It's a bird! It's a plane! It's Superman!

No, it's a pilot with presbyopia! Chances are, on your next trek in the air, your airline captain is going to have gray hair and a need for granny glasses. The percentage of civil aviators over the age of 40 has increased from about 39 percent in 1976 to 59 percent in 1996, according to Van Nakagawara, O.D., the research optometrist for the Federal Aviation Administration (FAA).

"The person with the most responsibility in the aircraft -- the senior captain -- is often a presbyope, or about to become one," says Warren V. DeHaan, O.D., a certified airline transport pilot who also owns an aviation consulting practice.

The pilots' market may be small, but it is crucial, says DeHaan, who also owned a pilots' vision specialty practice for 30 years. "Pilots tend to be affected earlier [in developing presbyopia] than the general public because of the exacting demands in the cockpit," he says.

Specifically, pilots need to see clearly at a range of visions, including close-range to view maps and charts; mid-range to view the instrument panel; and distance vision to avoid colliding with other aircraft and to land the plane. In addition, many airline pilots need to look overhead at the control panels on the ceiling. "Pilots have one of the most demanding visual requirements of any occupation," says J. Pat Cummings, O.D., of Sheridan, Wyo., who is also a private pilot.

Put Your Ear to the Sky

When treating pilots, O.D.s don't necessarily have to be pilots themselves -- although a good working knowledge of aircraft helps -- says William Spearman, O.D., a private pilot with an instrument rating.

"Just because they (O.D.s) aren't pilots doesn't exclude them. When presented with the opportunity, listen to the pilot and make it a team effort," he says.

Including the pilot in his presbyopia correction decision is often the best way to treat him, agrees DeHaan. Eyecare professionals should realize that pilots like complexity and challenge, which is why they chose flying as a career or hobby, he explains. "Pilots are very controlling. They won't like it if you sit them down and say, 'You need bifocals.' They want to help run the show. These are not people who go to the doctor and worship him."

Therefore, the first rule is to listen to your pilot patients. Not only will it make them feel included, but there are many different types of pilots and many different types of aircraft out there, meaning there are many solutions. Here are some considerations for making recommendations for presbyopic pilots:

Age. Obviously, this is a big factor, says DeHaan. If, after testing a 40ish pilot in the office, he appears not to need near correction yet, but is close, consider what could put him over the edge before sending him on his way without a prescription. Ask him if he has trouble flying at night, DeHaan says. This could be a clue that it may be time for a presbyopic correction.

Pressurized vs. Non-pressurized. The difference between pressurized and non-pressurized aircraft is an important distinction, De Haan notes. Most airline pilots always fly in pressurized cockpits, so oxygen will not be a problem. However, most smaller aircraft -- including helicopters and hot-air balloons, gliders, and most single-engine engine airplanes and light twin-engine airplanes -- are not pressurized. "When the atmospheric pressure is reduced, the pilot will get less oxygen into his bloodstream. Two things happen when a pilot gets into a non-pressurized airplane and goes above 10,000 feet: He can't think as well, and his eyes don't work as well," DeHaan says. "The net result is that someone who might test well in a doctor's office might get into an airplane, and at 10,000 feet, become presbyopic."

When flying in unpressurized aircraft, Federal Aviation Regulations (FARs) mandate pilots do not have to use supplementary oxygen when flying under 12,500 feet. However, between 12,500 and 14,000 feet, pilots are supposed to use oxygen 30 minutes after flying, and above 14,000 feet, they are supposed to use it all of the time. DeHaan points out that some pilots, however, don't always follow these standards. And when flying at 5,000 feet or above at night, lack of sufficient oxygen even more dramatically impacts night vision, he adds.

Vocation or Avocation? Most of the nation's pilots are private pilots, says Nakagawara. "They may be farmers, lawyers, or doctors, and they just fly," he says. Learn the type of aircraft your patients fly, and whether they have any special needs. For example, a crop duster pilot with presbyopia may be required to do some acrobatic maneuvers, and may need bifocals with a retainer to keep the frames on.

Measurements. Because every cockpit is different, specific distance measurements are crucial to getting the prescription right. This is where you can directly involve the pilot, DeHaan says. Send the pilot out with a tape measure to measure his aircraft. Have him sit upright in his normal seat position, and tell him to measure the distance from his eyes to the forward instrument panel; to the overhead instrument panel; to the center console; and to the chartholders and flight log sheets. If the pilot needs segmented vision correction, DeHaan will send him out with a frame and some black tape so he can position exactly where he wants the line.

Seating. Nakagawara points out that seating position has a major influence on bifocal segment heights. He says the bifocal segment has to be set at a height that will allow the pilot to see the instrument panel without interference with distant viewing. Presbyopic pilots who fly several different types of aircraft may need different types of spectacles for each plane.

Take a ride. There's no substitute for experience when treating patients. "Go for a ride in an airplane with one of your patients to understand their demands and needs," says Cummings.

Cockpit Correction

Once it's determined that a pilot has a presbyopia correction need, there are various options, just as with any presbyopic patient.

DeHaan says if the pilot is displaying the beginning signs of presbyopia, a simple half-eye may be a choice before moving him into a bifocal or trifocal or progressive. At that stage, DeHaan will present the difference between multifocals and progressives and let the pilot make the choice. "I would always present all the choices to the patient," he says.

He believes progressives are the best choice -- not just for cosmetic reasons -- but because they work best for the variable vision range. "With the progressive, you can adjust your head slowly, and bring something into perfect focus."

He says pilots should practice adapting to their progressives in flight simulators or cockpit procedures trainers (CPTs) before using them in flight. Or they could sit in the cockpit on the ground.

Jeffrey Hilowitz, O.D., the owner of the Pilots' Vision Center in Manhattan, disagrees with DeHaan that progressives are the optimal correction for presbyopic pilots. "Progressives are the last choice for a pilot when it comes to multifocals. Progressives limit peripheral view and give a narrow channel, so the pilot can't scan," he says.

Instead, Hilowitz, a private pilot, recommends bifocals such as the flattop 28 or 35 or trifocals such as the FD trifocal or the 12x35 lenses.

"I do have some patients who wear progressives, but it's because they are vain," Hilowitz says.

Near Air Disaster

Regardless of whether the O.D. recommends bifocals or progressives for presbyopic pilots, one option barred by the FAA is monovision contact lenses. Monovision contact lenses have never been an approved source of correction for presbyopic pilots, says Cummings. In fact, in at least one case, monovision contacts were ruled a contributing factor when a Delta McDonnell Douglas MD-88 attempted to land at New York's LaGuardia Airport on a rainy day in October 1996, but landed short of the runway deck. According to the final National Transportation Safety Board (NTSB) report, the probable cause was that the captain, who was wearing monovision contacts, was not able to overcome "his misperception of the airplane's position relative to the runway during the visual portion of the approach."

No one was killed, although three passengers sustained minor injuries. The report went on to say that "the incomplete guidance available to optometrists, aviation medical examiners, and pilots regarding the prescription of unapproved monovision contact lenses for use by pilots" was a contributing factor to the accident.

The American Optometric Association's Aviation and Presbyopia Task Force will examine this monovision issue in more detail, says Cummings, the chairman of this newly formed task force. According to him, the task force will conduct a demonstration project to compare pilots' performance in a commercial airline simulator when wearing spectacles versus wearing monovision contacts. The project, which he plans to start in the fall, should last for approximately six to eight months.

"There has been some research with pilots and monovision, but not a lot. We need to do something specific with the aircraft and look at the results," he explains. The task force will then present the results to the FAA. "I think the FAA is willing to look at more information," he says.

Pilots Wanted

With the average age of pilots increasing (the average age of medically certified civil airmen in 1998 was 43.4 years old), this is a growing optical market, says Nakagawara.

Most of the eyecare professionals interviewed for this article agree that developing this niche market can be done by word of mouth. Cummings says he lives in a small town, and he cultivated his pilot patient base with his reputation. He recommends O.D.s "hang out at airports" if they want to meet potential pilot patients.

Hilowitz went so far as to open his optometric practice overlooking the runway at New York's LaGuardia Airport in 1991, where he maintained a successful two-day-a-week practice, in which 95 percent of his patients were pilots. He even purchased an ATC-510 flight simulator. However, last year, Hilowitz moved the practice -- the Pilots' Vision Center -- to Manhattan, when he realized, for the most part, commercial pilots don't like to stay around the airport. Like everybody else, they want to go home when their work day is done. "Now, in my new location, I'm right in front of the train station, and I'm seeing more pilots than I did at LaGuardia." He says he's able to attract pilots on layover in his new location, as well as people off the street.

Hilowitz, however, plans to return to the airport venue with a one-day-a-week satellite office at Kennedy International Airport, which he will open within the next six months.

Location is key, but remember, too, pilots typically have access to aircraft, and most will think nothing of hopping in a plane and flying halfway around the world to visit a doctor with a good reputation and an enthusiasm for flying. EB