February 27, 2000 Vision Correction Surgery for Pilots

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by	Kim Broadwell, M.D.
	Contributor

Since the dawn of aviation, generations of pilots and would-be pilots have lusted after that which God did not give them. No, not wings -- they want perfect vision. In addition to the annoyance faced by mere mortals who have to wear glasses or contacts, pilots around the world also must deal with stringent visual standards from civil aviation authorities (like the FAA), the military, and airline companies. How wonderful it would be to toss away those spectacles and join the ranks of the 20/20 elite! Over two million eager people, many of them pilots, will reach into their pockets this year with just such a goal in mind, and will undergo an operation known as LASIK, which is an acronym for laser in-situ keratomileusis, and was first done in 1991. This form of corneal surgery to correct bad eyesight has become the most popular elective surgery in the U.S., but LASIK is not without its detractors. The LASIK boom has been accompanied by accusations that its benefits are over-hyped, and by reports of serious complications. Some of these complications could be of particular concern to pilots who might be eyeing a professional aviation career.

What's a LASIK, Anyway?

LASIK is a procedure that uses a programmed excimer laser to reshape the cornea of the eye. This redirects light rays so that they focus better on the retina, which is essentially what glasses or contact lenses do when they are placed in front of the eye. The eye surgeon uses a tiny scalpel (microtome) to partially cut through the top one-third of the cornea over the center of the pupil. This flap is lifted away, and the laser is used to vaporize predetermined areas underneath. After the zapping is finished, the corneal flap is replaced and heals without sutures. In most cases there is little post-op pain, and healing is relatively rapid, although it still may take up to six months for the flap to completely heal. The procedure is irreversible, as is the $1,500-to-$3,000-per-eye damage to your bank account (depending on your location.) Since this is considered cosmetic surgery, insurance benefits rarely cover the cost of the procedure.

LASIK is the latest technological development in the field of refractive surgery that began with radial keratotomy (RK) in the 1980s, and later evolved to photorefractive keratotomy (PRK). Where earlier procedures were applied primarily to myopia (near-sightedness), LASIK can also be used to correct hyperopia (far-sightedness) and degrees of astigmatism (irregularities in corneal curvature.) In one published series of LASIK results, 60% of patients with mild-to-moderate myopia achieved 20/20 uncorrected vision, versus 45% of those with more severe myopia. Another study showed 85-90% of treated eyes achieved 20/40 or better uncorrected. LASIK does NOT correct for loss of accommodation with aging (presbyopia), so if your medical certificate says "Must have available glasses for near vision," you will still need them after LASIK.

Visual acuity after surgery usually stabilizes within a matter of weeks, but may take as long as a year. If the initial improvement after LASIK is not satisfactory, another treatment can be performed. Data on how many eyes have to be re-done is hard to come by, but opinions vary from 2-10% to up to 30% in some clinics. Sometimes a third surgery is required. Ophthalmologists do not usually charge for the additional LASIK surgeries.

LASIK is still considered an "investigational procedure" by the Food and Drug Administration, but this has done little to dampen the enthusiasm of ophthalmologists eager to adopt the technique, or to prevent patients from clamoring for the service. This "off label" use of the excimer laser is permissible, but means that there are no official guidelines for its use in this particular application. The FDA is expected to approve the excimer laser for LASIK later this year, and to include specific warnings and recommendations for patient selection criteria, just as it does when a new prescription drug is approved.

Aeromedical Certification and Eligibility Issues

The FAA...

From the medical certification point of view, the FAA's approach to LASIK and PRK is relatively liberal. The FAA is primarily concerned that vision has stabilized post-operatively, that there have been no significant adverse effects or complications, and that the pilot meets the appropriate FAA vision standards for the class of medical certificate held. There is no longer a specified length of time a pilot must wait before returning to flying.

After a pilot's treating surgeon has released him or her to resume normal duties, the surgeon needs to document in the pilot's medical record that there have been no complications such as night glare, "haloing," or haziness, and forward a copy of the note to the Aeromedical Certification Division (ACD) in Oklahoma City. One way to accomplish this is for the doctor to fill out the standard FAA Form 8500-7, "Report of Eye Evaluation." The FAA has not been issuing new medical certificates, but at some point weeks or months later the ACD will send a letter of acknowledgment that corrective lenses are no longer needed (if that is the case).

A pilot should also carry a personal copy of the FAA letter or doctor's report that demonstrates you can meet the vision requirements for your class of medical. In the off-chance you get ramp-checked, it could be awkward if your required corrective lenses have suddenly vanished. Also, it would be a good idea to take these updates to your Aviation Medical Examiner at the time of your next flight physical. Barring complications, he or she should be able to issue you a new certificate if you are otherwise qualified. The latest FAA policy is available in the FAQ section of the Civil Aeromedical Institute Web site.

For those who are seeking a First or Second Class FAA medical certificate without corrective lenses, it is important to note that the standard requires 20/20 visual acuity in each eye separately. While it was surely emancipating to toss out your coke-bottle lenses when LASIK took you from 20/300 to 20/30 vision, that will not be enough to get you a First class medical without corrective lenses. The surgery needs to get you to 20/20 or better in each eye, and you have to stay there, to avoid a limitation on your Class I or Class II medical certificate. Not everyone gets so good a result.

...Transport Canada...

The policy of Transport Canada towards LASIK and PRK is more conservative than the FAA's, requiring a six-month waiting period after surgery before applying for recertification. Testing and reporting requirements are also a little more stringent for the first year post-op. Additional information on Transport Canada's guidelines for Canadians are also available.

...And The Military

If your desire is for a career in military aviation in the U.S., Canada, or any NATO nation, and you are looking at LASIK to help you meet military vision standards, save your money. It just isn't an option now or in the foreseeable future. The military, including the reserve forces, have too many doubts about long-term effects from the surgery to be comfortable allowing it in aircrew. Concerns include stress on the corneal flap with high g-loading, effects of an aircraft ejection, and long-term eye health in terms of glare and vision stability.

Several aviators, including flight surgeons, have tried to circumvent this policy with dire consequences when they were found out. One Army flight surgeon who had refractive surgery lost several years of flight pay retroactively, and was medically disqualified. The services are considering studying refractive surgery in aircrew more extensively, but the time required to obtain enough results to change military policy guarantees the status quo for years. If the military starts having trouble filling the fighter jock ranks with natural-born eagle-eyes, this could change. Don't look for NASA to buy into LASIK for astronaut candidates, either.

What About The Airlines?

Although it may not be true, many pilots feel that wearing corrective lenses hurts their chances of a career with the airlines. It's not possible to make iron-clad statements about how the major airlines regard vision correction surgery, because each company is free to set its own standards. Most major air carriers do allow their pilots to fly after having refractive surgery, although this was not the case in the early 1990s.

For air carrier pilot applicants, the situation is not clear cut. An airline may impose a waiting period of six months or more post-op before it will consider hiring an applicant. American Airlines responded to a query about LASIK with a somewhat cryptic, "Each case is decided on a case-by-case basis." United Airlines' official material for those interested in pilot positions does not mention LASIK. United does require a flight officer's uncorrected vision to be 20/100 or better in each eye, which is a higher standard than the FAA imposes for a Class I medical certificate. The U.S. Supreme Court last year upheld United's ability to require this higher level of qualification, in a case involving the Americans with Disabilities Act. If you think you are otherwise a candidate for getting that "big call" for an interview with the majors, the best advice is make sure you have the latest update on the airlines' position on LASIK before you see the surgeon.

Looking On The Dark Side Of LASIK

Why shouldn't all less-than-visually-perfect pilots rush out to have this surgery (aside from the cost)? The vast majority of patients who have the procedure are happy and have a successful (for them) outcome. No surgical procedure is without risk, however, and LASIK is no exception. The risk of a vision-threatening infection is very low, but is very real at one-to-five per 10,000 eyes. Other complications occur at a rate of about one per 100 eyes, including problems that can lead to corneal scarring. Irregular astigmatism can occur that decreases vision. Some patients have severe and persistent dryness of the eyes, which can range from merely annoying to the necessity for the near-continuous use of eye drops. Most of the immediate post-surgical complications involve the corneal flap and can be repaired, but corneal epithelium growing under the flap at a later date requires a flap revision in about 1% of patients.

Patients frequently experience a post-LASIK visual haziness, with glare and halos around lights at night. These problems usually clear after a few weeks to months, but some patients' night and dim vision symptoms become permanent. Also worrisome, especially for pilots, is that 5% of LASIK patients lose two or more "lines" of best-corrected visual acuity after the procedure (for example, from 20/20 to 20/40 on the eye chart). A rare patient suffers visual acuity that continues to fluctuate. While an initial under- or over-correction can often be fixed by a LASIK retreatment (which surgeons like to call "enhancement"), most complications do not have effective remedies.

With millions of procedures being performed, you can bet that the absolute number of people with refractive surgery horror stories is growing. For those not faint of heart, many of these stories have been collected at a Web site started by one of many with a poor outcome. These tales can't tell the visitor how often these problems can occur, but do give examples of some of the aviation-career-ending complications that can occur when refractive surgery goes wrong.

With all the emphasis that is placed on being able to read the fine print on the eye chart, it is important not to lose sight of the fact that true vision quality is a much more complicated concept. While an improvement on the eye chart may be a statistical success, a person will not be happy with the surgery if visual haziness, glare, dry eyes, poor vision in dim light, or decreased contrast sensitivity results. Critics of "LASIK mills" feel that "quick, safe and painless" is over-promoted to the detriment of informing prospective patients of the complications that can result from the procedure. Conservative observers of the phenomenon also point out that the long-term (beyond 10 years) risk of this procedure is simply unknown at present.

LASIK proponents have come under fire for not adequately warning their prospective patients of some of these risks, and for giving the impression that any problems which occur can be corrected by a repeat procedure if necessary. One unanswered question is how many complications result from poor equipment or surgical technique. The medical establishment would like us to believe that proper physician training, technique, equipment and patient selection will prevent most complications. How an individual near-sighted consumer is supposed to judge all of these parameters for himself is problematic, but your decision should definitely not be made based on price alone. The popularity of the procedure has caused many surgeons with relatively little experience to jump on the lucrative bandwagon, driving prices down in some areas. Finding a doc with thousands of LASIK eyes to his credit may be the most important part of the process of picking an eye surgeon.

Free Advice For The Wary

Here are some recommendations for pilots who are seriously considering LASIK:

• Consider LASIK as a serious surgical operation with aviation career- and vision-threatening consequences if things go wrong.
• Find a surgeon or clinic who will take the time to understand clearly what your expectations as a pilot are for this procedure.
• Use a clinic that will provide a thorough pre-op evaluation, that re-evaluates the day of surgery, and that provides follow-up. You need to clearly understand that you are a good candidate for LASIK, and why. (You do not want to be merely a mediocre surgical candidate for this procedure.)
• Make sure the clinic will provide free perpetual follow-up if there are any complications.
• Consider other options. LASIK is the hot thing right now, but implanted intracorneal rings have just been approved by the FDA and have the advantage of being removable or adjustable later. Actually implanting an plastic intraocular lens into the eye is also under investigation, and shows promise.
• Make sure your surgeon has lots of experience (thousands of cases is good), and it is prudent to use a facility that is part of a medical institution that will not fold up its tent and vanish a few years from now when economics change and you still need them.
• Learn all you can in advance, before anyone goes lazeing around. More semi-objective information is available on-line at the American Society of Cataract and Refractive Surgery Web site and the American Academy of Ophthalmology Web site has additional information on refractive errors and corrective surgery.