Detainee Optometry at Camp Cropper, Iraq,

Transcription

1 MILITARY MEDICINE, 177, 6:757, 2012 Detainee Optometry at Camp Cropper, Iraq, LTC Thomas M. White, MS USA*; LTC James B. Elledge, MS USA ABSTRACT This article details the first in-depth analysis of an Optometry Service working with a large Middle Eastern detainee population composed entirely of Iraqi males. The mission of the Camp Cropper Optometry Service was to provide eye care services to the detainee population consistent with the standards of optometric care that would be provided to any U.S. military member in the same geographic area. This included providing detainees with eyeglasses, therapeutic treatment of eye disease, and referral for treatment of medical conditions and surgical care, if it was needed and available at the U.S. military facilities in the Iraq Theater. Diagnoses, services provided, and medications given to the detainees are listed in detail and demonstrate the complexity of pathology encountered in this population. Cropper Hospital and the Camp Cropper Theater Internment Facility (TIF) were established in 2006 after the closure of Abu Ghraib prison. Although operational and under U.S. control, a total of four U.S. Army optometrists assigned to four different Medical Task Forces (21st CSH, 31st CSH, 115th CSH, and 14th CSH) provided optometric care to the detainees held at the Camp Cropper TIF. On June 16, 2010, the 14th CSH (Combat Support Hospital) completed a Transfer of Authority to the 322nd CSH, ending full-time onsite optometry services at Camp Cropper, Iraq. This article documents the demographics of the Camp Cropper detainees and the optometric services provided by the 14th CSH Optometry Service from July 23, 2009 to May 11, This article is also the first in-depth analysis of an Optometry Service working with a Middle Eastern detainee population composed entirely of Iraqi males. Camp Cropper was established in April 2003 and named for SSG Kenneth Cropper, a Maryland National Guardsman who died in March 2002 while supporting security operations at the Pentagon. 1 Its original purpose was to be a small camp that would permanently house high value detainees and temporarily hold other detainees for 72 hours as they were transferred to and from other detention facilities. In 2005, the U.S. Army enlarged Camp Cropper while curtailing detainee operations at Abu Ghraib prison. During the summer of 2006, the majority of the detainees from Abu Ghraib were transferred to Camp Cropper along with the 21st CSH, which provided all of their health care services. At that time, the Camp Cropper TIF had a detainee population of about 3,500 detainees divided into five 4-section compounds. The 21st CSH opened the Camp Cropper Hospital on July 30, Its mission was to provide the highest quality care to detainees and Coalition Forces equivalent to a Level III hospital facility. 2 Over time, the CSHs staffing the hospital changed, but their mission remained the same. The detainees *Optometry Service, Reynolds Army Community Hospital, 4301 Wilson Street, Fort Sill, OK Department of Optometry, Madigan Army Medical Center, Building 9040A, Fitzsimmons Avenue, Tacoma, WA at Camp Cropper received a full range of services to include inpatient care, emergency medicine, general and orthopedic surgery, nutrition care, laboratory services, radiology, pharmacy, optometry, dentistry, physical therapy, and occupational therapy services. The mission of the Optometry Service was to provide eye care services to the detainee population consistent with the standards of optometric care that would be given to any U.S. military member in the same geographic area. This included providing detainees with eyeglasses, eye medications, and referral for treatment of medical conditions and surgical care if it was needed and available at U.S. military facilities in the Iraq Theater. The optometry footprint in the hospital was never large, with only two rooms dedicated to the service. The clinic was well equipped for primary care optometry with chair and stand, phoroptor, slit lamp and tonometer, binocular indirect ophthalmoscope, multiple diagnostic examination lenses, gonioscopy lenses, and handheld instruments. A digital slit lamp camera recorded anterior segment photographs and indirect lens photographs of the posterior pole that were ed to specialists for consultation and included in the medical record. The screening room was equipped with a noncontact tonometer, Optec Vision screener, auto-refractor, frame repair and adjusting tools, and spectacle frames available for size measuring and ordering. Distance visual acuities were measured by the use of an Arabic number wall chart or tumbling E chart for detainees who were either illiterate or unable to understand Arabic numbers. Near visual acuities were measured using sentences of varying type sizes printed from an Arabic computer program. Detainees made optometry appointments by self-referral on a Form 510 submitted through their detention compound chief (a detainee selected to manage the affairs of the other detainees) to the Detainee Medical Clinic (DMC). The DMC would screen each request to determine the service requested and then deliver the requests to that service each afternoon. Eye care requests were researched by the optometry staff for validity based on previous examinations contained in the MILITARY MEDICINE, Vol. 177, June

2 Electronic Medical Record (EMR) and in a detainee patient data base. The detainee would then be scheduled for an appointment or denied the service if the review of the record indicated that the detainee s request had been previously addressed. Based on detainee medical examinations, hospital medical staff could refer detainees for eye care services at any time by utilizing a DA Form 513. On the day of their appointment, detainees were brought from the TIF to the hospital in the accompaniment of U.S. military guards. These guards were assigned to monitor and control detainee actions in the waiting area and during transit to and from the clinics. The guards were also present in the examination areas to protect the medical staff and other detainees from harm. For the majority of the detainees, the eye examination(s) they received at Camp Cropper were their first ever visual and ocular health examination. Detainees who wore glasses or needed glasses were impressed with the examination equipment as the norm for most optical shops in Iraq was the use of an auto-refractor or loose trial lenses to determine a prescription and forego any assessment of ocular health. Skilled interpreters were always in the clinic to assist the staff by gathering medical information from the detainees, instructing them what to do during the examination, and explaining the doctor s recommendations and/or treatment and therapy. The choices for detainees who needed glasses were limited to the standard military issue MS9 brown plastic frame in a single vision or bifocal correction or a plastic half-eye single vision frame for far or near corrections. These frames and lenses were ordered from a military fabrication laboratory (FABLAB) in theater or if necessary, from a military FABLAB in the United States. The half-eye frame was the more popular frame among the detainees because it was smaller and was perceived to be more stylish. The full-frame MS9 was looked upon by the detainees as something for an older person, regardless of the individual s age. For the majority of detainee patients, there were no significant adverse clinical findings and their problems were taken care of with glasses or eye medications. For those with more serious pathology, the situation was quite different than stateside eye clinics because of the expeditionary nature of eye care in a military deployment. Deployed military eye clinics have little need for specialized instruments to provide advanced diagnostic and disease management capabilities because at-risk service members can be evacuated for definitive diagnosis and treatment. Thus, the diagnosis and management of conditions ranging from keratoconus to glaucoma were made on the doctor s objective evaluation of the patient and with the available on-hand instruments. Detainees requiring services beyond the scope of optometry were transferred for evaluation and treatment by ophthalmologists assigned to the Air Force Theater Hospital (AFTH) at Joint Base Balad (JBB), the only location in Iraq where U.S. military ophthalmology services were available. Patients were referred to ophthalmology for two reasons: (1) for surgical evaluation and procedures, both acute and chronic and (2) for the management of severe ocular and periorbital infections and inflammations. Because of the risks involved to detainees and guards and the capabilities of the Iraqi medical system, detainees were rarely transferred to Iraqi civilian or government hospitals for care. However, a compassionate release program existed where qualified detainees with conditions not treatable in U.S. military facilities could be released to obtain care in the Iraqi medical system. The AFTH Ophthalmology Service offered a broad array of capabilities for a deployed surgical service. Their exam room contained the basic equipment present in a typical eye lane (electronic eye chart, slit lamp, phoropter) in addition to specialized equipment such as A and B scan ultrasound capable of measuring for intraocular lenses, a YAG laser for laser capsulotomies and peripheral iridotomies, and a portable argon laser unit for doing indirect panretinal photocoagulation and laser retinopexy. The operating room contained many of the standard surgical eye instruments, including an operating microscope and a phacoemulsification unit. Surgeries that could be performed at JBB included cataract surgery with lens implantation (in limited powers), corneal/scleral laceration repairs, lid laceration repairs, scar revisions, enucleations, dacryocystorhinostomy, chalazion excisions, and pterygium excisions. Given that the primary goal of medical treatment in theater was to not provide definitive medical care, the subspecialty ophthalmological services that could be provided were limited. Thus, there was no capability to treat advanced glaucoma, retinal detachments, or provide extensive panretinal photocoagulation treatments for diabetic retinopathy. Since Camp Cropper was not located near JBB, detainee transfers for ophthalmologic care were not an easy matter for the detainee or the military guards and medical staff. Detainees requiring transfer were transported by helicopter in a secure manner (handcuffed, blindfolded, mummy-wrapped with a blanket, and strapped to a litter), accompanied by a medical escort and guarded by military police during the entire time the detainee was hospitalized at JBB. PATIENT NUMBERS The data reported in this article is based on optometric examination findings recorded in the AHLTA-T Iraq Theater EMR between July 23, 2009 and May 11, During this time period, 1,728 separate detainees were examined encompassing 2,115 encounters. Between these dates, the patient population at Camp Cropper remained constant with approximately 3,000 detainees interned within the facility. Of course, these were not the same 3,000 detainees across the entire time period as the population was quite dynamic. Detainees all entered and exited the detention system through Camp Cropper and were transferred frequently between the different internment facilities in Iraq except for those with significant medical problems that were kept at Camp Cropper to be near the Level III hospital services. This constantly moving population made 758 MILITARY MEDICINE, Vol. 177, June 2012

3 continuity of care and the delivery of glasses to detainees a challenge. The detainees examined were all males between the ages of 18 to 75 years, as listed in AHLTA-T. The average age for this population was and the median age was 33 years. These ages are a rough approximation because many of the detainees did not know their true age or birth date as the documentation and recording of birth statistics were not done in many of the rural areas of Iraq and some detainees did not want to make their vital statistics known in order to conceal their identity. The Optometry Service kept detailed spreadsheets on four categories of patients that were constantly monitored for follow-up and annual appointments: diabetics, glaucoma patients, blind patients, and prosthetic eye patients. Diabetics were managed in a co-ordinated fashion with nurse case managers and physicians at the DMC. The number of diabetic patients tracked ran from a high of 132 to a low of 91 with the majority being type 2. At the termination of services, 79 type 2 and 12 type1 were retained under the Government of Iraq authority. As of May 2010, 98.9% had received annual dilated eye exams with 8 being monitored for moderate or severe preproliferative changes and/or diabetic macular edema. These detainees required close monitoring of blood sugar levels with the diabetic team and fundus exams every 3 to 6 months. Detainees with glaucoma were constant in number with 24 to 28 individuals being monitored at all times. As of May 2010, there were 14 detainees diagnosed with POAG, 3 with pseudoexfoliation glaucoma, 3 with secondary glaucoma, and 4 glaucoma suspects based on the appearance of their optic nerves. 60% of the glaucoma patients were managed with single medications. Only 2 detainees had pressures outside of acceptable norms (>30 mm Hg); 1 was due to neovascular glaucoma in one eye and the other was due to pseudoexfoliation glaucoma in one eye. There were 6 blind detainees examined (20/400 or worse vision in both eyes by WHO standards); one with bilateral cataracts who refused surgery, one with Best s disease, one with bilateral retinal detachments and cataracts, one with retinitis pigmentosa, one with central choroidal dystrophy, and one with pellucid marginal dystrophy and pathological myopia. Of these detainees, those who were functionally blind and required assistance for mobility in the internment facility were submitted for compassionate releases. The number of detainees with prosthetic eyes ran from a high of 15 to a low of 7 at the end of services. Their management involved monitoring their ocular and orbital health with either the personal custom prostheses they wore before internment or fitting/refitting with an Ocular Concepts Natural-Iris Conformer. This product, available in six colors and three sizes, had an iris imaged on a white conformer for a life-like appearance. Of the final 7 prosthetic patients, only 2 had an enucleation with the placement of an orbital implant. These 2 patients had a fairly normal appearance with the Natural-Iris Conformer, but the 5 patients without the orbital implant had considerable orbital collapse with the Natural-Iris Conformer in place. Over the year, only 1 patient required surgical removal of an eye because of trauma during incarceration; all others were due to blast trauma before incarceration. Since there were no military medical facilities available to custom fit and manufacture prosthetic eyes, the Natural-Iris Conformer was the best alternative as it gave a pleasing cosmetic result, was inexpensive, developed goodwill, and offered protection to the orbit and remaining ocular tissue until the detainee was released and could obtain a custom prosthesis. PROCEDURES AND NUMBERS As seen in Table I, which lists the Top 20 CPT Codes, the Optometry Service primarily provided comprehensive eye exams and refractive care with 1,455 pairs of single vision glasses, 191 bifocal, and 1 multifocal fitted to 1,728 detainees. Given that the average age of the population was years, the high number of single vision glasses fitted was not unexpected, but to fit optical corrections on 95% of patient encounters is of interest. The reasons for the high number of glasses dispensed are several-fold. First, it was found through examination that the detainees tended to lose accommodation earlier in life than the assumed age of 40 for Western populations, a common finding in populations living in areas with high average environmental temperatures. 3 This was identified because all detainees were offered a copy of the Holy Koran upon entering Camp Cropper which was often the only reading material available while detained. Thus, uncorrected refractive errors, presbyopia, and accommodative infacility brought many detainees to the clinic seeking reading glasses. Second, some TABLE I. CPT Codes Description Code No. of Cases Determination of Refractive State ,785 New Patient Comprehensive Care ,696 Spectacle Service Monofocal Fitting ,455 Prior Patient Intermediate Care Spectacle Service Bifocal Fitting Prior Patient Intermediate Care Slit Lamp Exam with Photography Gonioscopy Service on Emergency Basis in Office Repair and Refit of Glasses New Patient Intermediate Care Excise Chalazion a Excise Lid Lesion a Eyelash Epilation Suture Removal Removal of Embedded Conjunctival FB a Removal of FB Eyelid FB Conjunctival Removal Lid Lesion Destruction a Spectacle Service Multifocal Fitting a Service by visiting ophthalmologist. MILITARY MEDICINE, Vol. 177, June

4 detainees possessed glasses before incarceration, but in the process of apprehension, detention, and transfers between facilities, they were lost, broken, stolen, or confiscated as contraband. Third, it was also found that many presbyopic patients preferred single vision reading glasses or even two pairs of glasses over the use of bifocals, which helps account for the low number of bifocals and multifocal glasses dispensed to detainees. Because of the number of patients requiring reading corrections, the clinic kept a constant stock of 15 to 20 pairs of prescription reading glasses in each power ranging from DS to DS. Because detainees were transferred and released without notice, the typical 2-week delay in ordering/receiving glasses from the FABLAB often had the detainee departing Camp Cropper without receiving any glasses. Thus, the stocking of reading glasses allowed the clinic to dispense glasses to the detainee immediately after the examination so the detainee could experience the improvement in vision through the glasses while in the clinic on the available Arabic reading material and also allowed the clinic to immediately replace lost or stolen glasses. DIAGNOSES AND PERCENTAGES The diagnoses listed in Table II are compiled from the 2,115 patient examinations at Camp Cropper and reflect only the first three diagnoses listed for each patient visit in AHLTA-T. A table showing the top 40 diagnoses is attached. The refractive diagnoses show that the predominant diagnosis was for hyperopia 864 (40.85%), followed by astigmatism 682 (32.25%), presbyopia 510 (24%), myopia 251 (11.87%) and lastly myopia greater than 5.00D 12 (0.57%). A search of the literature showed that there were no published comparable studies of incarcerated persons or of Middle Eastern populations in the same age range as this population or any TABLE II. Optometry Diagnoses ICD-9 Diagnosis Number Code % of encounters Hypermetropia Astigmatism Presbyopia Chronic Allergic Conjunctivitis Myopia Disorder of Accommodation Diabetes Mellitus Dry Eye Syndrome Pterygium Blepharitis Amblyopia Pinguecula Open Angle Glaucoma Nuclear Cataracts Pseudophakia 33 V Macular Degeneration Surgical After-Care of Sense Organs 29 V Preglaucoma Combined Forms of Cataract Chalazion Trachoma Prosthetic Eye Visits Malingering 18 V Iritis Combined Mechanism Glaucoma Corneal Scar Eye Trauma Surgical Aphakia Keratoconus Retinal Detachment Capsular Cataract Internal Hordeolum Pathological Myopia Optic Atrophy Traumatic Cataract Vernal Conjunctivitis Cortical Cataract Pseudoexfoliation Glaucoma Vitreous Disorders Congenital Cataract MILITARY MEDICINE, Vol. 177, June 2012

5 that involved refractive error, ocular diagnoses, and prescribed medications. Osuobeni s study of refractive error prevalence in Saudi Arabians was based on 152 subjects, aged from 16 to 50 years, which showed prevalence rates of 5.9% for hyperopia, 47.4% for emmetropia, and 46.7% for myopia. 4 Mallen s study of refractive error in Jordanians was based on 1,093 subjects, aged from 17 to 40, which showed prevalence rates of 53.71% for myopia, 5.67% for hyperopia, and 40.62% for emmetropia. 5 It is of interest to note the differences in the amounts of myopia found in the Osuobeni (46.7%) and Mallen (53.7%) subjects and the detainees (11.67%). The Osuobeni population of staff and students from the College of Applied Medical Sciences at King Saud University in Riyadh, Saudi Arabia was literate and urban. 4 The Mallen population was also literate and urban with subjects from places of work and higher education establishments in the cities of Amman and Irbid, Jordan. 5 Based not on detainee records, for which there was no access, but on informal patient health histories, the detainee population in our study was different as it wasn t weighted by any one demographic group but came from a broad population that ranged from an illiterate rural population to college professors and physicians. Thus, our population follows the association between myopia and higher education as noted in Shah s study of Bangladeshi adults and in Thorn s study of indigenous Brazilian peoples, where older illiterate adults were remarkably free of myopia (2.0%) but younger slightly educated Brazilians had a higher prevalence of myopia (9.7%). 6,7 One diagnosis that was frequently seen was a disorder of accommodation or an accommodative infacility/insufficiency 221 (10.45%), where the patient was usually between the ages of 18 to 25 and unable to sustain comfortable accommodation for extended reading tasks and based on subjective examination was prescribed low power (+0.50 to +1.00D) reading glasses. Looking beyond refractive error, this population exhibited considerable extraocular pathology such as allergic conjunctivitis 267 (12.62%), dry eye syndrome 138 (6.52%), pterygium 79 (3.74%), blepharitis 50 (2.36%), pinguecula 41 (1.94%), chalazia 20 (0.95%) and inactive trachoma 19 (0.90%). Significant intraocular pathology was also present, with diagnoses for open angle glaucoma 39 (1.84%), pseudophakia 33 (1.56%), preglaucoma 23 (1.09%), combined mechanism glaucoma 17 (0.80%), pseudoexfoliation glaucoma 10 (0.47%), nuclear cataracts 38 (1.80%), combined forms of cataract 20 (0.95%), capsular cataract 13 (0.61%), cortical cataract 10 (0.47%), and congenital cataract 8 (0.38%) being the most prevalent. Ocular trauma and its effects were a common diagnosis with prosthetic eye visits 19 (0.90%), corneal scars 16 (0.76%), surgical aphakia 15 (0.71%), retinal detachment 14 (0.66%), and traumatic cataract 11 (0.52%). The majority of these conditions were the result of penetrating trauma from blast injuries and ocular injuries before incarceration. Aside from the more common ocular conditions previously mentioned, there were also patients examined with macular deterioration (30), keratoconus (15), bacterial conjunctivitis (6), HSV keratitis (5), dacryocystitis (5), proptosis from thyroid disease (3), retinitis pigmentosa (3), rosacea (2), aniridia (2), and one case each of Bell s Palsy, Fuch s dystrophy, macular hole, oculocutaneous albinism, cyclodialysis, and a failed corneal graft. MEDICATIONS Because of its deployed nature, the formulary of eye medications at the Camp Cropper pharmacy was not as robust as would be found in a stateside MEDDAC, but it still offered a broad range of medications to treat most eye conditions. The Optometry Service maintained a stock of the most commonly prescribed eye medications to dispense immediately to the detainee when the condition warranted it. The usual procedure was for the medication(s) to be ordered from the pharmacy via electronic means called TC2 in theater. When the medication was ready for pickup, the DMC clinic would come to the hospital, pick up the medications which included the patient ID number and instructions for use in Arabic, sort them by compound, and then deliver the eye drop to the detainee who managed the medication(s) himself. If an oral medication was ordered, it was distributed as a single dose medication to the detainee who consumed it under direct observation therapy by an LPN once or twice a day. Eye drop refills were available based on the original prescription and were delivered to the patient in the same manner on a one-for-one replacement basis; when the eye medication bottle was empty, the detainee would give the empty bottle to the LPN and then be given a new bottle of drops at the next medication distribution if he had refills remaining on his prescription. Table III contains a list of the top 20 medications of the 2,489 prescriptions written by the Optometry Service. Looking at the top six medications, it will be seen that the primary use of eye medications in this population was for dryness, extraocular conditions requiring eye lubrication, and allergies as they accounted for 75.01% (1867) of all the prescriptions given to detainees. Because of the harsh weather conditions and that at Camp Cropper, the detainees stayed outside in a common yard as they were not restricted to cells or a common indoor facility, there was a significant need for eye lubrication to combat the effects of wind, heat, and dust. Artificial tears were prescribed for most allergy patients, which increased the number of lubricant drops prescribed. Working with the available antiallergy drops in the pharmacy, it was discovered on slit lamp examination and from patient comments during follow-up visits that tetrahydrozoline and olopatadine drops were not beneficial to this population. Thus, the use of ketorolac (244) and prednisolone acetate (134) was quite high as more often than not; these were the only eye drops that gave the patient relief and showed any effect on the allergy conditions prevalent in this area of Iraq. MILITARY MEDICINE, Vol. 177, June

6 TABLE III. Medications Prescribed by Optometry: New and Refills Drug Name No. Dispensed % of Total Tears Naturale II Equiv OPT 0.4%/G Olopatadine Opt 0.1% SOLN Ketorolac Opt 0.5% SOLN Visine A Opth Opt % SOLN Akwa Tears Opt 3.5 gm Oint Prednisolone 1% Opth Susp Opt 1% S Timolol 0.5% Opthalmic Solution Erythromycin Opt 5 mg/gm Oint Tobramycin/Dexamethasone Opt Oint Bimatoprost Opt ml Soln Maxitrol (OR Subst) Opt Oint Doxycycline PO 100 mg Tab Fluorometholone OPT 0.1%/GTT Soln Atropine Opt 1%/GTT Soln Latanoprost Opt 0.005% Soln Brominidine (Alphagan-P) Opth 0.15% Moxifloxacin Opth Sol Opt 0.5% Sol Cephalexin PO 500 mg CAP Sodium Chl Ophth Oint 5%, 3.5 gm/tu Tobramycin/Dexamethasone Opt Susp The remainder of the table reflects the amount of glaucoma treated during the year with 195 prescriptions (7.83%) issued for glaucoma medications. It was in this area that an expanded formulary containing a medication with dorzolamide would have been a benefit as the reaction in many detainees eyes to bimatoprost and lantanprost was quite dramatic causing many to discontinue its use because of discomfort, injection, and irritation. Having an additional medication on hand would have been helpful in trying to get the patients with advanced glaucoma (large C:D ratio) closer to target pressures. CONTACT LENSES Because of the limited amount of personal property a detainee could keep, there were no detainees examined wearing contact lenses. SUMMARY The main tenet in providing medical care to detainees is that personnel in U.S. custody shall receive medical care consistent with the standard of medical care that is given to U.S. military personnel in the same geographic area. 8 The United States has always provided health care to detained persons, prisoners of war, and displaced civilians. 9 The Abu Ghraib prison scandal, however, highlighted the importance detainee health care has on the strategic mission. 9 The mission to provide compassionate, caring, and comprehensive health care to detainees has continued unabated until the detainment medical facilities at Camp Cropper were turned over to the Government of Iraq and the 14th CSH returned home. As an integral part of this Level III hospital, optometry played a significant role in helping to win the hearts and minds of the detainees that passed through Camp Cropper s gates. Detainee eye examinations were performed in a professional and respectful manner. As a result, each medication or pair of eyeglasses subsequently dispensed to them became tangible proof of the United States commitment to providing them with high quality health care. In addition to documenting how the Optometry Service functioned within the confines of an internment facility and the demographics of an interned population, this report demonstrates the complexity of the ophthalmic cases that were managed by the 14th CSH. The number of glasses dispensed and the number of medications provided to the detainees will stand as testament to the commitment the U.S. Army made in improving the visual welfare and ocular health of this population. REFERENCES 1. Wikipedia. Camp Cropper. Available at Camp_Cropper; accessed May 9, Department of Defense, United States Forces-Iraq Press Release. New hospital to treat detainees, Soldiers (03 August 2006). Available at accessed May 9, Miranda MN: The geographic factor in the onset of presbyopia. Trans Am Ophthalmol Soc 1979; 77: Osuobeni EP: Ocular components values and their intercorrelations in Saudi Arabians. Ophthalmic Physiol Opt 1999; 19: Mallen EA, Gammoh Y, Al-Bdour M, Sayegh FN: Refractive error and ocular biometry in Jordanian adults. Ophthalmic Physiol Opt 2005; 25: Shah SP, Jadoon MZ, Dineen B, et al: Refractive errors in the adult Pakistani population: the national blindness and visual impairment survey. Ophthalmic Epidemiol 2008; 15: Thorn F, Cruz AA, Machado AJ, Carvalho RA: Refractive status of indigenous people in the northwestern Amazon region of Brazil. Optom Vis Sci 2005; 82(4): Department of the Army, Field Manual Interim , Medical Support to Detainee Operations (Washington, DC: U.S. Government Printing Office [GPO], 5 November 2007). Available at accessed December 8, Patton B: Detainee health care as part of information operations. Military Review; 2009: MILITARY MEDICINE, Vol. 177, June 2012