LASIK for Pilots?

 

Safety, Air-Worthiness and other considerations

David A. Wallace, M.D.

 

Manuscript of article published in the October, 2000 Plane & Pilot Magazine

 

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

Laser vision correction refers to eye surgery using a computer-guided laser to re-shape the cornea (the curved front surface of the eye), correcting the optical prescription of the eye. The same laser can be used to perform LASIK or 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 corneal surface are removed, and the laser is used to re-contour the front layers of corneal tissue.  In LASIK, a precision microsurgical 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; the laser optically sculpts the collagen just under the flap; and the flap is returned to its original position. Creating the flap in this way eliminates the need to mechanically remove the covering cells of the cornea, 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.

Impressive Statistics

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).

Presbyopia and monovision

Presbyopia, the medical term for ageing eyes, makes it necessary to start wearing bifocals or reading glasses after about age 45.  There is no surgical cure for presbyopia, and LASIK typically does not improve or worsen this condition.  Monovision (derived from the Latin mono - one eye for distance, one eye for near focus) is in my opinion not appropriate for pilots, because it can impair binocular vision and depth perception.  Monovision was cited by NTSB as a contributing cause in at least one incident involving a Delta MD88 in 1996).

FAA Considerations

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. FAA does require a minimum of 6 weeks after LASIK to achieve visual stabilization, and expects individual Aviation Medical Examiners to certify a pilot based on standard medical and visual criteria.  Refer to the FAA and AME websites for a description of the published recommendations and reporting requirements that FAA maintains regarding LASIK and other forms of vision-correcting eye surgery.

Military Policy

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). To review official U.S. Navy Bureau of Medicine and Surgery policy on refractive surgery, see their website. .

 

Commercial carriers and Air Line Pilots' Association

Most US carriers (American, Continental, Delta, FedEx, and others) allow LASIK and adhere to the 6-week recovery guideline set by FAA.  United Airlines mandates 12-weeks of healing and stabilization after care.  Apparently, some carriers look the other way, practicing a form of “don’t ask, don’t tell,” wherein pilots can return to work right away, as long as they can pass the same visual tests all other pilots are given.

R. John Stepp, MD, an aeromedical advisor for ALPA, points out to all pilots that LASIK is surgery, and though results are typically very acceptable, a surgical mishap can be career-ending for someone in this occupation.  “All pilots should consider the downside very carefully before proceeding,” he cautions.  This hypothetical concern has also been voiced in relation to LASIK for professional athletes, but I am unaware of a single case in which a pilot's or pro athlete's career has been negatively impacted.

Pilots Considering LASIK

Pilots looking into LASIK should have their pupil size measured in darkness, preferably with an infrared-based measuring device. In my opinion, very large pupil sizes (7.5 mm and up in darkness) may create 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. Other analyses may be appropriate, depending on the setting or the history (for example, tear function testing, retinal evaluation, etc.).

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.

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 for evidence of malpractice claims against a particular surgeon (for example, www.knowx.com).

Select a surgeon as you would a fellow pilot

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.

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Dr. David Wallace is a board-certified ophthalmologist specializing in LASIK.  In private practice since 1983, he has performed thousands of laser surgeries to date, and has been an investigator for several FDA clinical trials involving laser care.  He has served as Medical Director of one of the largest laser clinics in North America . For more information, see www.LA-Sight.com.