The Defense Health Agency’s Vision Center of Excellence has issued initial recommendations for eye evaluation and treatment of service members after a suspected laser exposure.

DHA approved the Practice Recommendation for “Ocular Evaluation and Disposition after Suspected Laser Exposure” in August 2022.

Laser exposures can damage the eyes, potentially leading to sudden loss of sight. Laser injuries may become more prevalent as technological advances dictate the way future conflicts are conducted.

VCE recommendations regarding laser eye exposures and injuries are primarily for Military Health System first responders, emergency care, and primary care providers.

A review of the Defense and Veterans Eye Injury and Vision Registry, or DVEIVR, from 2006 to 2018 found a small number of service members with laser exposure documentation in their medical records.

The goal is to improve treatment through consistent documentation in the electronic medical record of exposures, injuries, and severity as soon as possible post-injury, with appropriate follow-up intervals.

The practice recommendation includes an initial provider evaluation form and a laser incident questionnaire, including medical coding for a suspected injury.

The questionnaire, taken from a 2012 Air Force Research Laboratory guidebook, includes details the service member may recall such as:

• A description of the light exposure, including duration, color, brightness, uniformity, and whether the laser exposure was direct or reflected
• The date, location, and circumstances, such as if the exposure was airborne or surface-based, or if the patient was wearing eye protective equipment
• The effects, such as length of eye exposure, pain, lingering visual effects, or after-images

Commercial and recreational pilots routinely report lasers being directed at their cockpits. Some military aviators also have reported these instances. The Federal Aviation Administration said aviators are “particularly vulnerable to laser illuminations when conducting low-level flight operations at night. The irresponsible or malicious use of laser devices can threaten the lives of flight crews and passengers.”

Treatment Options

Based on the DVEIVR review, “a few service members were found to have permanent damage compromising visual function as a result of [laser] exposure,” the practice recommendation states, however, “permanent injury to the eyes and visual system is rare.”

While the main effect of most low-level laser exposures is a temporary flash blindness, which recovers quickly without treatment, some individuals experience a lasting visual injury. In such cases, the main effect of laser exposure is retina inflammation due to “absorption of energy by the retinal pigment epithelium,” said Dr. Felix Barker, VCE’s associate director for research. An academic optometrist specializing in lasers for most of his career, Barker holds a dual post at VCE and the Department of Veterans Affairs.

The primary treatment for laser exposure in which the service member’s vision is affected for more than two-to-four hours are oral nonsteroidal anti-inflammatory drugs, such as ibuprofen or indomethacin, although oral steroids are also sometimes used in consultation with an ophthalmologist.

The practice recommendation lists several telehealth options, so providers can use the expertise of ophthalmologists or optometrists when deciding how to treat an injured service member.

Taking these drugs after laser exposure “will minimize the inflammation as much as possible, but you will still have disrupted vision while the inflammation resolves and your retina heals,” Barker said. “Usually, if you can minimize the inflammation, your vision will go back to normal or near normal.”

A service member can return to full duty without restrictions if his or her vision returns to baseline within two-to-four hours, as recorded via an Amsler grid test. The Amsler horizontal and vertical grid lines detect retinal injury when a patient sees curvy lines or areas where they cannot see portions of the grid.

VCE also advises that if the deployed service member has a persistent vision complaint, they should be evacuated to an eye care center and undergo OCT (optical coherence tomography) imaging. OCT takes images of microscopic slices of the retina in depth to better diagnose and follow such eye injuries.

The test can take place at one of the four Ocular Trauma Centers recently established in the U.S. by the VCE or many other hospitals or clinics that have an OCT device.

Laser Exposures May Increase in the Future

Vision injuries could become more common if adversaries were to begin using high energy lasers to “sweep” the battlefield in an attempt to incapacitate large numbers of troops, according to Barker. The impact could seriously compromise the ability to execute mission-essential functions.

What happens is “flash blindness, the after-image effect, or bleaching of the vision effect,” where military personnel would have instantaneous loss of vision that could lead to missteps, such as tripping, accidental arms fire, the inability to respond to fire or even increased “friendly fire,” Barker said.

“Because of such laser weaponry’s potentially offensive nature, it’s often in the invisible range and can be quite powerful, causing eye injury without service members being aware of the threat,” he explained.

That scenario would violate the Geneva Convention, which are treaties that establish international legal standards for humanitarian treatment in war, but could happen in a future near-peer conflict, he suggested.

Laser weaponry that is visible, particularly what are called “dazzlers,” are often used in tactical situations where there is a potential escalation of force.

Dazzlers have been described as creating an effect much like having direct sunlight on car windshields, which can get the attention of the driver while only temporarily limiting vision.

“Pointing a dazzler laser at an oncoming vehicle that doesn’t look like it wants to stop or might not stop may alert the driver to the fact that you’ve got eyes on them” and avoid firing on the vehicle, Barker said.

“They do have enough energy to damage the eye, but usually they don’t because of the aversion reaction” when the person being dazzled is startled or averts their eyes, he explained.

The VCE practice recommendations are the first version and will likely evolve as more data from frontline laser exposures become available from MHS GENESIS and DVEIVR. The DHA practice recommendations are separate from the jointly developed VA and Department of Defense clinical practice guidelines, published by the DHA Joint Trauma System (JTS), that are based on rigorous literature review and synthesis, the DHA PR document states.