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tables (Friedenwald tables) are used to determine the intraocular pressure. For a given scale reading the ocular
pressure will depend on which tonometer weight was used.
11.10.7 If consistent values of intraocular pressures of 24 mm Hg or more are recorded, or if there is a
difference of 5 mm Hg or more between the two eyes, the applicant should be referred to an ophthalmologist
who will investigate further with gonioscopy, funduscopy, visual field studies and any other tests necessary to
determine the type and severity of the glaucoma and make the decision as to whether or not treatment is
required.
Treatment
11.10.8 This depends on the type of glaucoma. If the glaucoma is secondary to some underlying disease
such as anterior uveitis, the treatment will be that of the underlying disease.
11.10.9 Angle closure glaucoma, which is much less common than open angle glaucoma, is generally
managed with either laser iridotomy or surgical iridectomy.
11.10.10 Primary open angle glaucoma is by far the commonest type of glaucoma. It can be treated with
laser or conventional surgery but in most parts of the world topical drug therapy is the initial treatment of choice.
Laser therapy or filtering surgery is used for patients whose glaucoma cannot be satisfactorily controlled with
medications.
11.10.11 Numerous medicines are available for treating glaucoma, and this is a rapidly changing
therapeutic field. The main groups of pharmaca used for treating primary open angle glaucoma are the
following:
a) Epinephrine derivatives. These are used as drops. Potency is low. They act by reducing the
production of aqueous humour. They are useful in flight crew because they produce no
significant blurring of vision but can cause local irritation of the eyes and also systemic effects
such as cardiac arrhythmia. Dipivefrin is an example.
b) Miotics. These are used as drops. Potency is high. They act by increasing the outflow of
aqueous humour from the eye. They include pilocarpine, carbachol, eserine and phospholine
iodide. They induce miosis and accommodative blurring of vision, especially in young
individuals and for this reason are generally not allowed in flight crew.
III-11-58 Manual of Civil Aviation Medicine
c) Beta-blocking agents. These are used as drops. They act by reducing the production of
aqueous humour. They are potent, but may have numerous systemic side effects including
bradycardia, central nervous system effects, and aggravation of asthma. They are useful in
flight crew provided the systemic effects present no problems. Examples are timolol,
metipranolol, carteolol, levobunonol and betaxolol.
d) Carbonic anhydrase inhibitors. Topical and systemic preparations are used. They have
moderate potency. They act by reducing the production of aqueous humour. The systemic
preparations include acetazolamide and methazolamide. Systemic side effects generally limit
their use to short-term therapy. Drops can be used in flight crew as they rarely have systemic
side effects. Examples of topical carbonic anhydrase inhibitors include dorzolamide and
brinzolamide.
e) Prostaglandin analogues. These are used as drops. Potency is high. They act by increasing
uveoscleral outflow of aqueous humour. Side effects are few so they can be used in flight
crew. Latanoprost (Xalatan®) is an example.
f) Alpha 2 agonists. These drugs work by reducing aqueous humour production and by
increasing uveoscleral outflow. Apraclonidine and brimodine are used as drops. They may
cause allergic reactions in some patients.
g) Combinations. Mixtures of the above groups of medicines are available. These are useful
because they simplify the treatment regimen and lead to better patient compliance. Such
mixtures have the side effects of their components, and those containing pilocarpine will not
be suitable for most flight crew. Examples of available combinations are dipivefrin/levobunolol,
pilocarpine/ timolol, and dorzolamide/timolol.
11.10.12 The medical treatment of primary open angle glaucoma must be tailored for each individual.
Fitness for flying will depend on what medications are required to control the disease and what side effects, if
any, these produce.
11.10.13 Applicants whose ocular pressures are well controlled with medications which do not produce
serious side effects and whose visual acuity and visual fields are satisfactory may meet the visual requirements
of Annex 1 and can be granted a Medical Assessment.
11.10.14 Regular follow-up examinations which must include measurement of visual acuity, ocular
pressures, evaluation of the optic discs, visual field studies and assessment of side effects of the medications
are mandatory for glaucoma patients and for individuals with ocular hypertension.
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Manual of Civil Aviation Medicine 2(67)
