During my operation, I moved my left eye a significant amount. I remember having read in the literature (since they didn't give me any verbal instruction before starting the procedure) that I was supposed to focus on the light, but when I lost focus of the light, I adjusted my eye to try and refocus. I guess it didn't dawn on me that I was moving my eye - I did this twice after the flap was removed and before they started using the laser to reshape. At that point the doctor told me to stop moving my eye, but I think the damage was already done.

What I notice about my left eye, is that it's always somewhat uncomfortable compared to my right eye. Vision out of the left is always dimmer and not as sharp as the right eye. It's as if there is a layer of dust covering it, so everyting is slightly hazey. My optomotrist says that I have no correction needed in either eye, and that with the equipment he has, he cannot detect anything wrong with the health (besides the same level of dry eye in both at a 6 second tear break up time), or vision of my eyes.

One other thing I notice, is that the pupil size in the left eye, is at times noticeably smaller than that of the right. According to my records my right pupil diameter before the operation was 4.6 mm and the left was 4.4 mm, so that may account for this noticeable difference, but would .2 mm have the effect of making things appear dimmer and would the size difference be noticeable from looking in the mirror?

The main reason I'm inquiring about this is that I get headaches a lot. It seems to happen most when working on the computer a long time or if I'm outdoors where it's windy. I know that dry eye has something to do with this, but I'm also wondering if this haziness I have in my left eye is making me struggle to focus and affecting the nerves assoicated with that.

And secondly, I'm wondering, what has caused this? I imagine that since I moved my left eye while the flap was open, maybe my inner eye was exposed to the elements too long and micro-filaments of dust or whatever got trapped in there and are causing this irritation and haziness. Has this been know to happen?

Any insights anyone has would be great.

Thanks!

p.s.

Most importantly, can something like this be diagnosed and if so can it be corrected?

Misery,

It is possible that your ablation is de-centered. Did your OD do topographies? Can you get color copies and upload them to the site?

A 0.2 mm difference in pupil size might be mildly noticeable in a mirror but is probably not responsible for your vision complication in the left eye. As far as the headaches, dissimilar images between the two eyes can cause eye strain. A careful binocular refraction is helpful. It may be that you had some underlying binocularity issues (subclinical) and the changes you have experienced are stressing the system. I don't think the discomfort is due to exposure or dust. Your left eye is having a problem. How many opinions have you sought for your condition? There are so many possibilities here. You have dry eye. What measures have you taken to treat that?

This message has been edited. Last edited by: Dr. DavOD Hartzok,

Hi Dr. Hartzok,

I asked the doctor about de-centered ablation, and he said that I didn't have that, but that was the LASIK doctor, who I don't trust all that much.

So far I've seen 2 doctors at the LASIK center (one who is pretty well known for fixing LASIK problems), my optometrist who did the post-op and pre-op stuff, and 1 opthamologist on my health care plan. They all say that there's nothing wrong with my eyes, or anything that they can detect, besides the dry eyes, which is the same for both, although my left eye appears more irritated. So I've gotten 3 or 4 opinions I guess, depending if you count the LASIK doctors as one or two.

For dry eye treatment, I was using Restasis for the first 4 months following the operation and Refresh Tears when needed. Now I still use Refresh Tears .5% Carbroxymethylcelluslose sodium, which usually makes the vision clearer and sharper, and reduces some burning if there is any, and sometimes even lessens the headache. This is the same for Genteal Tears, which I use occasionally as well. I have also tried Dakrina, which I'm not that fond of because it's pretty goopy and doesn't feel all the good. I'm considering getting back on Restasis because part of the time I was using it, I wasn't having headaches every day. All the doctors said that that probably wouldn't make much difference for me because it wasn't a matter of a decrease in tear production, but that my tears evaporated too quickly. I have already had punctal plugs put in both eyes about 2 months after the surgery. I saw a slight improvement from that, but it hasn't made much difference, probably for the same reason mentioned above.

I’m thinking about going to see one of the doctors recommended by VSR in the SoCal area (Barbara Berney gave me some referrals). I’m wondering what I should ask them to check, what tests they should do, and what I should expect to pay for something like this.

Thanks for sharing your knowledge with me! :-)

I think I have a better clue as to what is causing my headaches, and I don't think the dry eyes are the primary issue. I think that you're right in that I could have a decentered ablation or an induced astigmatism. I experimented with this by wearing an eye patch over my left eye to see if it would affect my headache in any way, and it actually did. Is something like this correctable with glasses?

Thanks!

quote:

Now I still use Refresh Tears .5% Carbroxymethylcelluslose sodium, which usually makes the vision clearer and sharper

The fact that the introduction of artificial tears temporarily improves the quality of your vision suggests that you have irregular astigmatism at the corneal surface. Yes, eyes can be so dry that dryness alone can reduce your clarity but this sounds more like higher order aberrations. The logical test for this is to use a rigid gas permeable contact lens. If a well-fitted RGP improves the vision, then it is highly likely that HOAs are contributing to the headaches. Improving the clarity in both eyes would then allow the two eyes to coordinate better, further reducing the headaches. You need a doctor who can provide a decently fitted RGP and who also understands binocular vision issues.

"All the doctors said that that probably wouldn't make much difference for me because it wasn't a matter of a decrease in tear production, but that my tears evaporated too quickly."

In regards to the dryness and the evaporation of your tears, you need to be checked for meibomianitis - congestion and inflammation of the eyelids' meibomian glands. Lids scrubs, hot compresses and either 100 mg of oral doxycycline per day or 1000 to 3000 mg of flaxseed oil. Your doctor should be able to check your eyelids for this condition. Without the meibomian glands'secretions (oil), your tears will evaporate.

I'm not crazy about the idea of wearing a contact in my eye. Is it possible to get prescription glasses for this? I found the following site that talks about using wavefront technology for glasses. I'm assuming wavefront would detect any HOAs and the the glasses could correct for that.

http://www.allaboutvision.com/lenses/wavefront-lenses.htm

one other question I have is that over the years I expect my eyes to change, regress or whatever. will regression in a certain direction help to morph the HOAs into more ordinary aberrations - something a little easier to treat. Just like nearsightedness with a regular astimatism. i have some hope that i won't have to deal with this the rest of my life.

i'm going to see a RGP specialist. what sort of tests should i ask him to do? i want to be prepared for my appointment so i make sure that whatever it is i have is correctly diagnosed and i can get fitted for RGPs or get a prescription for glasses (still holding out for glasses).

Thanks again,

Chris

Unfortunately, Chris, the only way to have clear vision without aberrations is to wear an expertly fitted RGP lens. The docs to whom I've referred you are all very experienced in fitting lenses for post-RS patients.

What to ask? First, call and talk to the doctor, himself, before you make your appointment. Any of the docs to whom I've referred you will be able to understand your issues. Explain your vision situation, and discuss what can be done to help you achieve clearer vision. Be sure to ask about dry eye. They'll want to see some improvement in the tear film issues, and all of them are well acquainted with post-RS dry eye.

Glasses do little or nothing to improve HOAs. They are highly touted, but the reality is that the only relief for aberrations comes from the interaction of an RGP over the aberrated cornea. Wavefront lenses are just more hype, as far as I can tell. I've talked to a number of patients who've tried all the latest spectacle technologies. They've spent a fortune on glasses that do nothing.

Please try to be patient and take it one step at a time. Recovery and rehab are a process—there is no magic bullet that will make all this disappear, but with patience, a commitment to rehab and the right doctor, you will find management of your situation much easier.

Please check your email.

"Originally posted by miserylovescompany:
Is it possible to get prescription glasses for this?"

No. You can search VSRN's archives. This topic (wavefront glasses) has been discussed extensively. If wavefront glasses fixed RS problems, VSRN would not need to exist.

"... will regression in a certain direction help to morph the HOAs into more ordinary aberrations - something a little easier to treat."

There is no way to know how your corneal surfaces will change over time. There was nothing abnormal with your cornea before surgery. There is no healing process that would optically normalize the surface over time since the underlying ablation is permanent.

"i want to be prepared for my appointment so i make sure that whatever it is i have is correctly diagnosed and i can get fitted for RGPs or get a prescription for glasses (still holding out for glasses)."

A few basic steps prevail in all bona fide exams. (1) Make sure each eye has clear vision (probably an RGP in your case). (2) Determine that both eyes work together. If your eyes worked well together before surgery, then successfully completing (1) will probably take care of (2).

If (1) above is achievable with glasses, then the doctor must determine if something can be done to enhance (2). Problems with binocularity in post-RS patients are usually related to disturbed central vision or the fact that LASIK fails to correct the peripheral vision. This is where RGPs are great - they can correct central and peripheral vision if fitted well. (On that last point, i.e., the optics for RGPs correcting peripheral vision post-RS, if the overall RGP lens diameter is large, it will cover this omission which is inherent in all ablative treatments.)

Hi Dr. Hartzok and Barbara,

Thanks for all your help. I went to the see one of the docs that Barbara recommended and he checked my peripheral vision, which he determined was fine and he checked my eye muscle strength, which he said was really pretty good. The problem he thinks is that my eyes are imbalanced. The left one a bit flatter and then right one more steep so there's eye strain when struggling for visual acuity with this disparity - at least that's how I understood it. My topographies are probably a better indicator of what's happening than my explanation.

I also tried the RGP lens, but it didn't seem to make much of a difference and my vision was really cloudy because my eye was tearing up so much because of it. He said that this would indicate that it's not necessary to use the RGP, and that I could correct my problem with glasses.

I don't understand the prescription though. It's written on the topographies. Can someone explain this to me? Also, what do all the numbers like TK1, TK2, mean?

So what do you think? Should I try out the glasses?

Thanks,

Chris

chris'_file0002.pdf (1,511 KB, 19 downloads) Chris' Eye Topographies

Chris,

Your refractive error is not much, but with Lasik patients, often even a small amount of error can cause the problems you describe. Will the glasses help? Honestly, I can't say. If it were me, I'd be inclined to try them. I am quite surprised that the doctor only tried one lens and gave up on it. There is an entire fitting process that can take hours to complete, and if the proper lens is used, your eyes should not continue to tear excessively.

Unfortunately, the topography you've posted does not give us the kind of information we need to get an idea of the ablation zone, the amount of higher order aberration, corneal thickness, etc. Dr. Hartzok can explain this better than I can.

The prescription written for the right eye is Plano -0.50 x 165. This means you have a half diopter of residual astigmatism. The left eye Rx is +0.50 -0.75 x 015. This is referred to as a mixed astigmatism with one meridian being slightly farsighted while the opposite meridian is very slightly nearsighted. The overall astigmatism in the left eye is 0.75 diopter. We can equate Rx findings to their spherical equivalent - the right eye -0.25 and the left eye +0.12. This means the refractive imbalance is 0.37 (3/8) diopter - not much and it may or may not be responsible for the headaches you are getting.

It is important to remember that the inferences ODs make about symptoms and vision based on the prescription for glasses is relevant to NON-ablated eyes. After refractive surgery, a host of changes that are not easily defined by a simple glasses prescription are now a part of your visual experience, so the assumptions we make about glasses become less precise. Will the Rx your most recent OD determined provide relief? I don't know but I would not rule it out. I think getting a pair of glasses to try is worthwhile.

If the glasses fail to "scratch the itch", I wouldn't rule out RGPs because of your comment above: "I also tried the RGP lens, but it didn't seem to make much of a difference and my vision was really cloudy because my eye was tearing up so much because of it." If your eye was tearing a lot with the trial RGP, the trial was not an accurate assessment of the potential for an RGP to resolve the problem. A trial RGP doesn't have to fit perfectly but it has to be close enough for a consistent and reliable over-refraction, acuity assessment and a balance check between the two eyes. This is why post-RS trial lenses are so valuable.

TK1 refers to the curvature of the flattest curve of your cornea, TK2 the steepest. The difference between them is the surface astigmatism. In your case, the right eye has 0.79 diopters of astigmatism; the left eye 1.14 diopters. This is consistent with your new Rx. There is no significant difference between the two eyes in terms of steepness or flatness. The difference in the average curvature (avg) is only 0.34 - not an unusual difference even in non-ablated eyes. Remember, the numbers coming off topographers can vary with the blink. I always take four readings per eye and look for consistency. Topographers may not read ablated eyes precisely plus the graphical depiction of the topography can give different impressions. In looking at your topos, the right eye does in fact look steeper overall than the left eye and more than what the data suggests (0.34 difference). In any case, this difference in corneal steepness (flatness) is at the "corneal plane" and is not contributory to anisometropia. Anisometropia is a difference in the retinal image sizes at the back of the eye, typically a product of unequal refractive correction at the "spectacle" plane. If your pre-op corneal curvatures AND your pre-op glasses prescription were similar, I would not expect anisometropia to be the reason for your vision complaints. Again, try the glasses. Some small Rxs can provide a lot of relief. If the glasses are not effective, reconsider a longer RGP trial. A longer RGP trial might reveal a greater difference in the refractive error between the two eyes than standard refraction.

Thanks Barbara and Dr. Hartzok for the insights. I think I will try out the glasses and see if they help. And then if not, perhaps I'll retry the RGPs.

I forgot to mention that the doc identified a dry spot on my left eye. I think this is probably the cause of the discomfort that I feel pretty much all the time. I haven't heard of a "dry spot" before. Is this something that is permanent? I realize that my eyes are probably always going to be dry now, but can a dry spot be reversed or healed? And if not, what's the prognosis on something like this - can it cause more serious damage to the health of the eye?

Merry Christmas by the way, lol!

Thanks again!
Chris

Chris,

A dry spot may or may not be something you feel specifically as opposed to generalized dryness. The post-LASIK sense of dryness is not always dryness but could be associated with the actual singeing of the corneal nerves by the ablation.

You have to be careful not to read too much into any one finding. A dry spot is a dry spot. Unless it can be identified repeatedly, a dry spot may come and go. Patients may complain of dryness when there is no dryness apparent or there may be obvious dryness and yet the patient is asymptomatic.

Dr. Hartzok,

This is interesting. So could we say that there's just nerve damage there and that this sensation of there being something in my eye at all times is simply nerve irritation? This would explain why that when I put eye drops in it doesn't necessarily improve things, but sometimes just causes stinging and more irritation - it's very erratic like that. I suppose this could contribute to tension in the eye and collateral tension in the form of headaches.

I had flashes of hopefulness when I thought about embryonic stem cell research and that maybe this condition is something that could be treated with advances in that field. It will be interesting to see.

In any case, the mere fact of knowing or at least having a greater sense of certainty about what's causing these symptoms helps relieve the psychological impact. Thanks for your consultation.

You're welcome.

Anyone who has ever had abdominal or other surgery may have experienced a lack of sensitivity in their skin. You can have an itch that cannot be relieved by scratching. It's like scratching through a winter coat. Think of having your cheek numbed from anesthesia for dental procedures. You rub your cheek or lip, you can sense pressure but the natural sensitivity is gone. It may not be painful, but it is annoying and you are relieved when the sensitivity returns. Now, apply that thinking to your cornea. It may not be numb but a lot of corneal nerves are sensitive to surface dryness and their function is disturbed.

Nerves and, therefore, nerve endings carry specific senses. Some nerves respond to pressure or cold or heat. Corneal nerves are no different. The fact that corneal nerves are severed and/or ablated alters our sensitivity and awareness. It is presumed that the nerves grow back and resume their normal function but we know that not all nerves regenerate and the ones that do regenerate might be aberrant.

Post-LASIK dryness is usually assumed to be the same as dryness that is naturally occurring. Why? Because the patient says "My eyes feel dry." Logic demands a different explanation and mechanism.

I got the glasses and have been trying them out. Everything looks a lot crisper, and I can definitely tell it improves vision in the left eye. So I think the glasses can fix the vision disparity between the eyes, which is a relief. But I don't see that the headaches are diminishing. Is this because I haven't given it enough time?

I'm going back to the theory that my left eye dryness and nerve damage is the real cuprit in the headache saga. I don't know if it was the movement during the surgery or what, but my left eye is definitely the main irritant and I'm losing hope that things will improve. Both eyes were measured with the same level of dryness, but the left one has something else going on with it. I don't even notice the right one being bothersome, perhaps because it's overshadowed by the left's persistent sting.

I've been thinking of bandaging up my left eye and wearing an eye patch for a few months to see if I can just let the eye rest and heal. Is this magical thinking with no medical backing to support it? Besides tending to the dryness, what other sort of things can I do to help heal the nerves? Eye exercises, accupuncture...? Also, thinking of getting a job where I don't need to sit on the computer all day, to maybe cut down on eye strain. I am realizing that my eyes are really important (of course) and I want to put them first.

With appreciation,

Chris

quote:

Originally posted by miserylovescompany:
I got the glasses and have been trying them out. Everything looks a lot crisper, and I can definitely tell it improves vision in the left eye. So I think the glasses can fix the vision disparity between the eyes, which is a relief. But I don't see that the headaches are diminishing. Is this because I haven't given it enough time?

You are presuming a significant retinal image disparity exists between the two eyes when the improved vision is a matter of improved focus. The fact that the headaches are still present is suggestive that the problem is NOT relative to acuity or disparity.

I'm going back to the theory that my left eye dryness and nerve damage is the real cuprit in the headache saga. I don't know if it was the movement during the surgery or what, but my left eye is definitely the main irritant and I'm losing hope that things will improve. Both eyes were measured with the same level of dryness, but the left one has something else going on with it. I don't even notice the right one being bothersome, perhaps because it's overshadowed by the left's persistent sting.

Have your OD administer two or three drops of proparacaine to the left eye over a five minute period and see if the stinging is relieved. If it is, the indication is that the discomfort is at or near the corneal surface and possibly related to dryness.

I've been thinking of bandaging up my left eye and wearing an eye patch for a few months to see if I can just let the eye rest and heal. Is this magical thinking with no medical backing to support it? Besides tending to the dryness, what other sort of things can I do to help heal the nerves? Eye exercises, accupuncture...? Also, thinking of getting a job where I don't need to sit on the computer all day, to maybe cut down on eye strain. I am realizing that my eyes are really important (of course) and I want to put them first.

I don't think that is necessary or likely to be an answer. If the proparacaine temporarily relieves the discomfort, then do all you can to work on the dryness issue.

With appreciation,

Chris

This message has been edited. Last edited by: Dr. DavOD Hartzok,