Is Lasik just too risky for professional pilots?

 - May 8, 2008, 7:20 AM

You may have seen the ad featuring a picture of a stereotypical pilot in cool sunglasses and touting: “Fighter Pilot Requirements: Lightning Reflexes, Nerves of Steel, 20/20 Vision. Lasik. We’ve got the vision part covered.” For professional pilots whose vision is correctable to 20/20 with contacts or glasses, ads like this may tempt them to want to toss their glasses or contacts out the window.

And they may be further swayed by the industry touting a 97-percent success rate. But the voluntary election to have Lasik surgery may be more risky to professional pilots than to the general public based on data from the FAA, and personal experiences of some pilots who have had the vision-correction procedure.

Consider the experience of former United Airlines Boeing 737 captain Steve Post of Sierra Vista, Ariz., who had his medical revoked as a result of complications from Lasik surgery. Post, whose vision was correctable to 20/20 via glasses before the operation approximately one year ago, now suffers from permanent and severe night-vision problems, including starbursts, halos and ghosting. The result is a revoked medical that ended his flying career.

“When I first realized the problems were not going away, as they said they would, I was in a lot of turmoil,” Post told the Arizona Daily Star. “I loved my job, I was set for life. There has been a lot of difficulty accepting that this really is the end of my [flying] career. It’s been very hard to let go.”

What Is Lasik?
Lasik, short for laser-assisted in situ keratomileusis, is the latest in a long line of corrective eye surgeries that began in the early 1960s, including automated lamellar kertaoplasty (ALK), radial keratotomy (RK) and photorefractive keratectomy (PRK). These surgeries reshape the cornea of the eye using either scalpel incisions or, as is the case with Lasik, laser removal of corneal tissue, to correct various vision problems such as myopia (nearsightedness), hyperopia (farsightedness) and astigmatism (irregular corneal curvature).

The main instrument used in the Lasik procedure is the excimer laser, which can remove 39-millionths of an inch of tissue in 12-billionths of a second. Lasik patients usually undergo a brief examination a few days before the procedure to determine acceptability and to assess for risks of complication. Pupil size, visual stability and inability to wear contact lenses, although not automatically disqualifying, can all affect the outcome of the Lasik procedure.

But with the procedure taking only about five minutes per eye and generating a revenue of $500 to $1,500, Lasik has become an overnight money-maker for ophthalmologists and other vision professionals who sometimes engage in slick advertising and gloss over the risk factors. Between one and two million people are estimated to have had refractive surgery performed last year alone.

More Risky for Pilots?
Although the Lasik providers do inform patients of the risks of the surgery–including normal risks of infection, eye pain and mistakes due to handling the laser–the industry is generally not familiar with the visual standards that professional pilots must meet to keep flying. Some pilots and other aviation professionals have found that the average Lasik provider is not able to adequately warn them of possible post-operative side effects that may not cause “the average Joe” to pause. These effects include over and under correction, poor night vision (including night glare, halos and starbursts), extreme dryness and regression.

For example, a flight attendant from Houston experienced extreme dryness after Lasik surgery due to “pressurization in the cabin, which the surgeon said was a non-issue.” Severe sensitivity to light accompanied the dryness, and the flight attendant was unable to work until she had an “enhancement” procedure done months later.

Some of the complications that can affect a pilot’s career are not relatively rare, even by the Lasik industry’s own admission. According to TLC Laser Eye Centers, a network of Lasik providers in the U.S. and Canada, incidence of significant night glare is one in 50. “Night glare is common immediately following the procedure and will typically last for three or four months,” reads TLC’s Web site. “[After] six months have passed, your night glare tends to decrease and you should be back to where you began. However you may still require glasses for driving at night.”

“The problem with the Lasik industry’s high success rate is that it is based solely on the ability to see 20/20 on an eye chart,” said Ron Link, executive director of The Surgical Eyes Foundation, a nonprofit organization dedicated to alerting consumers of the risks of refractive surgeries. “You can have 20/20 vision after refractive surgery and still be severely compromised with multiple images, ghosting, halos, loss of contrast sensitivity and other complications. Unfortunately, those complications don’t make it into the visual acuity statistics.” Link points to a European study that found more than 53 percent of Lasik patients suffered haloing and other night vision-related side effects that were serious enough to affect their ability to drive a car at night.

Link explained that the problem is compounded by the fact that many of the complications and side effects are permanent and may not be correctable. “Many times if a person experiences complications, there may not be any recourse,” he said. Although there are new macrolenses on the market specifically to help combat some of the complications of Lasik, they are expensive, extremely hard to fit and do not work for everyone.

Another problem with Lasik is the possibility of regressing back toward non-20/20 vision without the option of using contacts or glasses to correct. A corporate pilot from Michigan, who does not wish to be identified, had the procedure done in Canada five years ago when it was still experimental and not approved in the U.S. Although he is thrilled with the results of his surgery, which corrected his former 20/400 vision to 20/20, his latest visit to his optometrist showed his vision was slipping to 20/25 and he was told that his vision would not be correctable to 20/20 with glasses. Fortunately, he still passed his last FAA medical exam, remarking that the letters “were not blurry, they were just very small,” but he worries about future exams.

“The risks for those of us in aviation are a little more pronounced than for most,” said the Michigan pilot. “If I had to make the decision, today, I don’t know if I’d do it again. Back then I was screened for four months, going in for an exam once a week to be sure my vision was stable before the procedure. The doctors spent a great deal of time trying to talk me out of it, and specifically told me that the procedure may leave me uncorrectable to 20/20. Nowadays I hear three different clinics hawking Lasik on the radio every day, and in these surgery mills I’ve had non-pilot friends who see the doctor on Tuesday and are under the laser on Friday.”

The FAA’s Position
According to Dr. Bill Salazar, Southwest region director of the FAA aeromedical division, the agency has no specific policy covering refractive surgery. “Pilots are free to have these procedures done,” he said, “but they must be able demonstrate applicable visual acuity to meet the standards for their class of medical after the procedure. Basically, that means a letter from the treating surgeon stating that their visual acuity has stabilized.” Salazar said that in many cases directly after surgery, the acuity of each eye can fluctuate wildly, going from 20/20 in the morning to 20/40 or worse in the afternoon.

In the case of ghosting, haloing or other night-vision complications resulting from Lasik surgery, Salazar said that it may be possible to obtain a day-only vision waiver, although this is probably not an option for a professional pilot. “We reserve the right to look at each individual case,” he said. “The FAA is willing to look at anything that will help keep people flying, and we’ll review every case to see what can be done.”

The statistics seem to support the FAA’s willingness to work with refractive surgery patients. According to the FAA’s office of public affairs, more than 6,800 airmen applied for waivers due to refractive eye surgery last year, and only 59, or less than 1 percent, were denied medicals because of the procedure results.

“From the medical certification point of view, the FAA’s approach to Lasik and PRK is relatively liberal,” said Dr. Kim Broadwell, a corporate pilot and physician who was a flight surgeon for both the U.S. Army and NASA. “But for those who are seeking a first- or second-class medical certificate without corrective lenses, it is important to note that the standard requires 20/20 visual acuity in each eye separately. While it is emancipating to toss out your coke-bottle lenses when Lasik takes you from 20/300 to 20/30 vision, that will not be enough to get you a first-class medical without corrective lenses.”

Meeting the visual acuity standard for each eye is key, since some Lasik practitioners are commonly recommending the procedure be done for only one eye at a time, for both financial and medical reasons.

Although the FAA maintains a fairly liberal stance on refractive surgery in general, the armed services take quite a conservative stance on Lasik surgery in particular. Although the U.S. Air Force and Navy currently have waiver programs for aviators who have PRK performed, Lasik is still unauthorized in both services and results in immediate disqualification of pilot duties. The U.S. Army still prohibits both procedures for its aviators, but does provide PRK procedures free to certain non-pilot soldiers.

Minimizing the Lasik Risk
While, statistically speaking, the FAA’s 1-percent denial rate on medical waivers for complications to refractive surgery may seem like a good risk to take, 28 of the 59 refractive surgery denials last year were professional pilots seeking first- or second-class medicals. Depending on the nature of the complication and factoring in the relatively low rate of correctability for post-Lasik procedure complications, this means the careers of 28 professional pilots may have ended last year due to this elective surgery.

It is clear that performing any sort of eye surgery can be risky, especially to a currently licensed pilot who does already have visual acuity correctable to 20/20 in each eye. But there are some steps that the professional pilot can take to minimize those risks if he or she is determined to have a vision-correction procedure.

First, do your research on the procedure itself. A good place to start would be the Surgical Eye Foundation’s Web site ( The site is packed with information regarding various refractive surgery procedures, additional resources and personal accounts of those who have had these procedures performed.

Second, find a clinic that is willing to work with you as a pilot, understanding the increased risk you face. Be sure that the clinic will conduct a thorough exam that assesses your risk as a patient, including your pupil size, current eye dryness and visual stability before you elect to have the surgery, and that a reevaluation will be done the day of surgery. Also be sure that the clinic will work with you post-operatively to make any additional corrections that may be needed or to help with any complications that may occur.

Third, look into procedures other than Lasik, such as PRK, implanted corneal rings and other surgical eye procedures. Although Lasik is becoming relatively widespread, that doesn’t mean that it is the best solution for pilots who want to rid themselves of coke-bottle glasses.