RMP-EYE-002 Routine vision checks for spaceflight-associated neuro-ocular syndrome: near and distance reading charts, Amsler grid and eye questions, relay to the flight surgeon (the robot never compares results)

1 · Identity and scope

At the times the flight surgeon sets (and whenever a crewmember asks), the robot runs a short routine vision check for spaceflight-associated neuro-ocular syndrome (eye and optic nerve changes linked with long stays in weightlessness): red-flag questions first, then the eye questions the flight surgeon sets, then a near and a distance reading chart (how small a line each eye can read) and an Amsler grid (a square grid of lines with a dot in the middle, used to notice wavy, missing or blurred patches in central vision). The robot holds the screen still at a set distance, records only what the crewmember reads, says or draws, shows the same layout every time, and sends everything to the flight surgeon, who compares the results with earlier checks. Imaging is a separate protocol (RMP-EYE-003).

Why this protocol was chosen. NASA reports that about 70% of long-duration crew show one or more signs of spaceflight-associated neuro-ocular syndrome and about 18% have clinically concerning changes (MTB-001); with optic disc swelling as the main measure, the NASA evidence report gives an overall rate of 16%, and 38% to 51% of long-duration crewmembers had one or more findings. In questionnaires from about 300 astronauts, about 29% on short and 60% on long missions noticed worse distance or near vision, and some changes have not gone away years after flight (Mader 2011); the findings include optic disc swelling, flattening of the back of the eye, folds in the layers at the back of the eye and a shift toward far-sightedness (Lee 2020). NASA checks reading charts (near and distance) and the Amsler grid before, during and after flight, with in-flight "eye weeks" around flight day 30, flight day 90 and 30 days before return, and every crewmember flies with at least 3 pairs of glasses of different strengths (space anticipation glasses). NASA-STD-3001 requires periodic monitoring for spaceflight-associated neuro-ocular syndrome [V1 3003 item m] and the means to give crewmembers stronger glasses [V1 3004 item g]. Crewmembers have not reported the type of headache usually linked with raised pressure inside the head (NASA evidence report), so a new headache with a vision change is a red flag here, not an expected symptom. A robot that holds the chart still at the same distance every time, and records the answers exactly without comment, gives the flight surgeon comparable numbers between the eye weeks. The Amsler grid can miss change (pooled sensitivity 67-71% for neovascular AMD), so it supplements, and never replaces, the eye-week examinations and imaging (Bjerager 2023; Faes 2014; Earth studies, applied by extrapolation). A tablet chart read about 2 lines worse on a glossy screen with glare, and agreed with standard charts with an anti-glare surface and away from reflections (Black 2013), so the distance, letter size, brightness, contrast, glare and lighting are fixed and validated before flight. A distortion the crewmember says is new or sudden is URGENT (RF7): the College of Optometrists lists sudden change in vision, wet macular degeneration and central serous retinopathy among conditions needing prompt referral, and NASA notes that folds near the centre of the retina can distort vision (MTB-001); the URGENT level is a clinical judgment for the flight surgeon to confirm.

Autonomy: Tier 2 as in the library contents. The robot holds a screen still at a set distance and records what the crewmember reads or draws; it never touches the face and never compares results.

Related: RMP-EYE-003 · RMP-EYE-001 · RMP-EYE-004 · RMP-NEURO-002 · RMP-NEURO-007 · RMP-EVA-001 · RMP-ENV-004 · RMP-BEH-002

2 · Roles

Medical authority

Flight surgeon (ground). Holds medical authority for every run.

Onboard lead

Crew medical officer (CMO), acting under delegated care; uses the pre-approved onboard checklist when there is no link.

Others

• Crewmember being checked: reads the chart, draws on the grid and can stop at any time
• Second trained CMO: receives alerts if the CMO is the patient

Commercial flights

On commercial flights, 'flight surgeon' and 'CMO' mean the operator's designated medical authority and trained onboard responder. If no trained responder is aboard, this protocol is not used. (NASA-STD-3001 requires two CMOs per vehicle for NASA programs [V1 3006]; FAA rules set no medical standards for spaceflight participants.) [17]

3 · Preconditions and consent

• PRE-1 The crewmember accepted the scheduled prompt, or a crewmember or the CMO started the check by command.human_start == trueV2 10174
• PRE-2 The crewmember is awake and answering. If not, stop and alert at once (X7).crew_responsive == true
• PRE-3 The crewmember's position and the robot's screen are restrained; the screen distance, size and brightness are the values set by validation; the room lighting is as set for the check.V2 7046
• PRE-4 Robot self-test passed, including the distance sensor used to hold the screen at the set distance.V2 10161
• PRE-5 Link status and current delay known.link_state in [live, delayed, down]

Consent

The crewmember agrees to the check by voice. They can decline any question or test; an explicit "no" is logged as declined for that item only.

Emergency consent

If the crewmember cannot answer, the robot stops the check; it sends an URGENT alert and a crewmember checks in person (X7).

Withdrawal

The crewmember can stop at any time; results already recorded are kept and marked "check stopped".

4 · Required sensor inputs

5–6 · Steps and decision points

Each step names who acts. Decision points sit after the step they follow and say who decides: Robot Crew Ground. Any stop rule in section 7 can interrupt any step.

1. S1RobotRung 2

   When the crewmember accepts the scheduled prompt or gives a command, open the check log and send a "routine vision check started" note to the flight surgeon (queued if the link is down).

   Done when: Note delivered or queued.

   V2 10174V1 6003

2. S2RobotRung 2

   Ask the red-flag questions first. Log answers word for word. D1 is checked after every answer and at any point in the check.

   Done when: Answers logged, or "no response" logged.

   D1DecisionRobot decides

   Checked after every answer and at any point in the run (even mid-question or mid-step): does any answer, reading or observation meet a red flag?

   • Yes → Stop the current question or step at once and apply the action listed for each matching red flag (URGENT alert, flag, or stop), with the answer or reading itself, never a cause. Every URGENT alert goes to the CMO and the flight surgeon at the same time (queued for the flight surgeon if the link is down). If the CMO is the patient, is busy treating, or does not answer, the alert goes to the second trained CMO, or the crewmember named before flight [V1 3006]. An URGENT alert that is not acknowledged within <set by validation> seconds is repeated and sent to the next named crewmember. The routine check stops; the robot shows no chart until a human restarts the check.
   • No → Continue.
   D2DecisionRobot decides

   Did the crewmember answer the question?

   • Yes → Continue.
   • Declined explicitly (the crewmember says no to a question) → Log "declined" for that question only; the alert already sent stands.
   • No response, or the answer does not make sense → URGENT: log "no response" (never "declined"); the CMO, or the second trained CMO if the CMO is the patient, checks the crewmember in person at once.
3. S3RobotRung 2

   Ask the eye questions the flight surgeon set, and record which pair of glasses the crewmember is wearing, as they state it.

   Done when: Answers logged.

4. S4RobotRung 2

   Move slowly to the set position and hold its screen still at the set distance in front of the crewmember, outside the keep-out zone. Show the near reading chart, then the distance chart, in the same layout every time, for each eye in turn (the crewmember covers the other eye themselves). Record the smallest line the crewmember reads, as they state it. It never shows earlier results.

   Done when: Lines recorded for each eye, or "not done" logged with the reason.

   Limit: <set by validation>

   V2 10172

5. S5RobotRung 2

   Show the Amsler grid for each eye in turn. The crewmember marks any wavy, missing or blurred area on the touch screen, or describes it; the robot records the drawing and the words exactly and says only "recorded". If an area is marked or described, it asks "Is this new since your last check?" and records the answer word for word; it never says whether the area is new.

   Done when: Grid drawings recorded, or "not done" logged with the reason.

   D3DecisionRobot decides

   Were the charts and the grid done as set?

   • Yes → Continue to S6.
   • Not done or incomplete (the crewmember stopped, the screen could not be held at the set distance, or the lighting was not as set) → Log "not done" or "incomplete" with the reason; never estimate a result; tell the flight surgeon in the package.
6. S6RobotRung 2

   Move back to its rest position and send the flight surgeon one package: red-flag and eye answers, lines read, grid drawings, glasses worn, settings used and any alert. It sends no comparison and no comment. The package states: "An Amsler grid with no marks, or a chart line read, is a record only; it does not rule out change."

   Done when: Package delivered or queued.

   V1 6003V1 7001V1 7003

7. S7RobotRung 2

   After any URGENT alert: After an URGENT alert the robot does not leave on its own: it stays at its rest position in the module, with its screen and voice link available, until a human has taken over or tells it to go. It never follows, blocks or touches anyone. It keeps time-stamping what humans say they did, and repeats the alert if it is not acknowledged.

   Done when: Robot at rest in the module until a human releases it; alert acknowledged or escalated.

   V2 10173V1 3006

8. S8Crew

   The CMO sees the crewmember in person when asked or on any red flag. Any extra check, imaging (RMP-EYE-003) or change of glasses is decided by the flight surgeon or CMO; the crewmember changes glasses themselves.

   Done when: CMO entries logged.

   V1 3004

9. S9Ground

   The flight surgeon compares the results with preflight and earlier checks and decides any imaging, change of glasses, change to the check schedule, or other step. The robot logs the decisions.

   Done when: Decision logged.

   V1 3003V1 3004

   D4DecisionGround decides

   What is the plan (imaging, glasses, schedule, other steps)?

   • Link live → Flight surgeon decides; robot logs.
   • Link down or delay too long → The CMO decides under the pre-approved onboard checklist; the flight surgeon reviews the log at the next contact.
10. S10RobotRung 2

    Offer the next check at the time the flight surgeon set (for context, NASA's in-flight eye weeks are around flight day 30, flight day 90 and 30 days before return; extra checks can be done at any time). At each scheduled time the robot prompts the crewmember on their own screen; it approaches only when the crewmember (or the CMO) accepts, and a prompt never starts the robot. A prompt never wakes a sleeping crewmember.

    Done when: Prompt accepted, postponed or answered.

    V2 10174

7 · Stop and escalate rules, red flags

Red flags

The robot reports the sign or value only, never what it means. Numeric thresholds are placeholders for the clinical lead.

8 · Safety limits

9 · Logs and audit

• LOG-1 Every input, robot action, decision (with who made it) and hand-off, time-stamped to the second.V2 10163V2 10164
• LOG-2 Mode changes and safety-limit events are announced to the operator as they happen and logged.V2 10162V2 10172
• LOG-3 Records are stored and sent as private medical data, encrypted, with access limited to the medical team.V1 6003V1 7003
• LOG-4 Results are kept in a permanent, retrievable format so the flight surgeon can see trends.V1 7001
• LOG-5 Each check: time, settings used, glasses worn, answers, lines read and grid drawings exactly as given, items not done with the reason, and alerts.
• LOG-6 Each URGENT alert, who received it, the time it was acknowledged (or the escalation to the next named crewmember), and the time a human released the robot.V2 10163

10 · Links to NASA-STD-3001

IDs as published in Volume 1 Revision C [12] and Volume 2 Revision F [14]. NASA-STD-3001 binds NASA programs; it is not a regulation for commercial flights. Its robot rules are general automation requirements, not medical-device rules.

11 · Validation

1. Simulation. Scripted checks covering every red flag, no response, a distance-sensor fault, a CMO who is the patient, and lost link. Pass: Every red flag acts as listed; zero comparisons or "changed/unchanged" statements; zero glasses suggestions; zero results shown from earlier checks.
2. Earth analog. Volunteers read the robot-held charts and grid and the same charts on a fixed stand, at the set distance, and the standard eye-week charts under flight-like lighting. Pass: Agreement with the fixed-stand results within <set by validation> lines; acuity read on the robot-held screen agrees with the standard eye-week charts under flight-like lighting, at or above <set by validation>; screen distance held within <set by validation>.
3. Parabolic or station demonstration. Screen held at the set distance in weightlessness, without a patient. Pass: Distance held within <set by validation>; zero contacts.
4. Flight use under flight surgeon supervision. First use alongside the usual in-flight eye checks, with a periodic comparison of the robot-screen chart with the eye-week chart for the same crewmember, analysed by the flight surgeon only (the robot never compares). Pass: No safety events; the flight surgeon finds the results comparable with the usual checks.

No stage has been run. Pass and fail criteria must be fixed in advance by the clinical lead and safety board.

12 · Human sign-off

Before any use

• Clinical lead for the specialty (sets every clinical threshold marked <set by clinical lead>)
• Flight surgeon, as medical authority
• Robotics and medical-device safety board
• Program approval for the mission

Each run

Started by an accepted prompt or a crewmember's command. The flight surgeon reviews every result; red flags go to the CMO and flight surgeon at once.

Restart after a stop

Human only. After any emergency or protective stop, a crewmember must restart the robot; the robot never restarts itself.

None of these sign-offs has happened. This is a Draft v0.5.

13 · Change control for learning

• Every change gets a new version number and a written reason; earlier versions are kept.
• Any change to steps, thresholds, limits or software that touches the patient repeats validation from the simulation stage before use.
• Software and learned-skill updates follow a pre-agreed change plan (what may change, how it is tested, how to roll back), modeled on the FDA predetermined change control plan approach.
• If a new version misbehaves, the robot rolls back to the last validated version and the event is reviewed by the flight surgeon and safety board.
• The robot never changes its own protocol, thresholds or limits.

Change-plan model: FDA guidance [16].

Loss of signal and Mars delay

Live link

Low Earth orbit: the flight surgeon sees summaries at the private medical conference and can be alerted at any time.

Loss of signal

• Only the robot pauses; crew care never waits for the link or the robot.
• The robot pauses any movement and tells the CMO; on the CMO's confirmation it keeps running the check and logging offline.
• Red flags go to the CMO (or the second trained CMO) at once; the CMO decides under the pre-approved onboard checklist.
• At the next contact the robot sends one package: the log, alerts and decisions.

Mars-class delay

• Replies may take up to about 21-23 minutes each way, with blackouts of about 2-3 weeks; red-flag thresholds and the check-in schedule are set before flight and the CMO acts on them.

[15]

Sources

1. NASA OCHMO. Spaceflight Associated Neuro-ocular Syndrome (SANS). Medical Technical Brief OCHMO-MTB-001 (2024). www.nasa.gov/wp-content/uploads/2024/02/ochmo-mtb-001-sans.p… Supports: NASA MTB-001 (2024): about 70% of long-duration crew show one or more signs and about 18% have clinically concerning changes; reading charts (near and distance) and the Amsler grid are used before, during and after flight; in-flight eye weeks around flight day 30, flight day 90 and 30 days before return, with extra testing at any time; all crew fly with at least 3 pairs of prescription glasses of different strengths; NASA-STD-3001 V1 3003 item m and V1 3004 item g.
2. NASA Human Research Program. Evidence Report: Risk of Spaceflight Associated Neuro-ocular Syndrome (SANS) (2017). humanresearchroadmap.nasa.gov/evidence/reports/SANS.pdf Supports: With optic disc edema as the primary metric, the overall incidence is considered to be 16%, and 38% to 51% of long-duration crewmembers have developed one or more findings; no crewmembers have reported the type of headaches typically associated with raised intracranial pressure; the classic symptoms of raised pressure inside the head on Earth include chronic headaches, double vision, transient visual obscurations and pulse-synchronous tinnitus.
3. Mader TH, Gibson CR, Pass AF, et al. Optic disc edema, globe flattening, choroidal folds, and hyperopic shifts observed in astronauts after long-duration space flight. Ophthalmology. 2011;118(10):2058-2069. PMID 21849212. doi:10.1016/j.ophtha.2011.06.021 Supports: Postflight questionnaires from about 300 astronauts documented that about 29% on short and 60% on long-duration missions experienced a degradation in distant and near visual acuity; some of these vision changes remain unresolved years after flight. Only the abstract was read.
4. Lee AG, Mader TH, Gibson CR, et al. Spaceflight associated neuro-ocular syndrome (SANS) and the neuro-ophthalmologic effects of microgravity: a review and an update. NPJ Microgravity. 2020;6:7. (Author correction: NPJ Microgravity. 2020;6:23.) PMID 32047839. doi:10.1038/s41526-020-0097-9 Supports: Review of the clinical findings of spaceflight-associated neuro-ocular syndrome: one-sided and two-sided optic disc edema, globe flattening, choroidal and retinal folds, hyperopic (far-sighted) refractive shifts and cotton wool spots. Only the abstract was read.
5. The College of Optometrists. Guidance for Professional Practice, Annex 4: Urgency of referrals table. Primary-care optometry guidance. www.college-optometrists.org/clinical-guidance/guidance/guid… Supports: Checked by column against the live table on Oct 20, 2026. Emergency (as soon as possible): sudden complete loss of vision under 6 hours; retinal detachment with the macula on; chemical burns (irrigate first); penetrating injuries; severe eye pain with nausea or vomiting. Emergency (within 24 hours): sudden visual loss of unknown cause; floaters or flashes of light under 48 hours with pigment in the vitreous; symptomatic retinal tears and breaks; retinal detachment with the macula off; papilloedema; acute onset double vision, squint, drooping eyelid or nerve palsy; pain on eye movement; sudden severe eye pain. Urgent (priority): sudden change in vision under 2 weeks; optic neuritis; wet macular degeneration; myopic choroidal neovascularisation; central serous retinopathy; new pupil defects.
6. The College of Optometrists. Clinical Management Guidelines: Trauma (chemical) (last updated March 13, 2026) Primary-care optometry guidance (public sections only). www.college-optometrists.org/clinical-guidance/clinical-mana… Supports: Flush the eye immediately with sterile salt solution, or tap water if that is not available, and continue to irrigate for at least 20 minutes before seeking medical attention; damage is generally greatest with alkalis such as ammonia; severe cases need immediate referral to hospital eye services or emergency care. (Only the publicly visible sections were read; the full guideline needs a login.)
7. The College of Optometrists. Clinical Management Guidelines: Trauma (penetrating) (last updated March 13, 2026) Primary-care optometry guidance (public sections only). www.college-optometrists.org/clinical-guidance/clinical-mana… Supports: Penetrating trauma is a full-thickness injury of the cornea or outer coat of the eye; first aid is followed by emergency referral, with an ophthalmologist seeing the patient as soon as possible the same day; foreign bodies are identified but not removed. (Public sections only.)
8. Bjerager J, Schneider M, Potapenko I, et al. Diagnostic accuracy of the Amsler grid test for detecting neovascular age-related macular degeneration: a systematic review and meta-analysis. JAMA Ophthalmol. 2023;141(4):315-323. PMID 36795396. doi:10.1001/jamaophthalmol.2022.6396 Supports: Pooled sensitivity of the Amsler grid for neovascular age-related macular degeneration was 67% against healthy controls and 71% against non-neovascular disease; its sensitivity may be at levels typically not recommended for monitoring, and patients should have regular eye examinations regardless of their grid results. Only the abstract was read; an Earth macular-degeneration population, applied to spaceflight by extrapolation.
9. Faes L, Bodmer NS, Bachmann LM, Thiel MA, Schmid MK. Diagnostic accuracy of the Amsler grid and the preferential hyperacuity perimetry in the screening of patients with age-related macular degeneration: systematic review and meta-analysis. Eye (Lond). 2014;28(7):788-796. PMID 24788016. doi:10.1038/eye.2014.104 Supports: Pooled sensitivity of the Amsler grid was 0.78 (95% CI 0.64-0.87) and specificity 0.97; almost all included studies had a case-control design. Only the abstract was read; applied to spaceflight by extrapolation.
10. Black JM, Jacobs RJ, Phillips G, et al. An assessment of the iPad as a testing platform for distance visual acuity in adults. BMJ Open. 2013;3(6):e002730. PMID 23794568. doi:10.1136/bmjopen-2013-002730 Supports: A glossy tablet screen was highly susceptible to glare, giving acuity about 2 logMAR lines poorer than standard charts; with an antiglare screen and positioned away from reflected glare, results were equivalent to gold-standard charts; such devices suit only settings where glare can be eliminated. Only the abstract was read; adults with normal vision on Earth, not a robot-held screen in weightlessness.
11. National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. Clinical guideline CG150. www.nice.org.uk/guidance/cg150/chapter/Recommendations Supports: Headache features that need further investigation or referral include sudden-onset headache reaching maximum intensity within 5 minutes and a new neurological deficit.
12. NASA. NASA-STD-3001, Space Flight Human-System Standard, Volume 1: Crew Health, Revision C (2023). www.nasa.gov/wp-content/uploads/2023/11/nasa-std-3001-vol-1-… Supports: NASA-STD-3001 Vol 1 Rev C: V1 3003 item m (periodic monitoring for spaceflight-associated neuro-ocular syndrome); V1 3004 items e (physical exam) and g (stronger glasses).
13. NASA OCHMO. Medical Operations. Technical Brief OCHMO-TB-044 (2025). www.nasa.gov/wp-content/uploads/2025/08/ochmo-tb-044-medical… Supports: The crew surgeon keeps medical authority when care is delegated; crew medical officers train on the JSC 48522 medical checklist.
14. NASA. NASA-STD-3001, Volume 2: Human Factors, Habitability, and Environmental Health (Rev F, 2026), including Section 10.6 Automated and Robotic Systems. standards.nasa.gov/standard/NASA/NASA-STD-3001_VOL_2 Supports: Requirement IDs beginning V2.
15. NASA. Mars communications disruption and delay (fact sheet, 2023 Moon to Mars Architecture Concept Review). www.nasa.gov/wp-content/uploads/2024/01/mars-communications-… Supports: One-way Earth-Mars delay up to about 21-23 minutes, plus blackouts of about 2-3 weeks near solar conjunction.
16. U.S. Food and Drug Administration. Marketing submission recommendations for a predetermined change control plan for artificial intelligence-enabled device software functions (guidance). www.fda.gov/regulatory-information/search-fda-guidance-docum… Supports: A model for planning, validating and rolling back software updates.
17. U.S. Code of Federal Regulations, Title 14, Part 460: Human space flight requirements. www.ecfr.gov/current/title-14/chapter-III/subchapter-C/part-… Supports: Federal rules for crew and spaceflight participants on licensed commercial flights; they set no medical standards for spaceflight participants.

Checked on 2026-10-20: links opened (HTTP 200 or publisher redirect), DOIs and PubMed IDs matched, NASA documents read in full text. The framework comes from Part 1.