May 26, 1996 The Vision Thing

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by	Ken Ibold
	This article originally appeared in the February 1996 issue of AVIATION CONSUMER and is reprinted by permission of Belvoir Publications.

About the Author ... Ken Ibold is an editor and freelance writer who lives in Nashville, and owns a Mooney 201. 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.

Eagle-Eyed Myth

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 out applicants."

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 lenses.

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 this procedure...)

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 improvements?

"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 Institute.

"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.

Lasers

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," he jokes.

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 use here.

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 trust advertisements.

Nonsurgical Options

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 may work."

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 bottom.

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."