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b) Scars and adhesions of the lids to each other or to the eyeball
c) Ptosis interfering with the visual field
d) Growth or tumour of the eyelids other than small, benign, non-progressive lesions causing no
symptoms
e) Obstruction of the lacrimal drainage system sufficient to cause tearing
Cornea
a) History of recurrent keratitis, corneal ulcers, corneal scars or vascularization which interferes
with vision
b) Corneal dystrophy of any type including keratoconus
Uveal tract
a) History of anterior uveitis except on a single occasion and without sequelae. Any history of
posterior uveitis (choroiditis) or signs of chorioretinal scars except minor scars not affecting
central or peripheral vision when tested by ordinary clinical methods
b) Coloboma of iris or choroid
Retina and optic nerve
a) Any of the tapeto-retinal degenerations of the retina including pigmentary retinopathies
b) Significant macular lesions from any cause
c) Retinal detachment or retinoschisis
d) History of optic neuritis from any cause
e) Optic atrophy from any cause
Lens
a) Lens opacities (cataract) affecting visual acuity, visual field or causing glare
b) Aphakia, unilateral or bilateral
III-11-56 Manual of Civil Aviation Medicine
c) Dislocation or subluxation of lens
Miscellaneous defects and diseases
a) Glaucoma — dealt with in detail below
b) Tumour of eye, adnexa or orbit
c) Fracture of orbit impairing ocular motility or with any communication between orbit and nasal
sinuses or intracranial cavity
d) Pathological nystagmus from any cause
e) Loss of normal pupillary reflexes from any cause
f) Retained intraocular foreign bodies
g) Night blindness (nyctalopia)
h) Any other injury, disease or disorder of the oculo-visual system which, in the opinion of the
examiner, might interfere with safe performance as flight crew or air traffic controller.
11.10 GLAUCOMA
11.10.1 Although glaucoma is more common in older persons, it can occur at any age and measurement
of intraocular pressure (tonometry) should be part of the ocular screening examination in all applicants.
11.10.2 The diagnosis of glaucoma is not always easy. Increased intraocular pressure is only one of the
risk factors. Above normal intraocular pressure not accompanied by demonstrable optic nerve damage does
occur (ocular hypertension). Other cases occur in which typical glaucomatous damage to the optic nerve with
associated visual field loss — the hallmark of glaucoma — is seen in spite of intraocular pressure
measurements generally considered to be normal (normal pressure or low pressure glaucoma). Such cases
are difficult to diagnose and manage.
Methods of screening intraocular pressure
11.10.3 Estimation of ocular pressure by palpation is highly inaccurate and only useful in detecting marked
increase in intraocular pressure such as might occur in acute angle closure glaucoma.
Tonometry
11.10.4 Measurement of intraocular pressure is called tonometry and there are two methods used clinically.
The most accurate method is by applanation or flattening of the cornea utilizing a contact tonometer mounted
on a slit-lamp. Such instruments are expensive and not usually available to non-specialist physicians.
Hand-held instruments such as the Perkins tonometer are satisfactory, less expensive and may be practical in
Part III. Medical Assessment
Chapter 11. Ophthalmology III-11-57
situations where fairly large numbers of screening examinations are done.
11.10.5 Air-puff applanation tonometers are available and are reasonably accurate. They have the
advantage of not requiring topical anaesthesia.
11.10.6 The second method of tonometry is the indentation method. Indentation instruments such as the
Schiøtz tonometer are widely available and reasonably accurate if they are properly maintained and correctly
used. Schiøtz tonometry is done with the applicant lying supine. The appropriate weight is placed on the
tonometer plunger. A drop of topical anaesthetic (such as proparacaine hydrochloride 0.5 per cent) is placed in
the applicant’s eye. After ten to fifteen seconds to allow the anaesthetic to work, the examiner uses thumb and
forefinger or middle finger to hold the eyelids open without pressing on the eye. The applicant is instructed to
look straight upwards (looking at his own finger held up in front of the eyes is helpful) while the tonometer is
lowered gently onto the centre of the cornea, care being taken to keep the instrument vertical. Gentle
fluctuation of the tonometer needle is a good indication that the instrument is correctly positioned and is
transmitting the normal ocular pulsations. The scale reading is noted and the tonometer removed. Standard
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Manual of Civil Aviation Medicine 2(66)
