Is LASIK the Holy Grail?
February 27, 2000
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?
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
Aeromedical Certification and Eligibility Issues
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.
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
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.
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.
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
- 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
- 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.