FAA Ophthalmology Updates and Prevention of Eye …civilavmed.org/.../2016/12/12-Dr-Kozarsky-Ophthalmology-Update.pdf · FAA Ophthalmology Updates and Prevention of Eye Disease

Federal AviationAdministration

OphthalmologySeptember 2017

Ophthalmology

FAA OphthalmologyUpdates and Preventionof Eye Disease


OphthalmologySeptember 2017 2

PhoenixAir

CartersvilleGA

• AME since 2010• North Georgia





AviationMedical

Examiner• AME 2010• North Georgia• Phoenix Air



Aviation

• 1973• ATP, Multi, Helicopter• 40 and 70 year old

aircraft– MU-2– Luscombe





















The vast majority of my pre-operative cataract patients could

easily pass the vision requirementsfor a 3rd Class FAA Medical

Certificate.



•Many US patients undergo cataract surgery while their vision is 20/40 or better; some have 20/20 but also have night vision and other glare impairment

•Quality of vision is the major determinant determining the need for cataract surgery

•Cataract surgery with lens replacement is our most accurate refractive surgery









What do dental hygienists, WWII pilotsand Marcus Welby have to do with

innovation and improvement in cataractsurgery?











Posterior Chamber IOL





Multifocal and AccommodativeIOLs (Cataract Replacement)3 months, meets standard, 8500-7





Multifocal Devices

• Multifocal/Accommodating Intraocular Lens Implants– 3 month wait post op

• Multifocal/Bifocal contact lenses– 1 month wait– Corrects for all distances unlike monovision contact lenses– Patients love them or hate them - convenient or blurred all distances

• Multifocal devices must be FDA approved• Must be well tolerated, no disabling visual symptoms• Get FAA Eye Form 8500-7, current status report



Regarding multifocal implants - there are twogroups of patients that love their surgeon

1. Among well screened patients - they love theimplanting surgeon

2. Among more perfectionistic and demandingpatients - they love the consulting surgeon whoremoves and exchanges the multifocal IOL



“Doctor, I love this new implant, I cansee far away and I can even read withoutmy reading glasses. But most of all, you

have made the moon so so beautifulwith that amazing ring that I see around

it every clear night”



LASER Cataract Surgery ??





How good must a pilot see?



Who are these guys?







• Near Vision Acuity isdetermined for each eyeseparately and for both eyestogether



•If the airman cannot pass the FAA vision standard with the best glasses available, it is reasonable to obtain an eye exam and glasses rather than defer. (Within 14 days)



Contact Lenses



MUST wear a rigid contact lens

» Advanced keratoconus - progressive ectasiaand steepening of cornea

» Orthokeratology - for nearsightedness, Theuse of a rigid contact lens to temporarilyreshape cornea and improve uncorrectedvision



Presbyopia

• Age 40 and older• Dependence on reading correction alone or

in addition to distance correction• Drug store Readers• Bifocal or Progressive Glasses• Bifocal or Multifocal Contact Lenses• Near Vision Contact Lens



MonovisionQuestion 17b





Monovision• October 19, 1996, McDonnell Douglas MD-88• Descent below visual glidepath and collision with terrain• Monovision from contact lenses implicated by NTSB



•It is disqualifying for a pilot to wear a contact lens on one eye which provides only near vision



Acquired Monovision

• Result of refractive surgery– Vision without correction - one eye sees distance and

the other can read (less than required distancevision)

• Acquired monovision pilot can fly withcorrection to meet binocular distancestandard.

• To fly uncorrected, FAA requires 6 monthadaptation, 8500-7, Medical Flight Test,SODA


Ophthalmology UpdateSeptember 2017



•New Procedures for Near Vision

Kamra Implant Raindrop Implant



Monocular Patient

• One eye fails FAA visual acuity standards• Result of eye trauma or pathology• Must defer• FAA Decision and Medical Flight Test• At least six months adaptation following loss

of binocular status



Monocularity

• 6 month adaptation period• 8500-7• Defer to FAA• Requires Medical Flight Test• SODA because defect is permanent• Absolute loss of eye or eye failing FAA

vision standard get 6 month wait and MFT



• Six months adaptation• Defer• Medical flight test

required• SODA• 3,000 – 4,000 certified

monocular pilots

Monocular “One Eyed” Pilots



PreventionSun and UV Protection

Ordinary UV protective Sunglasses

No Photochromic

No Polaroid!!

Aircraft Windshields not UV protective



FAA 8500 - 7



LASIK and Cataract Surgery

• > 2 years ago– Meets standard and no adverse symptoms– Issue

• < 2 years ago– Obtain 8500-7 Eye Consultation form from operating

surgeon



Color Vision





•No reason to defer based on color vision. Use easier approved screening test or issue with light gun/night flying limitation



FedEx 727 Accident

26 July 2002Tallahassee, Florida(NTSB Report:AAR-04/02)

Abnormal Color Vision



Color Deficiency

• 8% of males• X-linked• 0.1 % females• Red/Green deficiency



Ishihara and similar tests



Farnsworth Lantern FALANT



FAA

Color Vision

Testing

Flowsheet

(Google it)



Operational Color Vision Testing



Color Vision Testing

•If airman passes color vision test– Mark “Pass” in box 52 and issue no restriction

•If airman does not pass color vision screening test– Mark “Fail” in Box 52 and issue the restriction

• Not Valid for Night Flying or by Color SignalControl

• (Or utilize “easier” screening test)



• If airman fails office based color visionscreening test and desires anUNRESTRICTED 1st or 2nd Class MedicalCertificate:

• 1. Pass Daytime OCVT• 2. Pass Color Vision Medical Flight Test



Options Available to Applicant who failsthe Screening Test (usually a student Pilot)

• Pass an alternate test (best option)• Accept the limitation• FSDO arranged testing to have the limitation

removed



Applicant Fails Color Vision Screening

Select Night Vision, Light Gun signalrestriction

Allow airman to take alternative screening testand obtain written documentation of resulteg. Another local AME has FALANT

Lots of discussion



FAA Approved Tests:Pseudoisochromatic plates

Test Edition Plates Fail

American Optical CompanyAOL

1965 1-15 > 7 errors

AOC-HRR 2nd 1-11 Any error in test plates 7-11

Dvorine 2nd 1-15 > 7 errors

Ishihara 14 plate 1-11 > 6 errors



Richmond 1983 1-15 > 7 errors



Test Fail

OPTEC 900 Vision testerFarnsworth Lantern test

an average of > than 1 error per seriesof 9 color pairs in series 2 and 3

Titmus Vision TesterTitmus 2 Vision TesterTitmus i400OPTEC 2000 Vision Tester(2000PM, 2000 PAME, 2000 PI)Keystone OrthoscopeKeystone View Telebinocular:

any errors in the 6 plates

LKC Technologies, Inc.APT-5 Color Vision Tester

The letter must be correctly identified inat least 2 of the 3 presentations of eachtest condition

Richmond-HRR, 4th edition 2 or more errors on plates 5-24

Acceptable Substitutes



FSDO Testing

• 3rd Class– Operational Color Vision Test - OCVT

• Office test regarding aeronautical charts, etc.• Day signal light test

– If passes, restriction removed and Letter of Evidence issuedindicating that airman passed

• Bring to all subsequent flight physicals– If fails completely, can never retake the test– If passes map reading but fails the daylight light gun test, may

take light gun test at night• If passes at night, may fly at night but not by color light signal

during the day



Color Vision Test Restrictions

– SLT failed in daylight• “Not Valid for Night Flying or by Color Signal Controls”

– Took SLT at night, and passed• “Not Valid for Flight During Daylight Hours by Color

Signal Control”



To Upgrade to Class 1 or 2

• Must pass OCVT and day SLT and a medicalflight test (MFT) at night

• MFT– Much harder and more complicated than previously



Color Vision Medical Flight Test

Visual approach slope indicatorPrecision approach path indicator

Taxiway lights Runway approach lightsColored lights of otheraircrafts



Color Vision – Important

– Advise airman to contact CAMI/RFS to authorizeoperational testing if unable to pass any alternateapproved office-based test.

– Airman should advise CAMI/RFS as to which FSDOhe wishes to employ.

– Gain some flight experience before taking MFT

– Ask for one employing the newer LED SLT

– .



Glaucoma and Visual Field



Types of Visual Fields

Tangent ScreenManual

Goldmann FieldManual,Kinetic/Static

Humphrey andOctopus FieldAutomated

ConfrontationField and AmslerGrid



PreventionOpen Angle Glaucoma

• No symptoms in early stages• Gradual loss of peripheral vision• Disease is typically advanced once

patients are symptomatic• Importance of screening for early

detection and treatment



PreventionGlaucoma

• Progressive andcharacteristic opticatrophy

• Usually but not alwayselevated eye pressure

• Open vs closed angle



Glaucomatous Optic Nerve





Glaucoma

Optic Nerve Changes:













Experienced pilots with impaired vision can pass a medical flight test



PreventionGlaucoma

• Characteristic damage = glaucoma.• Primary Open Angle Commonest

– Normal IOP values: 10-21 mm Hg– Secondary, Narrow Angle, Low Tension Glaucoma

• Damage to Optic Nerve– Cupping, heme– Visual Field defects



Glaucoma

• Severe Glaucoma– Annual review by FAA, some get MFT without SODA

• Mild-moderate– AASI, visual fields and 8500-14/status report

• Mild– CACI

• Treating ophthalmologist finds the condition stable on currentregimen and no changes recommended…Yes

• Age at diagnosis…40 or older



FAA 8500 - 14



AME Assisted Special Issuance, AASI

• After initial authorization• AME may issue

– If meets standards– There is no significant worsening of the visual fields– The pressure is controlled without medication side

effects– 8500-14 must be submitted along with current fields

• AME must defer if the above is not true• Only for open angle glaucoma and ocular

hypertension



GLAUCOMA CACI







Glaucoma• CACI (continued)

– Documented nerve damage or trabeculectomy(filtration surgery)…No

– Medications…None or Prostaglandin analogs(Xalatan, Lumigan, Travatan, or Travatan Z),Carbonic anhydrase inhibitor (Trusopt andAzopt), Beta blockers Timoptic. Etc, or Alphaagonist (Alphagan). Combination eye drops areacceptable

– Not acceptable: Pilocarpine or other miotics,cycloplegics, cycloplegics (Atropine) or oralmedications



Glaucoma• CACI (continued)

– Medication side effects…None– Intraocular pressure…23 mm Hg or less in both

eyes– ANY evidence of defect or reported Unreliable Visual

Fields…No– Acceptable visual field tests: Humphrey 24-2 or 30-2

(either SITA or full threshold), Octopus (either TOP orfull threshold). Other formal visual field testing maybe acceptable but you must call for approval.Confrontation or screening visual field testing isnot acceptable



Glaucoma

• CACI (continued)– AME MUST NOTE in Block 60 one of the following:

• AME meets certification criteria for glaucoma

• Airman had a previous Special Issuance for this conditionand now meets the regular issuance certification criteria forglaucoma

• Airman does NOT meet certification criteria for glaucoma.I have deferred this exam. (Mail the supporting documents toFAA identifying which criteria were not met)



Phoria / Muscle Balance



Phorias vs Tropias

• Tropias– Eyes always deviated

• Esotropia, Exotropia, Hypertropia• Diplopia maybe

– Not usually if onset in early childhood, suppression

• Phorias– Eyes may deviate under stress

• Esophoria, Exophoria, Hyperphoria• Occur when fusion has been broken• Diplopia when deviated

– Visual confusion, may learn to ignore second image





• Amphetamines are not thought toworsen latent phorias leading todiplopia



Phoria

• No phoria standards for Third class.• For 1st or 2nd Class• Eso or Exo exceeds 6• Hyperphoria exceeds 1• Absent symptoms of visual fatigue or

double vision, OK to issue• FAA may ask for ophthalmic consultation





Visual Incapacitation



Malicious Laser of Aircraft• Stunned and distracted• Difficulties controlling the

aircraft– Particular in helicopter pilots

• Complaints can persist forseveral hours

• Pain, Foreign Body Sensation,Corneal Abrasion if Rub Eye

• Pressure feeling up to 48 hoursafter the attack

• Permanent retinal/visualdamage very unlikely



Refractive Surgery??



Refractive Options

• Most FDA-approved options are acceptablefor all classes of medical certification

• RK, LASIK, PRK, LASEK, Epi-LASIK, CK• “Blade-less” surgery• Wavefront correction



Refractive Surgery and Certification

• AME may issue:– If surgery was more than 2 years ago

• If standards are met• Without 8500-7• AME evaluation is sufficient, issue

– If surgery was less than 2 years ago• AME may still issue with 8500-7 and documentation of

stable vision, lack of complications, etc.• If meets standards







Refractive SurgeryLASIK, PRK and variants, current status from treating

physician or a completed 8500-7 if within 2 years

Post Op Stability and absence of adverse symptoms

Some are special issuances• Conductive keratoplasty, 6 month wait• Implantable Collamer Lenses (ICL), Intacs, Clear lens extraction





Retina



Dry Macular Degeneration



Wet Macular Degeneration

• Subretinal neovascularization withsubretinal hemorrhage and exudation



Treatment of Macular Degeneration

Anti-VEGF agentsInjected into center

of eyeVision stabilized in

more than 90%Vision improves in

up to 40%



Diabetic and “Vascular”Retinopathy



Thank You!

Documents

FAA Ophthalmology Updates and Prevention of Eye …civilavmed.org/.../2016/12/12-Dr-Kozarsky-Ophthalmology-Update.pdf · FAA Ophthalmology Updates and Prevention of Eye Disease