Vision Correction Surgery for Pilots

Is LASIK the Holy Grail?


Medical bagSincethe dawn of aviation, generations of pilots and would-be pilots have lustedafter that which God did not give them. No, not wings — they want perfectvision. In addition to the annoyance faced by mere mortals who have to wearglasses or contacts, pilots around the world also must deal with stringentvisual standards from civil aviation authorities (like the FAA), the military,and airline companies. How wonderful it would be to toss away those spectaclesand join the ranks of the 20/20 elite! Over two million eager people, many ofthem pilots, will reach into their pockets this year with just such a goal inmind, and will undergo an operation known as LASIK, which is an acronym forlaser in-situ keratomileusis, and was first done in 1991. This form of cornealsurgery to correct bad eyesight has become the most popular elective surgery inthe U.S., but LASIK is not without its detractors. The LASIK boom has beenaccompanied by accusations that its benefits are over-hyped, and by reports ofserious complications. Some of these complications could be of particularconcern to pilots who might be eyeing a professional aviation career.

What’s a LASIK, Anyway?

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

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

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

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

Aeromedical Certification and Eligibility Issues

The FAA…

FAA logoFromthe medical certification point of view, the FAA’s approach to LASIK and PRK isrelatively liberal. The FAA is primarily concerned that vision has stabilizedpost-operatively, that there have been no significant adverse effects orcomplications, and that the pilot meets the appropriate FAA vision standards forthe class of medical certificate held. There is no longer a specified length oftime a pilot must wait before returning to flying.

After a pilot’s treating surgeon has released him or her to resume normalduties, the surgeon needs to document in the pilot’s medical record that therehave been no complications such as night glare, "haloing," orhaziness, and forward a copy of the note to the Aeromedical CertificationDivision (ACD) in Oklahoma City. One way to accomplish this is for the doctor tofill out the standard FAA Form 8500-7, "Report of EyeEvaluation." The FAA has not been issuing new medical certificates, butat some point weeks or months later the ACD will send a letter of acknowledgmentthat 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’sreport that demonstrates you can meet the vision requirements for your class ofmedical. In the off-chance you get ramp-checked, it could be awkward if yourrequired corrective lenses have suddenly vanished. Also, it would be a good ideato take these updates to your Aviation Medical Examiner at the time of your nextflight physical. Barring complications, he or she should be able to issue you anew certificate if you are otherwise qualified. The latest FAA policy isavailable in the FAQsection of the Civil Aeromedical Institute Web site.

For those who are seeking a First or Second Class FAA medical certificatewithout corrective lenses, it is important to note that the standard requires20/20 visual acuity in each eye separately. While it was surely emancipating totoss out your coke-bottle lenses when LASIK took you from 20/300 to 20/30vision, that will not be enough to get you a First class medical withoutcorrective 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 IImedical certificate. Not everyone gets so good a result.

…Transport Canada…

The policy of Transport Canada towards LASIK and PRK is more conservativethan the FAA’s, requiring a six-month waiting period after surgery beforeapplying for recertification. Testing and reporting requirements are also alittle more stringent for the first year post-op. Additionalinformation 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, orany NATO nation, and you are looking at LASIK to help you meet military visionstandards, save your money. It just isn’t an option now or in the foreseeablefuture. The military, including the reserve forces, have too many doubts aboutlong-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 anaircraft ejection, and long-term eye health in terms of glare and visionstability.

Several aviators, including flight surgeons, have tried to circumvent thispolicy with dire consequences when they were found out. One Army flight surgeonwho had refractive surgery lost several years of flight pay retroactively, andwas medically disqualified. The services are considering studying refractivesurgery in aircrew more extensively, but the time required to obtain enoughresults to change military policy guarantees the status quo for years. If themilitary starts having trouble filling the fighter jock ranks with natural-borneagle-eyes, this could change. Don’t look for NASA to buy into LASIK forastronaut candidates, either.

What About The Airlines?

Although it may not be true, many pilots feel that wearing corrective lenseshurts their chances of a career with the airlines. It’s not possible to makeiron-clad statements about how the major airlines regard vision correctionsurgery, because each company is free to set its own standards. Most major aircarriers do allow their pilots to fly after having refractive surgery, althoughthis was not the case in the early 1990s.

U,S, Supreme CourtForair carrier pilot applicants, the situation is not clear cut. An airline mayimpose a waiting period of six months or more post-op before it will considerhiring an applicant. American Airlines responded to a query about LASIK with asomewhat cryptic, "Each case is decided on a case-by-case basis."United Airlines’ official material for those interested in pilot positions doesnot mention LASIK. United does require a flight officer’s uncorrected vision tobe 20/100 or better in each eye, which is a higher standard than the FAA imposesfor a Class I medical certificate. TheU.S. Supreme Court last year upheld United’s ability to require this higherlevel 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 thelatest 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 thissurgery (aside from the cost)? The vast majority of patients who have theprocedure are happy and have a successful (for them) outcome. No surgicalprocedure is without risk, however, and LASIK is no exception. The risk of avision-threatening infection is very low, but is very real at one-to-five per10,000 eyes. Other complications occur at a rate of about one per 100 eyes,including problems that can lead to corneal scarring. Irregular astigmatism canoccur that decreases vision. Some patients have severe and persistent dryness ofthe eyes, which can range from merely annoying to the necessity for thenear-continuous use of eye drops. Most of the immediate post-surgicalcomplications involve the corneal flap and can be repaired, but cornealepithelium growing under the flap at a later date requires a flap revision inabout 1% of patients.

Performing LASIK surgeryPatientsfrequently experience a post-LASIK visual haziness, with glare and halos aroundlights at night. These problems usually clear after a few weeks to months, butsome 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 (forexample, from 20/20 to 20/40 on the eye chart). A rare patient suffers visualacuity that continues to fluctuate. While an initial under- or over-correctioncan 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 absolutenumber of people with refractive surgery horror stories is growing. For thosenot faint of heart, many of these storieshave 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 dogive examples of some of the aviation-career-ending complications that can occurwhen refractive surgery goes wrong.

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

LASIK proponents have come under fire for not adequately warning theirprospective patients of some of these risks, and for giving the impression thatany problems which occur can be corrected by a repeat procedure if necessary.One unanswered question is how many complications result from poor equipment orsurgical technique. The medical establishment would like us to believe thatproper physician training, technique, equipment and patient selection willprevent most complications. How an individual near-sighted consumer is supposedto judge all of these parameters for himself is problematic, but your decisionshould definitely not be made based on price alone. The popularity of theprocedure has caused many surgeons with relatively little experience to jump onthe lucrative bandwagon, driving prices down in some areas. Finding a doc withthousands of LASIK eyes to his credit may be the most important part of theprocess 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.