Glaucoma is a relatively common eye condition that causes progressive vision loss and blindness. The risk of developing the condition is closely associated with age and rapidly increases after 65. It affects black people about three times more often than white people. Family history, along with other medical conditions like high blood pressure, diabetes, cardiovascular disease, and hypothyroidism, also tend to go hand-in-hand with glaucoma [1].

Open-angle glaucoma is the most common form of the disease. It tends to affect peripheral vision first, and many people do not recognize the symptoms until years after irreversible vision loss. Acute angle glaucoma occurs less commonly but tends to be more attention-getting with symptoms like vision changes, headaches, and pain. 

Taking care of your vision

Pilots need to maintain their vision to function effectively in the air. What may not be as obvious is that your AME exam and even regular check-ups with your primary care physician probably will not identify early glaucoma until significant damage has already been done. Detecting it early requires the use of specialized equipment and detailed examination by an optometrist or ophthalmologist.

Especially if you have one or more of the risk factors mentioned above or when you start to need reading glasses, you may want to consider visiting an eye doctor regularly. Even if you forego that measure, take even subtle vision changes very seriously. There are effective treatments to slow the progression of glaucoma, but not to get back vision you have already lost.  

Your FAA medical and glaucoma: lousy news first

As it has done for many common conditions, the FAA has designated glaucoma as a Condition AMEs Can Issue or “CACI.” The CACI program was designed to allow pilots with well-controlled, common conditions to keep flying without waiting for centralized review by the Aeromedical Certification Division (AMCD) in Oklahoma City.

That is good news for those who caught their glaucoma early and are established on effective treatment. Unfortunately, many others will still need to wait for a formal FAA decision and may even have their medical certificate application denied due to their condition. 

With that in mind, you should anticipate a much longer and more complex certification process if any of the following apply to you:

• You were less than 40 at the time of your diagnosis
• You have a history of acute angle glaucoma that has NOT been surgically treated
• You have normal tension glaucoma
• Your glaucoma was caused by trauma, inflammation, or another underlying condition.on
• Your intraocular pressure is more than 23 mmHg
• You already have visual field deficits or other significant eye disease

For just about everyone else with uncomplicated open-angle glaucoma, the FAA has designed a streamlined process that – executed correctly – should not delay your medical certification whatsoever. 

Qualifying for a Glaucoma CACI

Like with most other CACI conditions and FAA medical certificationr receiving a medical certificate under the Glaucoma CACI protocol begins well before the AME exam. 

The first step is having your condition diagnosed by an appropriately qualified physician and starting treatment. The FAA’s medical certification standards are generally reasonable, but they rely on pilots proactively approaching their health and doctors providing well-documented medical care. 

In the case of glaucoma, an ophthalmologist must treat you and you must see them regularly. This additional tidbit might seem very basic to some. However, based on experience, it needs to be said. Ophthalmologists are physicians who have completed specialized residency training in the field of ophthalmology. It will not satisfy the FAA’s requirements if you receive your care from a non-physician such as an optometrist, nurse practitioner, or physician assistant. 

Glaucoma CACI Criteria

Once you have established care with an ophthalmologist, you must schedule an appointment with them or me. Your AME needs to review a detailed clinical progress note from that visit, which directly documents the following information [2]:

• Your condition is stable, and your ophthalmologist is satisfied with your current treatment 
• Your age at the time you were diagnosed
• The type of glaucoma you have and any relevant history
• Whether or not you have any optic nerve damage
• Whether or not you have undergone any eye surgeries
• The medication(s) you use to treat your glaucoma. Pilocarpine, miotics in general, cycloplegics like atropine, and oral medication will disqualify you from the CACI program. Most other topical glaucoma medications are acceptable. 
• Whether or not you experience any medication side effects. If you do not, it should be stated.
• Your current intraocular pressure measured in each eye
• Results of formal visual field testing using one of the FAA’s approved methods, such as Humphrey 24-2 or 30-2 or Octopus

The FAA has even taken the step to develop a template that ophthalmologists can use to document this information. Using FAA Form 8500-14 will provide all the necessary information to the FAA in a format its reviewers are used to seeing. Your ophthalmologist can also choose to use a different format, but they must include all the same information. 

General Medical Certification Advice

FAA medical certification procedures can be confusing to many pilots. How you approach the process can mean between leaving your AME’s office with a valid certificate or waiting many months to get back in the air.

Choosing the right AME can make a huge difference, but what you do before your FAA certification exam has even more impact. Most AMEs do not structure their practice to guide the medical certification process. They are primarily concerned with evaluating your eligibility to hold a medical certificate based on the information you provide on the day of your exam. 

That leaves you with the responsibility to ensure your health and provide the supporting documentation to prove it. If you have any doubts about how to do that or whether your AME will be willing and able to help, seeking expert advice may save you months of bureaucracy and time on the ground.      

References

[1] D. S. Friedman et al., “Prevalence of open-angle glaucoma among adults in the United States,” Arch. Ophthalmol. Chic. Ill 1960, vol. 122, no. 4, pp. 532–538, Apr. 2004, doi: 10.1001/archopht.122.4.532.

[2] “Guide for Aviation Medical Examiners | Federal Aviation Administration.” Accessed: Jun. 30, 2024. [Online]. Available: https://www.faa.gov/ame_guide