THE CIVIL AVIATION MEDICAL EXAMINER AND YOU

FEATURE

Refractive Eye Surgery

by Dr. Jim Pfaff, Senior Consultant, Policy and Standards, Civil Aviation Medicine, Civil Aviation, Transport Canada

Civil Aviation Medicine receives a lot of questions regarding the visual requirements to be a pilot. Contrary to popular belief, perfect uncorrected vision is not a requirement to be a pilot or an air traffic controller. Glasses, contact lenses and refractive surgery are all (with certain limitations) acceptable ways to correct visual acuity problems. This article will address the expanding realm of refractive surgery as an approach to achieving better vision.

Technological changes and medical experience has brought forward a proliferation in the availability and options in eye surgery directed at improving visual acuity. Civil Aviation Medicine has monitored the progress and has adapted the medical guidelines regarding certification for flight to reflect the growing body of knowledge and experience in this important area.

Which procedure does Transport Canada (TC) recommend?
TC’s position in this regard is that refractive surgery is an elective procedure, i.e. a voluntary personal decision entered into after careful consideration of the risks and benefits, and discussions between the pilot and their attending physicians.

While there are many techniques available, some earlier methods are dropping out of favour while others are evolving rapidly both in technical precision and popularity. The list includes clear lens extraction, Radial Keratotomy (RK), Astigmatic Keratotomy (AK), Automated Lamellar Keratoplasty (ALK), Photorefractive Keratectomy (PRK), Laser-assisted in-situ Keratomileusis (LASIK), Laser Thermokeratoplasty (LTK) and Intrastromal Corneal Rings (ICR), to name only a few. The details of these procedures are beyond the scope of this article; further information is available from the ophthalmology community.

Which surgical centre does TC recommend?
TC’s medical advisors cannot direct prospective candidates to a specific service provider. There are many providers available who use a variety of techniques and have a wide range of experience and success. Anyone considering a procedure should spend some time investigating the procedure and the provider. The watchword should be caveat emptor—buyer beware.

Why does TC have concerns about this procedure?
While the advances in this area of surgery have been impressive and the outcomes have improved in terms of fewer complications and shorter period of incapacitation, there are still issues that have a serious potential to affect safety in flight. The most important risks from an aviation standpoint are loss of best corrected visual acuity, undercorrection or overcorrection, fluctuation in vision at different times of the day, glare, “halo” or “starburst” effect due to corneal haze, loss of contrast sensitivity, loss of low contrast visual acuity, and regression or return towards pre-operative refractive levels.

It is, therefore, quite important that these concerns be adequately addressed in the post-operative period before a return to active operational flying or air traffic controller duties is permitted.

Who needs to know when this surgery has been done?
You need to inform the eye centre that you are a pilot or air traffic controller. They have an obligation to report your situation to TC Civil Aviation Medicine. You should inform your Civil Aviation Medical Examiner (CAME), as they need to update your file and ensure that you are aware of your obligations with respect to grounding yourself. While there is no requirement to inform the regional Civil Aviation Medicine office directly, you might want to consider it if you are in a career situation where return to authorized flying activities is a priority. This would alert Civil Aviation Medicine and help to expedite the re-certification when the reports are ready.

Failure to inform TC Civil Aviation Medicine about this surgical procedure could lead to enforcement action, should the circumstances come to light in the future. “Miraculous” improvements in visual acuity found at renewal medical examinations with your CAME will be pursued.

Non-disclosure to aviation employers will undoubtedly result in a similar dim view of the situation. The majority of carriers and employers will accept these procedures if TC has approved the medical certificate. For those thinking about a flying career in the Canadian Forces, it would be prudent to check the military’s current medical policy for aircrew entry and activity.

What documents do I need to submit in order to reinstate my licence after undergoing this procedure?
Submit a report 30 days (4 weeks) post-surgery to the local office of your Regional Aviation Medical Officer (RAMO), using the Refractive Surgery form found on the TC Civil Aviation Medicine Web site (http://www.tc.gc.ca/eng/civilaviation/opssvs/cam-eyesurgery-75.htm).

If ophthalmic medications (eye drops or oral) are still being used to control pain or other symptoms, then the report should be delayed until medications have ceased. This does not apply to the so-called “artificial tears.”

The report can be from the attending ophthalmologist or an optometrist and should include information concerning:

  • the pre-operative visual acuity,
  • the date of the surgery,
  • the type of procedure,
  • the size of the ablation zone (area of surgery),
  • the post-surgery visual acuity, and
  • any comments regarding side-effects, such as haze, glare, night vision problems, or contrast-sensitivity issues.

Will I need any other reports?
TC Civil Aviation Medicine is currently requesting a follow-up report if there are any post-operative complications that arise beyond the initial assessment period. You can use the same form as the original reports. An ophthalmologist or an optometrist can complete this report.

What about “touch-ups”?
Generally speaking, a “touch-up” is a repeat procedure to improve upon the original surgery. In these cases TC Civil Aviation Medicine would need another report 30 days (4 weeks) after the touch-up procedure to confirm the visual acuity and lack of side effects.

How long does one have to wait before returning to flying or air traffic controller activities?
Your return to flying must be delayed until TC Civil Aviation Medicine has reviewed the results of the surgery. A follow-up report should be submitted 30 days after the procedure. You can fax or mail the report to your local RAMO and you should receive prompt notification that you can return to flying if all is satisfactory. 

What about the restrictions printed on my current medical certificate referring to glasses or contact lenses?
Refractive surgery usually results in a change in visual acuity that permits flying without corrective lenses. If this is the case, your file will be re-assessed and you will be issued a new medical certificate or a label (for the new Aviation Document Booklet) that reflects the change.

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