Evidence-based Clinical Practice Guidelines 

Comprehensive Adult Eye and Vision Examination, Second Edition, the AOA evidence-based clinical practice guideline referenced by the RAND report, is a valuable resource that enables doctors of optometry to: 

• Recommend appropriate timetables for eye and vision examinations for adults. 
• Select appropriate examination procedures for adults. 
• Examine eye health, vision status and ocular manifestations of system disease in adults. 
• Minimize/avoid the effects of eye and vision problems in adults through prevention, early detection and diagnosis, and patient management through education and counseling. 
• Inform/educate individuals and other health care practitioners on the importance of good vision and the need for, and frequency of, comprehensive adult eye and vision exams. 

Developed over the course of 16 months by the AOA Evidence-Based Optometry Committee, the adult guideline recommends comprehensive eye examinations annually for people 18 to 39 years of age to optimize visual function, evaluate eye changes and provide for the earlier detection of sight-threatening eye and systemic health conditions. The consensus statement will likely facilitate earlier diagnosis of eye and vision problems and prevention of vision loss, the committee notes. 

Learn more about the AOA’s evidence-based optometry process.