This page is written to address the special needs of pilots considering laser vision correction. I wrote an article on this topic which is now several years old, and much more updated information is available. We will review all relevant information herein.
Laser vision correction—and more specifically, LASIK (for laser-assisted intrastromal keratomileusis)—is a very popular means of correcting common vision problems, including nearsightedness (myopia), farsightedness (hyperopia) and astigmatism. It’s estimated that more than 2 million people in the U.S. have had laser eye care; worldwide, the number may exceed 8 million. The fairy tale promulgated by many who offer this care is that perfect, crystal-clear vision can be obtained overnight, with no side effects and with excellent long-term stability.
As good as LASIK sounds (and, in fact, is—in the overwhelming majority of cases), there are special considerations that pertain to pilots who may be considering this type of care. What makes you a good candidate for LASIK? What should you expect as part of a careful and complete consultative evaluation? What’s the FAA’s position regarding flight status and LASIK? What are the sentiments of the major commercial carriers, pilots' unions and the military regarding LASIK in pilots? And, should you decide to seek care yourself, what’s the best way to find a LASIK specialist for your care?
How LASIK Works
LASIK refers to eye surgery using a computer-guided ”excimer” laser to re-shape the cornea (the curved front surface of the eye), thereby correcting the optical prescription or refractive error of the eye. The same laser can be used to perform PRK (photo-refractive keratectomy), now a much less-popular procedure, though equivalent to LASIK in accuracy, safety, and stability.
In PRK, the cells covering the outer corneal surface are removed, and the laser is used to re-contour the front layers of corneal tissue. In LASIK, a precision instrument is used to create a flap of corneal tissue a few thousandths of an inch thick. The flap is opened like a page of a book, and the laser then optically sculpts the tissue just under the flap. When complete, the flap is returned to its original position. Creating the flap in this way eliminates the need to mechanically remove the outer covering cells, as done for PRK, and thereby dramatically reduces any scratchy “foreign-body” sensation or pain following surgery. Visual recovery is much faster with LASIK than with PRK— virtually immediate in some cases, as the optical integrity of the cornea is preserved. The benefits of LASIK include faster visual recovery, more rapid healing, less risk of haze or scarring and less potential discomfort than with PRK.
Recent clinical studies of LASIK reflect impressive accuracy. One such study, by Navy ophthalmologist Steven Schallhorn, analyzed visual outcomes in a population of navy recruits with nearsightedness up to 10.0 diopters and astigmatism up to 4.00 diopters. Schallhorn reported the results of his study at this year's American Society of Cataract and Refractive Surgery meeting (April 2000, Boston). In this study, 100 percent of patients recovered 20/40 (“driving”) vision, 92 percent achieved 20/20 ("normal") vision and 70 percent attained an impressive 20/16 vision (even sharper than normal).
Pilots sometimes ask me, "What’s the FAA’s policy on LASIK?" According to Steve Goodman, M.D., the FAA Regional Flight Surgeon, Western Pacific Region, the FAA has no policy on LASIK per se, as their only charter is the protection of federal airspace. They do require a minimum of 6 weeks after laser eye care for healing and stabilization. FAA looks to the individual AMEs to certify a pilot based on standard medical and visual criteria. And, as we know, AME's are human, and some may not be terrifically meticulous in their examination techniques.
The United States Navy has strong opinions about laser vision care. PRK has been extensively studied by the Navy and is currently the procedure of choice. All forms of corneal refractive surgery are disqualifying for general Naval and Marine Corps duty; however, refractive surgery waiver requests are considered on a case-by-case basis for applicants to Special Duty communities (undersea/diving/special warfare, surface warfare and aviation warfare). We suggest you review official U.S. Navy Bureau of Medicine and Surgery policy on refractive surgery, which as of April 2009 was not available on any public-facint website maintained by the Navy or Department of Defense. See our page on Laser Vision Correction and Military Sevice for more information.
Commercial Carriers and Pilot Unions
Commercial carriers each have different regulations about LASIK for their pilots. American, Continental, and FedEx permit LASIK, embracing the same 6-week healing and stabilization requirement as the FAA. United Airlines allows LASIK, but requires a 12-week healing period after care. Some carriers (America West) practice a form of "don't ask, don't tell" in which they allow their pilots to return to flying as soon after LASIK as an AME will flight-certify them.
Pilots Considering LASIK Surgery
Pilots looking into LASIK surgery should have their pupil size measured in darkness, preferably with one of several infrared-based measuring devices. In my opinion, very large pupil sizes (7.5 mm and up in darkness) may suggest an increased risk for halo and night vision disturbances after LASIK. It’s the night- vision effects that cause me to very carefully evaluate and counsel pilots (and air traffic controllers, for the same reasons). Both groups have high expectations and demands for a very high level of performance under low-light conditions and darkness. However, there are no absolute scientific references to back this up, and I will acknowledge that other, very experienced LASIK surgeons may not share this opinion.
The ideal LASIK workup should include a careful refraction (prescription measurement), evaluation of overall eye health, evaluation for disqualifying visual factors (corneal distortion, cataract, etc.), and screening to identify abnormal medical factors. Corneal topography (or more recently, integrated topography and tissue thickness analysis) should be performed and explained. Other analyses may be appropriate, depending on the setting or the history (for example, tear function testing, retinal evaluation, etc.).
Finding A Good LASIK Specialist
I would advise seeking care from someone who has performed at least 700 LASIK procedures. Check to see that the surgeon has a valid medical license (state medical boards list this information on their Websites) and is a board-certified ophthalmologist. Ask to speak with other patients, perhaps ask to view actual surgery, and request disclosure of the surgeon’s LASIK results. These results should be carefully tracked, and the more-proficient surgeons generally have less to hide. If you want to be extra careful, you may want to check one of the public information databases on the Internet evidence of malpractice claims against a particular surgeon (for example, www.knowx.com).
What’s On the Horizon?
Laser systems for vision correction, like aircraft, are continually being enhanced, improved and upgraded. Current "third-generation" laser systems do a pretty superb job for most people. In the future, laser systems hope to be able to offer individualized treatments based on the optical “fingerprint” of each eye. These new “wavefront” laser systems are currently in beta-test and are unlikely to be widely available for at least a year. They may be able to offer increased accuracy over current systems and greater control over certain optical aberrations (i.e., coma, chromatic aberration, spherical aberration), and night vision problems.
Surgeons, like pilots, are human. Like pilots, surgeons can suffer lapses in judgment, “pilot error,” equipment fault, or other errors. Remember, these are the only pair of eyes you've got. Be very careful. Try to find a surgeon who’s as conscientious, meticulous, methodical, insightful, experienced and compulsive as the best pilot you know, and you'll likely be in great hands.