Guidance following eye surgery

The Civil Aviation Authority (CAA) does not recommend refractive surgery purely for certificatory purposes. However, all refractive surgery procedures may be considered for certification. When an applicant undergoes refractive surgery, they must not exercise the privileges of their licence and related ratings, or certificates and they must inform their aeromedical examiner (AME) who will assess them as unfit. Following a complete recovery, Class 1 and 3 applicants require assessment at an aeromedical centre (AeMC); Class 2 applicants may be assessed by their AME.

A degree of monovision (where the refractive outcome is optimised for distance vision in one eye and more for intermediate/close tasks in the other eye) after both laser refractive surgery and intraocular lens implantation may be permitted subject to freedom from adverse effects and glasses being available where appropriate, which reverse the monovision and restore both eyes in full focus at distant, intermediate, and near.

Surface laser treatments (PRK, trans PRK, LASEK, epi-LASIK)

The applicant must provide a report from their treating surgeon once it is established that the vision and refraction are stable, full corneal epithelial recovery has been made and there is no significant corneal haze or other adverse effects or complications. It is also required that the applicant presenting for assessment has completed any course of eye drops and has not been advised against resuming other lifestyle activities. This would typically be no sooner than 8 weeks post-operative if uncomplicated. For Class 1 and 3 applicants, an assessment by an aviation eye specialist* at an aeromedical centre (AeMC) is required a minimum of 1 week after a follow up appointment by the treating surgeon (so that a measure of refraction stability can be assessed). It should be noted that higher pre-operative refractions are likely to result in a longer period post-operatively before revalidation can be considered.

*An aviation eye specialist is an ophthalmologist experienced in the assessment of vision in pilots and air traffic controllers, or a vision care specialist qualified in optometry and trained to recognise pathological conditions either working in an AeMC or qualified in aviation optometry.

LASIK, SMILE

No minimum periods between surgery and recertification are stipulated, however the applicant must provide a report from their treating surgeon once it is established that the vision and refraction are stable and there are no significant adverse effects or complications. It is also required that the applicant presenting for assessment has completed any course of eye drops and has not been advised against resuming other lifestyle activities. The report from the treating surgeon would typically be available no sooner than 3-4 weeks post-operative. For Class 1 and 3 applicants, an assessment by an aviation eye specialist at an AeMC is required a minimum of 1 week after the follow up appointment by the treating surgeon (so that a measure of refraction stability can be assessed).

Conductive keratoplasty 

No return to fit status of any class until 3 months post-operative. Due to the higher incidence of refraction regression following this procedure, ongoing 3 monthly refractions will be required until stability is confirmed. For Class 1 and 3 applicants, an assessment by an aviation eye specialist at an AeMC is required.

Clear lens exchange

Policy as for cataract surgery; please see below.

Implantable contact lenses

No minimum periods between surgery and recertification are stipulated. However, the applicant must provide a report from their treating surgeon once it is established that the vision and refraction are stable and there are no significant adverse effects or complications. Details should include dates and type of surgery performed, pre-operative refraction and details of any complications.

It is also required that the applicant presenting for assessment has completed any course of eye drops and has not been advised against resuming other lifestyle activities. The report from the treating surgeon would typically be available no sooner than 3 weeks post-operative. For Class 1 and 3 applicants, an assessment by an aviation eye specialist at an aeromedical centre (AeMC) is required a minimum of 1 week after the follow up appointment by the treating surgeon (so that a measure of refraction stability can be assessed).

All assessments shall include detailed refraction and slit lamp examination. There should be no post-operative complications (for example, corneal scarring) that may impact on flight safety. No pre-operative refraction limits apply. However, pre-operative refractions outside the standard limits for Class 1 or 3 should follow the appropriate requirements and guidance material for high refractions (and, in the case of Class 1, these shall be referred to a Civil Aviation Authority (CAA) medical assessor after satisfactory ophthalmological evaluation). For radial keratotomy (RK), stability of refraction must be demonstrated before recertification (less than 0.75 dioptres diurnal variation).

For all cases, glare sensitivity and mesopic contrast sensitivity should be satisfactory. Class 1 and 3 applicants for should be assessed by an aviation eye specialist at an aeromedical centre (AeMC) by objective testing; additionally, there should be no significant symptoms such as glare, haloes (rings of light) or starbursts (streaking of point lights). In cases of doubt, referral to a consultant aviation ophthalmology adviser should be considered. For Class 2 applicants, there should be no symptoms such as glare, haloes or starbursts. In cases of doubt, referral to an aviation eye specialist at an AeMC to conduct objective testing should be considered.

If there are concerns of insufficient refraction stability or full recovery not being achieved, medical recertification may be postponed, and a further assessment may be required.

A number of types of intraocular lens implant are available and may be offered by the pilot's surgeon. These include monofocal (single vision), extended depth of focus lenses, monofocal toric (to correct for astigmatism) and multifocal (to correct both distance and close vision) implants. The Civil Aviation Authority (CAA) does not recommend or approve a particular intraocular lens (IOL) for certification.

Scientific data indicates that monofocal IOLs are likely to be less problematic than multifocal IOLs for the issue of an aeromedical certificate as adverse subjective visual phenomena, particularly haloes, are more common and troublesome in people receiving multifocal IOLs.

The decision to proceed with a multifocal implant should be made by the applicant and their surgeon, considering the potential impact on the applicant’s occupation. Applicants should be aware of the possible adverse effects from any type of lens as aeromedical certification may not be possible if they occur.

Cataract surgery will result in an unfit assessment for at least 6 weeks. Fitness can be reassessed following complete recovery from surgery.

Class 1 and 3

Once a minimum of six weeks has elapsed since surgery and any course of eye drops is complete, the applicant should be assessed by either their local vision care specialist or an aviation eye specialist at an Aeromedical Centre (AeMC). A CAA ophthalmology form should be completed and should include measurement of contrast sensitivity in the operated eye in normal and low light conditions and in the presence of a glare source, along with documentation of slit lamp findings. The aeromedical examiner (AME) or aviation eye specialist should question the applicant about any dysphotopsia symptoms (see questions below) before a certificatory decision is made. A surgeon’s report to include the date(s) of surgery, the type of implant used and details of any complications should also be provided.

Class 2

Applicants should provide a surgeon’s report to their AME to include the date(s) of surgery, the type of implant used and details of any complications. Once a minimum of six weeks has elapsed since surgery and the applicant is not taking any eye drops, the AME should question the applicant to establish if there are any dysphotopsia symptoms present, subsequent to the surgery. These questions should include:

• How do you find oncoming car headlights (dipped beam) when in a car at night?
• Do the headlights prevent you seeing other objects on the road?
• Do you find the brightness of the headlights intolerable?
• How do you find driving towards a low sun?
• Do you notice haloes or rings around lights (such as street lights) at night?
• Do you notice streaking or starbursting of lights at night?

If there are concerns of dysphotopsia symptoms, the AME should request objective testing with a vision care specialist which should include measurement of contrast sensitivity in the operated eye in normal and low light conditions and in the presence of a glare source, along with documentation of slit lamp findings. If there are remaining concerns, then further assessment with an aviation eye specialist at an AeMC is required for a certificatory decision to be made.

If, after the medical is revalidated, the applicant develops symptoms of glare, haloes or starbursting of lights at night, all medical certificate holders should report this to their AME. Posterior subcapsular opacification is a common longer term side effect of cataract surgery and would require further ophthalmological review and treatment. This is normally conducted with a YAG laser and, provided uncomplicated, the applicant can return to duties after providing an appropriate surgeon’s report.

A report shall be provided from the consultant ophthalmologist who performed the procedure and should include full details of the treatment carried out, current management, postoperative distant and near visual acuities, and up to date visual field results (please refer to separate guidance material on visual fields).

For Class 1 and 3 medical certificate holders, an assessment by an aviation eye specialist may be required before recertification can be considered.

Regular follow up by an ophthalmologist should be carried out for Class 1 and may be required for Class 3.

** Glaucoma drainage devices create alternate channels to drain the aqueous humour from the anterior chamber through a long tube to a reservoir placed at the equator of the globe. The use of glaucoma drainage devices indicates that the glaucoma being treated is particularly severe and has not responded to medication, laser or traditional trabeculectomy surgery OR that the patient has an atypical form of glaucoma such as neovascular glaucoma, where it may be used as the primary procedure.

A report should be obtained from the consultant ophthalmologist who performed the procedure based on a review at 3 months. This should include full details of the procedure, and in particular whether any medical gases were used; post-operative recovery should be complete and up to date visual acuities and Esterman visual field test should be provided. The report should either confirm absence of post-operative ocular motility problems (except with vitrectomy) or incorporate an orthoptic report.

For Class 1 and 3 medical certificate holders, an assessment by an aviation eye specialist may be required before recertification can be considered. Recertification following laser retinal treatment can be considered once recovery complete and a surgeon’s report and post treatment Esterman visual fields are provided (please refer to separate guidance material on visual fields).

Regular follow up by an ophthalmologist should be carried out for Class 1 and may be required for Class 3.

Due to the risk of corneal haze following this procedure, assessment for dysphotopsia is required (see refractive surgery guidance).

Class 1 and 3 - Refraction and consultant ophthalmology report at 2 months and then further refraction and objective dysphotopsia at an aeromedical centre (AeMC) at 3 months.

Regular follow up by an ophthalmologist should be carried out for Class 1 and may be required for Class 3.

Class 2 and LAPL - Refraction and consultant ophthalmology report at 2 months and then review by a local optometrist and review of any subjective dysphotopsia symptoms by an aeromedical examiner (AME) at 3 months. Note that the presence of dysphotopsia symptoms at 3 months would require further objective testing at an AeMC.