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
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,
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. See www.cami.jccbi.gov/AAM-300/amcdfaq.html
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: https://navymedicine.med.navy.mil/default.cfm?seltab=bumed&ecmid=93E9008D-802E-D019-ABBA0925B2764081&docid=15144.
Commercial
carriers and Air Line Pilots' Association
Most
R.
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