To See or Not to See
Airline pilots should stop and think before even considering LASIK for vision problems.
By Capt. Jolanda Witvliet (United)
Air Line Pilot, August 2003, p.27
I was like a lot of pilots, tired of wearing contact lenses and ready for a fix. I looked into a variety of eye surgeries and rejected all of them except laser-assisted in-situ keratomileusis (LASIK). I am sure that almost every one has heard of LASIK and has read the advertisements in the newspaper: Have LASIK performed for $499 per eye! LASIK corrects vision problems, primarily if you are myopic (unable to focus on distant objects).
I started my research into the procedure itself and its possible side effects by locating a good surgeon. I found an eye surgeon who came highly recommended. He had performed numerous LASIK surgeries, including on colleagues. This surgeon was considered to be in the top 5 percent of the world’s best eye surgeons. How could I go wrong? The procedure was touted as an easy in-house 10-minute operation. You walk in with your glasses and walk out a new person without them. I read the brochures and considered the risks. I felt that the risks that were addressed, at that time, were minimal, both in percentage and in complications.
I had to be tested first to determine if I was eligible for the procedure. Because I live in Denver and the surgeon’s office is located in Toronto, I was tested locally and considered a great candidate for the LASIK surgery. I scheduled some days off for the surgery (travel time up and back to Toronto, another test the day before the surgery, a day for the procedure, and a day to recover).
The "unfortunate incident"
Tested again when I arrived in Toronto, I was again deemed an excellent candidate for the LASIK surgery. The day of the procedure, I was given some Valium (to relax, I was told) and led into the operating room. The surgeon started with my right eye (OD is the code for the right eye). Before the laser can penetrate, a micro-keratome blade has to cut a very thin flap in the cornea. The flap then has to be peeled back and the laser is then activated.
Unfortunately for me, the doctor’s assistant at the clinic had improperly assembled the micro-keratome. Although she was trained on the proper assembly of the keratome blade, she had left off a spacer required for this procedure. The surgeon did not double-check the blade and inserted it on my cornea. It penetrated the full thickness of my OD cornea, damaging the iris and pupil and obliterating the lens. The surgeon quickly noted the error and shouted to stop the blade. However, the damage was done. I was rushed to the emergency room at a Canadian hospital. There, the surgeon removed the remnants of the damaged lens and sutured the iris and cornea.
I was without vision in that eye for more than 7 months. My depth perception was seriously affected. I had great difficulty with most normal tasks, such as bicycling, driving, walking, pouring a glass of water.
Of course, I could not fly during this time. Although some pilots have a SODA (Statement of Demonstrated Ability) for defective vision in one eye, I was never able to get used to not having vision in my right eye.
Every month or so, a suture had to be removed, as they would not dissolve. Going to the ophthalmologist was always a bit traumatic for me. He had to cut the suture and then pull out the remnants. What if he had to sneeze? What if I had to sneeze? Luckily, it all went well.
After the cornea had somewhat healed from the initial wound, I needed to have an intraocular lens (IOL) implanted. This plastic lens is also used for people with cataracts. I traveled back to Toronto and had the IOL implanted. This provided me with fixed-distance vision. An IOL does not focus like a natural lens, and therefore it is set at a fixed distance. This provides little unaided close-up and intermediate vision. However, I was excited to have regained some distant vision in my right eye.
Getting recertified by the FAA and by my airline took a little while; however, 3 months later, I had my medical certificate again.
Another setback occurred after a while. The lens clouded over, causing a secondary cataract. I was unable to fly during that period of time, as the cataract affected my night vision. Shortly thereafter, I had the secondary cataract removed by an ophthalmologist.
Several of the ophthalmologists I saw for these repairs remarked, "You are lucky that more damage was not done and that the surgeon performed a good fix-up job." Somehow that did not really comfort me. I did ask the surgeon if he and his assistant used a checklist for their procedures. We all know, as pilots, our checklists are usually "written in blood" by somebody who has made a major mistake. He replied that they did have a checklist. My response that, "Well, wouldn’t it have been nice if you had used it!!"
More side effects
Unfortunately, my troubles did not end there. After a while, I noticed that my vision fluctuates with altitude, not unlike the vision of radial keratotomy (RK) patients. I had my eyes tested at different altitudes and confirmed this problem. Fluctuation complications were the reason I did not want to have RK performed on my eyes.
Also, finding satisfactory glasses/contact lens prescriptions for flying is challenging for me because I am dealing with a healthy eye and one that is severely compromised. I have tried an avalanche of corrections—progressive lenses, bifocal lenses, trifocal lenses, reading glasses, soft contact lenses, rigid gas-permeable contact lenses, etc. While before my LASIK surgery I might have met with my optometrist once a year, nowadays, I often have monthly or more frequent visits!
Lastly, I am experiencing fluctuations that over time seem to be cumulative. As I fly more, my right eye fluctuates more, and I experience more pain. I am told that the cornea, because of the full thickness penetration, swells, causing the different refractive readings.
Navigating the legal aspects
You might ask why I, living in the United States, went to Canada for this surgery. At the time that I had my LASIK surgery performed, Canada was the leading place for excellent and experienced refractive surgery. To this day, it is still the leader, with more than 3 years of experience in the new custom LASIK procedures, while the United States was only recently approved by the FDA. After all, would you want a doctor who had been doing refractive eye surgery for many years, or somebody who is just breaking into the business?
Obviously, after my experience, I looked into a lawsuit for gross negligence. However, the laws in Canada are a bit different from those in the United States. Canada has numerous financial limits on lawsuits, and bringing expert witnesses to a trial can become extremely expensive. Damages for pain and suffering are limited to C$250,000 and are usually awarded only if the patient is severely injured during the surgery (to the point of having to use a wheelchair). A damaged eye might range from only C$20,000 to C$70,000. Also, future income loss can be very restrictive for the plaintiff (that would be you).
Although the actual damages and awards for income loss can be higher if you bring a lawsuit against a doctor or clinic in the United States, the experience is emotionally and financially draining. Also, these lawsuits might drag on for years through appeals. Insurance companies tend to be very reluctant to settle, and their pockets are much deeper than yours. You could end up being financially responsible for expert witness fees, reports, attorney fees, court costs, etc. I experienced firsthand how deep insurance company pockets are and had to take out a second mortgage to pay for all the fees.
Do you feel lucky?
If you consider having refractive surgery, I would say, "Think about it twice." The great news is, if you have LASIK surgery and it works well, it is great. Your distance vision can be corrected to 20/20 and you feel like a new person, waking up in the morning and being able to see the alarm clock. But, as in any operation, things can go wrong. Would you be able to continue flying as an airline pilot if you see glare or halos at night, experience fluctuation or loss in vision, and/or your vision could not be corrected properly? What if the surgery corrected your vision to only 20/30? You would still need glasses (contact lenses are usually hard to fit after refractive surgery) to meet the FAA visual requirements for pilots. You would also probably need reading glasses a lot sooner, especially if you are older.
Although the odds are low that something extreme will happen, the odds of side effects (which are included in the consent form that you sign), such as glare and halos occurring, are much greater. In one case, an airline pilot experienced 20/20 vision after LASIK surgery but has not been able to see at night satisfactorily because of severe glare, double vision, and halo problems.
On numerous occasions since my botched LASIK surgery, I have wished that I had never heard of the surgeon who performed the operation or of LASIK surgery! After I read a book on LASIK surgery written for refractive surgeons, I realized that 90 percent of the book was devoted to problems during and after surgery. Can you live with those odds with your eyes?
If you consider having refractive eye surgery, or you have had it done and are experiencing problems, I have some resources to recommend to you.
One organization is a clearinghouse of information for people with refractive eye surgery problems. It enlists the help of ophthalmologists and optometrists to try to find solutions to vision issues. If you are considering LASIK surgery, peruse this website. It makes for interesting reading! If you are experiencing problems after refractive surgery, consider reading its Forums—they have a lot of useful information. The organization’s website address is www.surgicaleyes.com.
Also, ALPA’s Aeromedical Office is an excellent resource, and your dues dollars cover costs for ALPA members. ALPA’s aeromedical advisors can provide you with the most up-to-date information regarding eye surgery and the FAA’s thinking on it. They can also help you in trying to get your FAA medical certificate back, if complications occur. The Office is located in Aurora, Colo., 303-341-4435. Have your ALPA membership number ready when you call.
If you have any questions regarding my case or need additional information, please feel free to e-mail me at firstname.lastname@example.org.
Capt. Witvliet also co-wrote "Emily Warner—The First Female Pilot Member of the Air Line Pilots Association," June/July 2000.
on Vision-Correction Surgery
By Donald Hudson, M.D., ALPA Aeromedical Advisor
As Capt. Witvliet so vividly describes, a professional pilot who has LASIK or other vision-correction surgery is potentially putting his or her career at risk for what is, essentially, cosmetic surgery. At the present time, the FAA will allow pilots to fly following successful vision-correction surgery. Once the vision stabilizes (for the vast majority who undergo LASIK this occurs in about 4–7 days), the pilot should have the ophthalmologist complete FAA Form 8500-7, Report of Eye Evaluation. This form is available at the AME’s office or may be downloaded from the FAA website.
A pilot whose vision corrects to FAA standards (correctable to 20/20 in each eye separately for distant vision and 20/40 for near vision and intermediate vision if more than 50 years of age) and who has no other serious complications, such as night glare, hazy vision, or fluctuating acuity, may return to work and report the surgery at the time of his or her next FAA physical examination. Reporting the surgery to the FAA and obtaining written clearance before returning to duty is no longer necessary. However, some airlines (United, in particular) require clearance from their medical departments before one of their pilots may resume flight duties.
Another potential problem is that often the pilot’s medical certificate still bears the limitation "Must wear corrective lenses." This could turn an FAA inspector’s routine ramp check into a "bureaucratic adventure"—even though the pilot meets the FAA vision standards without glasses. Two realistic options exist in this situation: One is that the pilot could continue to carry glasses when flying until the next certificate is issued without any vision limitation.
Alternatively, the completed FAA Form 8500-7 may be mailed to the FAA in Oklahoma City, and the FAA will respond with a letter acknowledging that the vision limitation is no longer required on the medical certificate. This may take several weeks, but it will make the next FAA physical exam much more straightforward for the AME and remove any doubt about whether the pilot may be issued a "clean" certificate. The ALPA Aeromedical Office recommends this course of action and can help pilots who are not comfortable with the process. At the very least, pilots going for their next medical exams should discuss this issue with their AMEs before starting to fill out the paperwork to get their certificates. This also avoids the disastrous possibility that an unsure AME would defer issuance to the FAA in Oklahoma City—potentially leaving an airline pilot without a medical certificate for as long as several weeks!
Although LASIK is by far the most common visual refractive surgery performed today, others will become available in the next few years. For a complete discussion of these surgeries and the potential FAA implications, visit the Virtual Flight Surgeon’s website at www.aviationmedicine.com and go to the subject index. As always, ALPA pilots with questions may consult the ALPA Aeromedical Office in complete confidence and free of charge at 303-341-4435.