The Vision Thing

Corrective eye surgery for pilots has become routine. The FAA says it's okay and it's relatively low risk.

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The stereotype of pilots – tall and fit, with lots of hair andperfect vision – is one that not many of us live up to. Butthat doesn’t mean we can’t aspire to the image of dashing barnstormeror cocky cockpit commander.

Poor vision not only shatters that image, but for many peopleit represents an inconvenience severe enough to affect the waythey live. Modern medicine has had a couple of surgical answersto poor vision for more than a decade, but messing with your eyesightis a scary proposition. For pilots, there comes the added uncertaintyof whether they would run afoul of the FAA or, for those aspiringto professional pilot jobs, the airlines or corporations thatoperate the heavy iron.

These images persist despite mounting evidence that “uncorrectedvision” is largely irrelevant. How well a pilot can see whileflying is more important than how well he or she can see in theshower. Even that may be overplayed.

Eagle-Eyed Myth

Where the perfect vision requirement came from and why it seemsto persist is a good subject for speculation but the fact is,there’s almost no data to support the notion that people withgood eyes make better pilots. Or those with correctable eye problemsmake poor ones.

“There’s no handicap to wearing contacts, and very littlein glasses. There have been no accidents that are a result ofvisual loss,” says Steven Sieper, a Philadelphia-area airman’sexaminer, ophthalmologist and researcher.

“It takes 20/200 vision to land an airplane. We have to berealistic. The airlines are just looking for reasons to screenout applicants.”

The good news is that several techniques exist for correctingnearsightedness without alienating the government or potentialemployers. The bad news is that none of them are sure-fire solutions.Glasses and contact lenses are the tried-and-true solutions topoor vision and many pilots have gone this route. But for vanityor 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 nearsightednesscalled radial keratotomy, or RK, which has been around for a numberof years, even though some people still seem to think of it asan experimental procedure. On the horizon, techniques called LASIKand PRK show promise of being better options. For those reluctantto let a surgeon loose on their baby blues, there’s an exerciseprogram that may help them shed their dependence on correctivelenses.

No Help For The Farsighted

While nearsightedness is fairly common, farsightedness has farfewer options. Surgical solutions for farsightedness are relativelyexotic and generally outside the realm of “cosmetic surgery.” Other visual problems that lie far beyond the scope of the relativelysimple procedures mentioned here are cataracts, retinal problemsand complications from glaucoma. While each would be serious businessfor anyone seeking to retain a medical, that problem is secondaryto maintaining enough visual prowess to live a normal life.

Corrective lenses address two kinds of vision problems. One iscaused by a misshapen cornea. The cornea provides most of theeye’s focusing power, so defects here show up as nearsightednessor farsightednes. The other is typically caused by a hardeningor other deterioration of the lens in the eyes. This is calledpresbyopia and causes the visual deterioration found in middle-agedpeople who need bifocals.

Most nearsightedness stems from a result of a flaw in the shapeof the cornea. Essentially, the curvature of the cornea is toogreat for the depth of the eye, causing light to focus in frontof the retina. Glasses and contacts correct this flaw by spreadingout the light before it reaches the eye, then the eye can pullthe image into focus in the right spot.

Radial keratotomy is a treatment for nearsightedness that involvescutting 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 incisionscause the cornea to flatten, and the degree of correction canbe controlled by varying the depth and location of the cuts.A related malady – astigmatism – is caused by variations inthe curve of the cornea from one part of the eye to another. RKcan correct astigmatism, too, by flattening some parts of theeye more than others.

In general, people in their 30s through 50s are better candidatesfor RK than those who are younger. Eyesight can change substantiallyfor people in their teens, and those in their 20s have tissuethat’s so flexible and resilient that RK may not cause the corneato flatten much.

The Tricky Cut

RK surgery takes about 20 minutes per eye and is done using onlylocal anesthetic in the form of numbing eye drops. The psychologicalimpact of watching a knife homing in on your eye is somethingonly you can assess. (Imagine the first person who sat still forthis procedure…)

After the surgery is completed, improvement is nearly immediate.It is, however, as much art as science and the results are farfrom guaranteed. If you still require corrective lenses afterthe surgery, contacts may not be an option. You may be stuck withglasses. By most estimates the success rate of RK – definedas 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 outbetter than before. The operation costs about $1000 per eye andit can be done more than once to tweak the eyeball into shape.

Follow-up operations are generally done at no additional costbut most surgeons will not perform the operation more than twiceon a single eye. Normally, only one eye is done at a time. Thebig question is, what does the FAA think of RK-induced visionimprovements?

“The FAA says okay to RK in all classes [of medical certificate],and there’s no reason not to,” says Stanley Mohler, directorof aerospace medicine at Wright State University in Dayton, Ohio,and former director of the FAA’s Civil Aviation Medicine ResearchInstitute.

“The military has had some concerns, but they’re lettingsome people fly with it on a trial basis.”

The airlines vary on their policies regarding hiring pilots whohave had RK. The majors are following the military’s lead andhave been skeptical about candidates with RK in their past andwith so many candidates to choose for so few jobs, they can affordto 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 considerlasers to have the potential to surgically alter vision more precisely,on a wider variety of patients and with less pain and greatersuccess 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-situkeratomileusis, or LASIK. A thin layer of tissue is cut from thesurface of the cornea but left attached at one point, leavinga hinged “flap.” A computer-controlled laser then sculptsthe surface of the cornea to correct the nearsightedness, andthe flap is repositioned without sutures over the wound. Visionis noticeably improved within 24 hours and continues to improveover two to four weeks as the swelling goes down.

.”The doctor who did it was a researcher specializing inlaser treatment, so he was biased in favor of it,” says MarkSteele, a 39-year-old private pilot who participated in the clinicaltrial 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 20/20vision in both eyes. Cost of the procedure at Emory Vision CorrectionCenter in Atlanta was $3600.Some patients may end up with a bitof astigmatism from the operation, although this percentage sofar appears to be very low, researchers report. Another laserprocedure is called photorefractive keratectomy, or PRK. It’ssimilar to LASIK except that the laser sculpts the surface ofthe cornea without a flap of tissue being cut.

Between 5 percent and 10 percent of patients report a slight hazingof the cornea as a result of the surgery, but this is significantin only about 1 percent of cases. The process results in 20/40vision or better in 95 percent of cases and 20/20 vision in 66percent of cases. Both LASIK and PRK rely on excimer lasers. Thesedevices use ultraviolet light to heat and instantly vaporizethe corneal tissue.

The computer control allows the laser to skim about 1/3000th ofan inch from the surface of the eye. So far, only one excimerlaser, made by Summit Technologies, is approved for eye surgeryin the U. S. Several others used in other countries are undergoingclinical trials and should be approved in the near future foruse here.

Rewards and Risks

Anyone considering surgery should be aware of the downside. Theimportant thing is not uncorrected vision, but “best correctedvision.” For about 3 percent of surgical patients, the bestcorrected vision is worse after the surgery than before. As withany surgery, there’s a risk of complications ranging from infectionto an outright botch.

Sieper recommends that anyone seeking more information on surgicaloptions ask their family doctor or the American Society for Cataractand Refractive Surgery for a recommendation. Make sure the surgeonchecks your best corrected vision beforehand and measures thetopography of your eyes by computer.

Talk to other patients. Call the hospitals where the surgeon practicesand ask the nurses and office staff. Most of all, don’t blindlytrust advertisements.

Nonsurgical Options

Obviously, not everyone wants to trust their eyesight to surgery.One interesting non-surgical option we looked into is a seriesof eye exercises marketed under the name Vision Freedom. The premiseis that the muscles that control the lens of the eye can be developedthrough exercise, just as any others, allowing the lens to bestrong 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 $99.95from Brian Severson in Victor, Montana. The regimen requiresabout two hours per day, every day and contact lenses are a no-no.The company provides three pairs of glasses to wear while exercisingand a complete instruction manual.

Miller reports the glasses were of high quality and the manualmade sense. But for him, it wasn’t enough. As with any exerciseprogram, some people make it work while others lapse back to thevisual equivalent of couch potatoes. After a month, Miller andhis wife gave up, despite the fact that both of them noticed theirvision had “noticeably” improved.

“Unless you’re committed to it, it’s not going to do youmuch good,” he says.” What he says to do does work,but it’s probably unrealistic to think you could go from 20/200to no glasses.”

The company offers a 100 percent money-back guarantee it sayshas never been requested. Miller says he’s undecided if he’llask for a refund. A complicating factor in the exercise programis this: As your vision improves, you should get new prescriptionglasses to meet only the new level of correction.

In theory, that keeps the eye working and prevents the musclesfrom getting lazy from relying on what is now overcorrection.That means a trip to the eyeglasses store every few weeks. Someophthalmologists are skeptical that such exercises could do muchgood anyway. “There isn’t much you can do with those [internaleye muscles] because they’re so small,” Mohler says. “Besides,you’re always exercising those muscles anyway, every time youshift your focus from a book to the window and back.”

Given the relatively low price, Miller suggests Vision Freedommay be worth a try but don’t count on miracles. “I don’tthink it’s deceptive in any way. For someone who’s committed itmay work.”

With the range of options, the risk and the price tags, it’s clearthat anyone looking for clearer vision has a lot to consider.Keep in mind, however, that none of these techniques will preventor even correct the normal vision deterioration that comes withage. Someone who is slightly nearsighted approaching age 40 mayhave some options, but the same cannot be said of any other group.

Unlike myopia and hyperopia, presbyopia is the slight farsightednessthat occurs with age. The symptoms typically appear about age40 and for pilots, are most notable when trying to read charts at night. So far, the only treatments for presbyopia are bifocals/trifocalsand bifocal contact lenses that are optically weighted at thebottom.

You can prevent bad vision from getting worse by taking commonsense steps such as wearing UV-blocking sunglasses, avoidinglooking into the sun and refraining from smoking. You can alsomake 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 importantpart of the pilot anyway.”