Cataract Surgery: Success for Many Pilots

Its considered one of the safest surgeries out there and it should let you keep, or regain, your flying privileges.

Just when youve got a few decades of aviation experience under your slightly expanding belt, and have lost that wide-eyed rookie look … things start to look blurry and hazy. Every day. And then your doctor drops the hammer: Youve got cataracts.

But the news isnt as bad as it could have been 30 years ago. Cataracts are fixable.

Cataract Surgery


Anatomy of a Cataract

A cataract occurs when the normal clarity of the lens of the eye is reduced, resulting in blurred, cloudy vision. These chemical changes are frequently caused by normal aging, but can also be caused by medications, injury, diseases, or environmental factors such as UV exposure or smoking.

Cataracts usually occur in people 55 and older, and usually develop in both eyes, although at different rates. They impair your visual acuity in dim light, and also create light sensitivity and glare. Vision with a cataract is similar to looking through a steamy window.

In addition to cloudy vision, cataracts also cause a number of other symptoms, such as dark shadows that seem to move with the eye (similar to “floaters,” or loose cells within the fluid of the eyeball), the need to use more light to read, double vision, a loss of color vision, as well as increased nearsightedness as the lens becomes denser.

When the vision impairment becomes a quality of life issue, then its usually time to look at surgery.

Glenn Pomerance, M.D., an FAA Designated Medical Examiner located in Chattanooga, Tenn., who has practiced ophthalmology for 29 years, recommends getting a referral from a trusted primary care practitioner or family member who has had a good experience.

“There is no specific number of procedures that magically makes one a good surgeon,” Pomerance notes. “A young, talented surgeon, for instance, may be light years ahead of the veteran surgeon who hasnt kept up with modern technologies. … A cataract cowboy who does thousands of cases a year, but whose time is so limited that he pays little attention to individual patients, may not be the best choice.”

Dani Richard, a commercial pilot in Huntsville, Ala., who had the surgery on both eyes in May 2008, suggests, “Whatever surgeon you choose, they should do the procedure at least three times a week and have completed at least 300-500 procedures. That is the measure eye surgeons use to evaluate each other.”

How Correction Works

The most common operation, called phacoemulsification with intraocular lens (IOL) implant-called phaco (fay-co) in the industry-is performed by an ophthalmologist, often as an outpatient procedure, using local or topical drop anesthesia. Pioneered by New York surgeon Charles Kelman in 1967, it takes between 10 and 20 minutes in the hands of most surgeons, and requires a commitment of a few hours out of your day.

More than 2.5 million people in the United States have this surgery every year, and its considered to be one of the safest surgical procedures available.

During the procedure, the eye is numbed, and looking through a specialized microscope, the surgeon makes a small incision in the eye, near the junction of the sclera (white of the eye) and iris (colored part surrounding the pupil). He then passes a tiny probe into the incision, where it uses ultrasound to dissolve the cataract-containing lens, which is then drawn into the instrument and removed from the eyes interior.

Another method uses instruments to physically break the cloudy lens into tiny pieces (phacofracture) and remove them through the incision. The incisions are usually self-sealing, although the occasional incisions may be sutured; these stitches usually dissolve and dont need to be removed.

Pomerance compared the lens of the eye to an M&M peanut candy, consisting of three parts analogous to the parts of the candy. “Each of the three parts of the lens can be discolored by a cataract. During the operation, the nucleus (peanut), cortex (chocolate) and the front of the candy coat (capsule) are removed. The IOL, usually made of acrylic plastic or silicone (the safe kind), is implanted.”

Recovery is usually rapid, with return to normal function in one day or less. Post-op care varies but often includes prescription eye drops and a shield over the eye while sleeping for a couple of weeks. Youll also avoid heavy lifting (over 25 pounds) and swimming, close your eyes while showering and have someone else change the cats litter box for a week or so. Of course, this is a brief overview compared with the full discussion youll have with your doctor.

Another, less common, procedure is extracapsular cataract surgery. Its generally used for very advanced cataracts where the lens is too dense to dissolve. A larger incision is made so the cataract can be removed whole, and the artificial lens is inserted as with phacoemulsification. Larger stitches are needed, and the recovery time is longer.

A third type of surgery is intracapsular cataract surgery, requiring a yet-larger incision. The entire lens and capsule are removed entirely, and the IOL is inserted in front of the iris. This technique is not commonly performed, except in the case of significant injury.

Lens Options

There are three main types of IOLs used for these procedures. Monofocals are the most common lenses, and have equal corrective power in all areas of the lens. You may need glasses with a weak distance correction, and these lenses wont correct astigmatism.

Toric lenses have more corrective power in one area of the lens to correct astigmatism and distance vision, but they must be positioned precisely to work. Additional correction, such as reading glasses, is still necessary for near-vision tasks.

Multifocal lenses have several corrective regions on the lens, which correct near, intermediate and distance vision. The downside to these lenses is increased glare, as well as the inability to correct for astigmatism. Some patients need to have further surgery such as LASIK to address the astigmatism.

Your Medical

If an airmans medical certificate becomes invalid due to poor vision, it can reinstated by an aviation medical examiner, or by the FAA directly, if the airman has successful surgery followed by a period of recovery and stabilization. FAA Form 8500-7 (Eye Examination) must be submitted to the FAA by the treating eye surgeon; this is done when the physician believes recovery is complete and the pilots post-op vision can meet the FAA standards. The form should be turned into the AME at the next flight physical; its downloadable on the FAA and AOPA websites.

California pilot Mike Palmer recently regained his medical after his surgery and a battery of vision tests, including the peripheral vision test. He recently experienced double vision, which he believed was due to his dominant eye being out of service for so long.

“I notice it when looking at small targets. I see two pair of VASIs from far away, two airplanes in close formation at night. Its correctable with glasses (prisms) and we think Ill be able to pass my medical with those. Im doing eye exercises on my own, staring at stars at night to get my eyes back the way they used to be. So the story isnt over yet.”

Fellow Aviation Consumer writer Dave Higdon credits cataract surgery with saving his sight in 2001. He recalled, “A couple of issues arose during my first meeting with the surgeon. The most important one for pilots: In a darkened cockpit, the pupils can dilate to a diameter larger than the standard (flexible) implant typically employed. That can mean night vision with a sharp central area and a soft, unfocused area surrounding the focused region.”

The solution was larger-diameter implants. “I couldnt be happier with the results: perfect distance vision, perfect color acuity (which suffers immensely with the cataracts) and no night-vision issues, ever.”

The costs of cataract surgery are generally covered by health insurance, but IOLs to correct nearsightedness, farsightedness, astigmatism and presbyopia (the loss of reading vision that occurs as we age) are not always covered. If you choose a multifocal lens for cataract surgery, which would be used to correct those conditions, you may incur some out-of-pocket expenses.

Dani Richard paid $1500 per eye for her toric lenses, which include a UV filter. Her physician recommended that she wait until her cataract developed to the point where her insurance would cover it. Rather than wait for her vision to worsen, she got a consult from a cataract surgeon, who said he could do both eyes, covered by insurance.

Two weeks after surgery, her doctor filled out her FAA paperwork and certified that she had 20/20 vision for close and intermediate vision. She has not flown at night since the May 2008 surgery, and has some lens flare when looking at very bright lights.

Some of the considerations that Richard pondered included the balance between high-quality vision with the use of glasses, or poorer but acceptable vision with no glasses; she wears glasses with blended bifocals. She also considered the importance of night vision, the amount of surgical risk she was willing to take, and whether she was willing to risk a bad outcome. She considered the rigorous four-times-daily eye post-op care regime to be particularly important. She adds, “Dont get LASIK if you think you will need IOLs one day, and have as few eye surgeries as possible. Each surgery tends to dry out the eyes and increase the chance of complications.”

Manageable Risks

Phacoemulsification cataract surgery is one of the most common eye surgeries performed in the United States. Complications are rare, including spontaneous bleeding from the wound and post-op inflammation. Flashing, floaters and double vision may be present several few weeks after surgery, requiring you to check with your surgeon immediately. The sudden presence of floaters may indicate retinal detachment, a serious complication that may occur if the retina is weak or thin.

Another complication is endophthalmitis, an uncommon infection within the eye; improved surgical techniques and antibiotics have improved the recovery rate. Recent IOL designs make lens displacement rarer as well. The rarest complications include glaucoma and blindness.

Post-op death before the use of phacoemulsification was rare, mostly resulting from the risks of general anesthesia; the current use of local anesthesia reduces the risk further.

A pilots eyesight cant be compromised. As with any surgical procedure, do your homework, ask the hard questions and prepare well in time for your next medical exam. If your eyesight has been compromised by cataracts, and your overall health is pretty good, odds are that youll be back in the left seat again.

Cory Emberson is an Aviation Consumer contributor living and flying in California.