Corrective eye surgery for pilots has become routine. The FAA says it's okay and it's relatively low risk.
May 26, 1996
|Under the Knife:
A Firsthand Experience with RK
For many people, it's the ultimate Catch-22: They need their glasses
so they can see well enough to find their glasses.
I'd been wearing thick glasses since the first grade, which was
the first time anyone ever bothered to ask me if I could see.
Combine that with my last name and, well, kids can be cruel. I
was a 24-year-old newspaper reporter when I wrote an article on
radial keratotomy. In 1983, RK was a new procedure that seemed
closer to the Starship Enterprise than to Piper Cubs. I was intrigued
by the possibilities.
I wasn't exactly risk-averse, so I gave little thought to the
possible downside of messing with my eyesight. I took the plunge.
Having RK is like going to the dentist. It's definitely unpleasant,
but it takes only about 20 minutes and you leave thinking "That
wasn't so bad." My vision was so poor and my astigmatism
so severe that my ophthalmologist recommended doing the prodecure
twice on each eye. The first surgery would aim at 80 percent correction;
the second surgery would do the fine tuning. Only one eye was
done per visit, and I would have to wait several months between
operations to see how my eyes "stabilized."
The first surgery went well. The day after, my eyepatch was removed
and I could see in a crystal-clear, colorful way I'd never known
before. That night, the vision in my "fixed" eye had
degraded substantially, but was still dramatically better than
before. Over the next few weeks, I got used to waking up with
everything sharp as can be (perhaps even a bit farsighted) and
getting foggier as the day went on. After two months my vision
was stable and predictable.
The next three surgeries went the same way. The only side effect
I noticed was a starburst pattern on light sources when driving
at night. The bursts exactly followed the scar tissue from the
surgeon's knife cuts.These faded over the next few years, or perhaps
I've just gotten used to them. The only time I notice them now
is when I'm suffering severe eye fatigue. It has now been nearly
13 years since that decision and I consider it to be the best
$2400 my dad's ever spent. My vision went from 20/400 to 20/20
on a good day and 20-30 on a bad one. That's plenty good enough
to pass my Class III medical and otherwise function day to day.
The real difference, however, has been in the way I live my life.
My teenage years of water skiing, motorcycle riding and otherwise
carousing were dramatically complicated by messing with contact
lenses and glasses that were beyond Coke bottle bottoms. It's
amazing how much easier it is to ski when you can see your feet.
As a pilot, I can't blame my bad landings on the surgery. But
reading charts at night, spotting airport beacons and finding
VFR traffic is as easy for me as for any of the other pilots I
fly with. I have recommended the surgery to others and two close
friends have had it. Neither wears glasses today. RK may not be
for everyone, but it's hard to imagine where I'd be if I were
still stumbling around in the blur of bad eyesight.
The stereotype of pilots tall and fit, with lots of hair and
perfect vision is one that not many of us live up to. But
that doesn't mean we can't aspire to the image of dashing barnstormer
or cocky cockpit commander.
Poor vision not only shatters that image, but for many people
it represents an inconvenience severe enough to affect the way
they live. Modern medicine has had a couple of surgical answers
to poor vision for more than a decade, but messing with your eyesight
is a scary proposition. For pilots, there comes the added uncertainty
of whether they would run afoul of the FAA or, for those aspiring
to professional pilot jobs, the airlines or corporations that
operate the heavy iron.
These images persist despite mounting evidence that "uncorrected
vision" is largely irrelevant. How well a pilot can see while
flying is more important than how well he or she can see in the
shower. Even that may be overplayed.
Where the perfect vision requirement came from and why it seems
to persist is a good subject for speculation but the fact is,
there's almost no data to support the notion that people with
good eyes make better pilots. Or those with correctable eye problems
make poor ones.
"There's no handicap to wearing contacts, and very little
in glasses. There have been no accidents that are a result of
visual loss," says Steven Sieper, a Philadelphia-area airman's
examiner, ophthalmologist and researcher.
"It takes 20/200 vision to land an airplane. We have to be
realistic. The airlines are just looking for reasons to screen
The good news is that several techniques exist for correcting
nearsightedness without alienating the government or potential
employers. The bad news is that none of them are sure-fire solutions.
Glasses and contact lenses are the tried-and-true solutions to
poor vision and many pilots have gone this route. But for vanity
or other reasons, people opt out glasses and, as we get older,
the hassle factor makes these devices a nuisance.
There are other choices, namely a surgical solution for nearsightedness
called radial keratotomy, or RK, which has been around for a number
of years, even though some people still seem to think of it as
an experimental procedure. On the horizon, techniques called LASIK
and PRK show promise of being better options. For those reluctant
to let a surgeon loose on their baby blues, there's an exercise
program that may help them shed their dependence on corrective
No Help For The Farsighted
While nearsightedness is fairly common, farsightedness has far
fewer options. Surgical solutions for farsightedness are relatively
exotic and generally outside the realm of "cosmetic surgery."
Other visual problems that lie far beyond the scope of the relatively
simple procedures mentioned here are cataracts, retinal problems
and complications from glaucoma. While each would be serious business
for anyone seeking to retain a medical, that problem is secondary
to maintaining enough visual prowess to live a normal life.
Corrective lenses address two kinds of vision problems. One is
caused by a misshapen cornea. The cornea provides most of the
eye's focusing power, so defects here show up as nearsightedness
or farsightednes. The other is typically caused by a hardening
or other deterioration of the lens in the eyes. This is called
presbyopia and causes the visual deterioration found in middle-aged
people who need bifocals.
Most nearsightedness stems from a result of a flaw in the shape
of the cornea. Essentially, the curvature of the cornea is too
great for the depth of the eye, causing light to focus in front
of the retina. Glasses and contacts correct this flaw by spreading
out the light before it reaches the eye, then the eye can pull
the image into focus in the right spot.
Radial keratotomy is a treatment for nearsightedness that involves
cutting part way through the cornea in radii around the pupil.
The surgeon intrudes as little as possible into the visual field,
reducing the chance that scarring will blur your vision. The incisions
cause the cornea to flatten, and the degree of correction can
be controlled by varying the depth and location of the cuts.
A related malady astigmatism is caused by variations in
the curve of the cornea from one part of the eye to another. RK
can correct astigmatism, too, by flattening some parts of the
eye more than others.
In general, people in their 30s through 50s are better candidates
for RK than those who are younger. Eyesight can change substantially
for people in their teens, and those in their 20s have tissue
that's so flexible and resilient that RK may not cause the cornea
to flatten much.
The Tricky Cut
RK surgery takes about 20 minutes per eye and is done using only
local anesthetic in the form of numbing eye drops. The psychological
impact of watching a knife homing in on your eye is something
only you can assess. (Imagine the first person who sat still for
After the surgery is completed, improvement is nearly immediate.
It is, however, as much art as science and the results are far
from guaranteed. If you still require corrective lenses after
the surgery, contacts may not be an option. You may be stuck with
glasses. By most estimates the success rate of RK defined
as patients having post-surgical vision of 20/40 or better
is about 90 percent.
Those odds aren't bad but, still, no guarantees you'll come out
better than before. The operation costs about $1000 per eye and
it can be done more than once to tweak the eyeball into shape.
Follow-up operations are generally done at no additional cost
but most surgeons will not perform the operation more than twice
on a single eye. Normally, only one eye is done at a time. The
big question is, what does the FAA think of RK-induced vision
"The FAA says okay to RK in all classes [of medical certificate],
and there's no reason not to," says Stanley Mohler, director
of aerospace medicine at Wright State University in Dayton, Ohio,
and former director of the FAA's Civil Aviation Medicine Research
"The military has had some concerns, but they're letting
some people fly with it on a trial basis."
The airlines vary on their policies regarding hiring pilots who
have had RK. The majors are following the military's lead and
have been skeptical about candidates with RK in their past and
with so many candidates to choose for so few jobs, they can afford
to be picky. Policies at commuters and corporate flight departments
are likely to vary case by case.
Though RK has had generally good results, doctors now consider
lasers to have the potential to surgically alter vision more precisely,
on a wider variety of patients and with less pain and greater
success rates. These laser surgeries have the same goal as RK
flattening the curvature of the cornea.
One procedure currently undergoing FDA trials is laser in-situ
keratomileusis, or LASIK. A thin layer of tissue is cut from the
surface of the cornea but left attached at one point, leaving
a hinged "flap." A computer-controlled laser then sculpts
the surface of the cornea to correct the nearsightedness, and
the flap is repositioned without sutures over the wound. Vision
is noticeably improved within 24 hours and continues to improve
over two to four weeks as the swelling goes down.
."The doctor who did it was a researcher specializing in
laser treatment, so he was biased in favor of it," says Mark
Steele, a 39-year-old private pilot who participated in the clinical
trial last summer. "The long-term effects are not known,
but from a risk standpoint I figured I didn't have much to lose.
I'd either come out with good vision or come out a very rich man,"
Steele reports the procedure was painless and he now has 20/20
vision in both eyes. Cost of the procedure at Emory Vision Correction
Center in Atlanta was $3600.Some patients may end up with a bit
of astigmatism from the operation, although this percentage so
far appears to be very low, researchers report. Another laser
procedure is called photorefractive keratectomy, or PRK. It's
similar to LASIK except that the laser sculpts the surface of
the cornea without a flap of tissue being cut.
Between 5 percent and 10 percent of patients report a slight hazing
of the cornea as a result of the surgery, but this is significant
in only about 1 percent of cases. The process results in 20/40
vision or better in 95 percent of cases and 20/20 vision in 66
percent of cases. Both LASIK and PRK rely on excimer lasers. These
devices use ultraviolet light to heat and instantly vaporize
the corneal tissue.
The computer control allows the laser to skim about 1/3000th of
an inch from the surface of the eye. So far, only one excimer
laser, made by Summit Technologies, is approved for eye surgery
in the U. S. Several others used in other countries are undergoing
clinical trials and should be approved in the near future for
Rewards and Risks
Anyone considering surgery should be aware of the downside. The
important thing is not uncorrected vision, but "best corrected
vision." For about 3 percent of surgical patients, the best
corrected vision is worse after the surgery than before. As with
any surgery, there's a risk of complications ranging from infection
to an outright botch.
Sieper recommends that anyone seeking more information on surgical
options ask their family doctor or the American Society for Cataract
and Refractive Surgery for a recommendation. Make sure the surgeon
checks your best corrected vision beforehand and measures the
topography of your eyes by computer.
Talk to other patients. Call the hospitals where the surgeon practices
and ask the nurses and office staff. Most of all, don't blindly
Obviously, not everyone wants to trust their eyesight to surgery.
One interesting non-surgical option we looked into is a series
of eye exercises marketed under the name Vision Freedom. The premise
is that the muscles that control the lens of the eye can be developed
through exercise, just as any others, allowing the lens to be
strong enough to correct for imperfections on the cornea.
Curious as to how this process works, we contacted Dick Miller,
who had 20/200 vision when he ordered Vision Freedom for $99.95
from Brian Severson in Victor, Montana. The regimen requires
about two hours per day, every day and contact lenses are a no-no.
The company provides three pairs of glasses to wear while exercising
and a complete instruction manual.
Miller reports the glasses were of high quality and the manual
made sense. But for him, it wasn't enough. As with any exercise
program, some people make it work while others lapse back to the
visual equivalent of couch potatoes. After a month, Miller and
his wife gave up, despite the fact that both of them noticed their
vision had "noticeably" improved.
"Unless you're committed to it, it's not going to do you
much good," he says." What he says to do does work,
but it's probably unrealistic to think you could go from 20/200
to no glasses."
The company offers a 100 percent money-back guarantee it says
has never been requested. Miller says he's undecided if he'll
ask for a refund. A complicating factor in the exercise program
is this: As your vision improves, you should get new prescription
glasses to meet only the new level of correction.
In theory, that keeps the eye working and prevents the muscles
from getting lazy from relying on what is now overcorrection.
That means a trip to the eyeglasses store every few weeks. Some
ophthalmologists are skeptical that such exercises could do much
good anyway. "There isn't much you can do with those [internal
eye muscles] because they're so small," Mohler says. "Besides,
you're always exercising those muscles anyway, every time you
shift your focus from a book to the window and back."
Given the relatively low price, Miller suggests Vision Freedom
may be worth a try but don't count on miracles. "I don't
think it's deceptive in any way. For someone who's committed it
With the range of options, the risk and the price tags, it's clear
that anyone looking for clearer vision has a lot to consider.
Keep in mind, however, that none of these techniques will prevent
or even correct the normal vision deterioration that comes with
age. Someone who is slightly nearsighted approaching age 40 may
have some options, but the same cannot be said of any other group.
Unlike myopia and hyperopia, presbyopia is the slight farsightedness
that occurs with age. The symptoms typically appear about age
40 and for pilots, are most notable when trying to read charts
at night. So far, the only treatments for presbyopia are bifocals/trifocals
and bifocal contact lenses that are optically weighted at the
You can prevent bad vision from getting worse by taking common
sense steps such as wearing UV-blocking sunglasses, avoiding
looking into the sun and refraining from smoking. You can also
make the best of what you have by buying high-quality eyeglasses,
which have optical properties superior to low-cost glasses.
And after all, says Mohler, "The brain is the most important
part of the pilot anyway."