Vision Surgery Rehab Network VSRN.atinfopop.com http://visionsurgeryrehab.evecommunity.com Ask the doctors Complications/Dry Eyes/Pain Lasik Complications - Need help!!
VSRN.atinfopop.com http://visionsurgeryrehab.evecommunity.com Ask the doctors Complications/Dry Eyes/Pain Lasik Complications - Need help!!|
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It has been 2 months post-op lasik for me and I don't see any improvements. My vision is very clear in the daytime (probably 20/15) but I see day-time starbursts and I am very very sensitive to bright light. At night time it is hell. I see starbursts, double vision (depending what object I'm looking at), halos and contrast sensitivity.
I am wondering what I can do about this? My doctor says it is unfixable. Should I give more time to heal? I think the starbursts have actually increased in size since surgery and I have not noticed any gradual improvement or fluctuations. |
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Exec. Director, VSRN VisionMender™  |
Daniel,
The fact that your vision is particularly worse at night versus day is often related to the size of your pupils. The Orbscans you posted had a pupil size measurement but under the brighter conditions of the topographer. Your dark adapted pupils are no doubt much larger. In addition, due to having relatively hight myopia prior to surgery, your effective optical ablation diameter is probably smaller than the laser settings. These two factors result in light entering through the dark adapted pupil that is not accurately focused on the retina. Over time you may adapt to some of this but "healing" is not really a factor. There may be some further flattening of the cornea at the edge of the abltion zone but this is not a given. Hopefully your situation will gradually improve but there is no way to know. RGP lenses can help reduce the negative effects you are experiencing. In the meantime, ask your doctor to give you a sample of Alphagan drops for glaucoma. These drops keep the pupil from dilating as widely and should help a little with your night time vision problems. |
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Registered |
Are there any surgical options for this? I would rather rehab my eyes through surgery first from a doctor that is CAPABLE. If surgery isn't a safe option then I will look into RGP lenses.
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Exec. Director, VSRN VisionMender™ |
Redoing the surgery in an attempt to widen the ablation diameter requires deepening the ablation zone, removing more corneal tissue and adversely affecting more corneal nerves. This is not always wise and may be contraindicated in your case. The type of LASIK you had is supposedly more advanced than earlier surgeries so the question is, "If the surgery left you with these symptoms, what exactly went wrong and why would more of the same be a solution?" Is it your surgeon who says this is "unfixable"? Ask him WHY you are having these problems. Have you seen another doctor for a second opinion?
The experience you are having is not necessarily a reflection on your surgeon's capability but on the procedure itself. Patients who are thrilled with their outcomes credit picking the "right" surgeon and the best laser system but that's not it. LASIK is similar to the reason there are Lemon Laws for cars. Car after car comes off the same line, welded by the same machines, assembled by the same workers, but some vehicles come off the line plagued with problems while the majority are fine. We know the association between pupil size and ablation diameter - that larger pupils and smaller ablations cause problems. We know that ablations cause dry eye symptoms and corneal surface problems. We know that the flap can be the source of significant aberrations since it is covering a smaller volume of corneal tissue and doesn't fit exactly over the residual stromal bed, rendering it optically imperfect. But we don't know why some patients see well in spite of these adverse conditions while others with small pupils, low prescriptions and wet eyes may still be unhappy. LASIK is far from an exact science. No matter how precise the laser and the software guiding it, the procedure is performed on living tissue - very unique living tissue - that is clear and optically correct for most of our lives. The majority of people are "happy" with their surgery but outcomes vary from ecstatic to totally devastated. Some patients improve over time either physically, physiologically and/or psychologically to the point that residual aberrations or symptoms are of minor consequence. It is too early to know what your situation will be six months or six years from now. If we could interpret exactly what is wrong, perhaps an exact treatment could be rendered. Unfortunately no one has that kind of expertise and if they did, we would all, patients and doctors, be going to the lectures. This message has been edited. Last edited by: Dr. DavOD Hartzok, |
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Registered |
Thanks DoctorHartzok for the detailed replies. According to my records I think my pupils are 7.5mm when dilated. The laser used had a 6.2mm optical zone but it says the treatment area is 8.4mm*8.5mm. I don't understand the relationship between these two. What is the difference?
Also, this may be irrelevant but I examined my eyes under bright light and I noticed that the very top and bottom of my eyes (I guess the edges of the flap?) look very strange. They look kind of like carved glass and I can see light bouncing off of it at angles. You said that healing is not really a factor. So I guess my eyes are basically healed (like 90%) at this point and further healing won't make a significant difference on the starbursts? |
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Exec. Director, VSRN VisionMender™ |
Daniel,
The optical zone carries your prescription. The "treatment area" is the area between the optical zone and the more peripheral, untreated area of the cornea. Essentially this is a blending between the optical zone and the completely unablated cornea, designed to reduce the earlier "oblate" post-LASIK corneal profile to that of a more natural, "prolate" corneal profile. I am not sure what you are seeing when you look in the mirror but the change in corneal curvature may have altered the usual reflection off your cornea that you were accustomed to seeing before surgery. This is not something I remember being discussed on this BB before. Maybe some others have noted this. Healing is a relative term. It typically would mean when there is no longer any inflammation and the tissue has assumed a normal, healthy physiology. In that sense, your corneas are probably healed. However, post-LASIK or following other ablative surgeries, the corneal epithelium can thicken in an irregular fashion, a "re-modeling" of the surface tissue of the flap. This process may explain why some patients' vision changes for better or worse over the first six to twelve months. I have seen some rather irregular corneal surfaces improve over time. The trouble with any kind of visual analysis after ablation surgery is that we cannot point to the actual source of the starbursts, halos or glare. What you see is the combined total of the optics in the residual stroma, the flap-stromal interface, the corneal epithelium (and any irregular thickening present) plus the condition of the actual corneal surface which may be complicated by dryness and/or poor wetting. It is quite possible the starbursts may diminish somewhat over time but probably not disappear all together. |
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Registered |
Thanks doctor. So as long as your pupils are smaller than the "Treatment area" you should not have night vision problems, right? Or should they be smaller than the "optical zone"?
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Registered |
If you continue to be light sensitive (meaning in daylight or inside roomlighting is physically uncomfortable) you may need to restart the steroid drops. We see this sometimes, and it has been termed TLS for Transient Light Sensitivity. It can occur anytime in the first several months after LASIK. Ask you Doc about it, and whether steroids would help. Good luck.
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Thanks Tracy. That is great advice. I'm hesitant to use steroids though because I hear many people getting floaters like a year and a half after they use it. What is your opinion on this?
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Doctor Volunteer |
Higher order aberrations from your post-lasik cornea are causing you to experience these low-light and night-time visual distortions. I have fit a number of post-lasik patients who have excellent day- time vision, but horrible night-time vision with scleral lenses. Most of these patients only wear their lenses in the evening. These lenses fit under the eyelids and are supported by the white portion of the eye( the sclera). Since these lenses don't move, comfort and vision is usually very good to excellent. The back surface of the lens does not touch the compromised corneal tissue. Instead, a special fluid fills the space between the back surface of the lens and the front surface of the cornea.
Edward Boshnick, O.D.,F.A.A.O. Miami, Fl www.eyefreedom.com Ed Boshnick, OD |
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I AM ADDING TO THIS POST AS I DO NOT SEEM ABLE TO START A NEW THREAD AND i dont know why this should be but as this is a related thread hopefully this will not cause offence.
Some help if you can. I have posted many times about facial pain that I have experienced since prk 15 years ago. I now know that wearing lenses improves the (I assume) contrast ability of my eyes this lead to better vision and no resulting face pain. However no deal with lenses as my eyes are dry and I cannot get a comfortable fit - tried over twenty brands and RGP's I have just met again with the Doctor who carried out this initially surgery - this was carried out on NHS trials in the UK - He states that the issue is with the alabtion zone, this he tells me is smaller than it would be now due to early differences/development since. In order to improve the contrast and overall vision he says I would need the zone widening through 'theraputic wavefront treatment' This he says would alter my current refraction (6/5) and would mean I would need reading glasses as the outer untreated cornea is saving me from that at present (Im 43 yrs)_. This change he says may need a further, later refractive treatment. This is all on the record. Off the record he says that my fears regarding surgery are disproportionate to the risk as 34 million have been treated complications are few. He tells me dry eye worsening should improve after 9 months and in any case some of it currently may be naturally occuring. That continuing with contact lenses with punctal plugs could worsen my risk of CL infections. That there are no likely other non-surgical solutions now or in the future and he is unable to give me any percentage failure rate to the wavefront he or is team has carried out. He does not want to charge me for this new procedure as he says he just wants to get me well again. However without paying I fear he will only be overseeing the procedure. He also tells me that currently there is no point in continuing with punctal(smart)plugs as they are disappearing down my ducts due to the size of my ducts. He estimates a 70 per cent improvement in visual acuity if I go ahead. He will not accept that my face pain is caused by my vision on record. Off the record he says I could have been 'tipped into A-typical face pain' due to the brain not being able to accept the reduction in non-correctable vision. Sorry its long - Can you offer any thoughts -help advise. I am caught between a 'rock and a hard place.' No surgery means I have to continue with this vision which I know is the causal factor of face pain and is reducing my ability to work. Alternative more Frankenstein treatment. |
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Exec. Director, VSRN VisionMender™ |
Debbie,
Sorry to have overlooked your addition to this thread. When you say that lenses eliminated your face pain, I assume you mean contact lenses and not glasses? Is that correct? If indeed "the outer, untreated cornea is saving you from needing reading glasses", then you must certainly have very small ablations or very large pupils. Do you have and can you post recent corneal topographies? While there may be no reason to continue with smart plugs, (1) are you sure they are not in the lacrimal ducts? and (2) if your ducts are so large, why not use large, standard punctal plugs? Punctal plugs can help if the dry eye you are experiencing is truly dry eye but will not be as beneficial if the dry eye you feel is due to the nerve damage of the ablation. It is possible, of course, that both factors could be present and creating dry eye. If so, then plugs and other approaches to treating dry eye may benefit you. Regarding contact lenses: Soft lenses are a waste of time unless your pre-op Rx was quite low. I am assuming that you were quite nearsighted prior to surgery? And, if that is the case, RGPs post-ablation require more insight than what most prescribers possess. I wouldn't use the idea of increased chance of infection as a reason to not wear lenses, particularly if re-plugging your eyes increases an obviously reduced tear volume. The idea circulated heavily by refractive surgeons about the risks of contact lens infection is overplayed to the point of being a marketing tool. The risks or creating PERMANENT higher order aberrations due to ablation far outweigh the risks of contact lens infection, so - touche. You are 43. You had PRK fifteen years ago and yet you have had discomfort for all these years. On the up side, since it was relieved by contact lenses, then additional surgery may truly help. There is the risk of additional dry eye issues. "On or off the record", there is no way to know that your dry eye symptoms would be abated in nine months. Your surgeon sounds extremely confident that he can reduce your symptoms but I don't think you fears are disproportionate to the risk. You have been through a lot. If we have learned anything on this site, listening to patients' experiences, it is that second surgeries are not guaranteed. And yet your surgeon is suggesting a potential third procedure, I assume, to touch up the farsightedness the second surgery would create. This is the point that bothers me more than anything; doing hyperopic treatments over previous myopic treatments. Hyperopia typically creates more aberrations than myopic treatments. Again, your surgeon is highly confident. I would rather be sightly hyperopic with good vision than to risk a third surgery that might create more aberrations. I agree that you are between a rock and a hard place. Refractive surgery is never a slam dunk. Yes, the procedures have improved over the years but certainly there were patients with your Rx fifteen years ago who faired better. Ten patients with exactly the same prescription before surgery are not going to have ten identical outcomes even with the same surgeon using the same laser on the same day. But if you feel you have exhausted your contact lens options and glasses cannot provide relief, then a second surgery seems reasonable. At the very least, consider what your vision is like with a drop of pilocarpine that shrinks your pupil. If your vision is notably better after the drug is instilled, than widening the ablation zone may help. Have you done this? |
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Registered |
"I can see light bouncing off of it at angles" Daniel: that exact same thing happened to me after my PRK surgery 22 months ago and I also experienced most of the things you are experiencing. Eventually I stopped noticing that little shiny light comming out off my eyes when I looked in the mirror, it just vanished I don't really know when, but don't worry I don't think is anything serious... it's been months and I still can see (with lots of stars), but not much worse
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When I see the surgeon in Leicester I will ask him to do this. You are right the surgeon is very confident, and I have been concerned about the ability/arrogance ratio. He is very experienced, I do know this, He leads the whole team in quite a highly respected hospital. I have written back to him stating that I am still giving the procedure consideration and will only allow him to undertake the procedure if I go ahead. I am going back to see the opthamologist/surgeon in Leicester who initially referred me to back to this surgeon (to find out what was causing my problems.) He is not a laser doctor so I will see what he thinks too. Going to work is very difficult now though, the newer, softer lighting we know have to help 'normal' people working on VDU's really seems to heighten my contrast issues and I dont get a day without barely bearable pain. The pain comes on like clock work as soon as I am exposed to looking at a computer and working in that light. It drives me insane to think that they can dismiss the correlation between my vision and this pain. Despite the denials of this being symtomatic to this surgery - I feel certain that this side effect is well known in this industry If I could find any expert fitter in the UK who could help with RGP's then I would go for it but I can find no-one here. My symptoms seem exactly the same as the person who has recently supplied the second posting to rehab success. Although I have the torturous face pain to contend with too. Thanks for your response, I can see you have been very balanced in your analysis and I thank you for that. |
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Veteran |
Debbie,
I don't know how things work in the UK, but in the US, if you can get a doctor to write a letter explaining that the low lighting is detrimental to your ability to work, it is possible to have accommodations made. In my office, I have 8 daylight 6500K fluorescent bulbs that make everyone else see spots, but they allow me to see with far less ghosting and glare than the lighting in any other part of the building. There are screens that can be used over the monitor to help with the glare, and there are also "computer" glasses that are supposed to help reduce strain. Unfortunately, I know of no practitioner in the UK who is an expert RGP fitter, which means you would have to travel to the US or elsewhere for help. Some patients have done this, but I understand that financial considerations may preclude this. I'll continue to make inquiries for you to try to find someone. Artistwoman/Barbara Berney President, Vision Surgery Rehab Network "An eye for an eye leaves the whole world blind." ~Mahatma Gandhi |
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Exec. Director, VSRN VisionMender™ |
You may be dealing with two issues here: (1) surface aberrations and (2) stromal haze. PRK, especially in the early years, produced a fair amount of anterior stromal hazing (read, scarring). This could be scattering the light as it enters the eye, reducing the contrast and making you uncomfortable. While a soft lens should not help that scenario, a soft lens might positively impact aberrations on the corneal surface, picking up contrast. If there is some surface irritation due to dryness, the soft lens would act as a bandage and relieve some discomfort. It is critical that your doctor give you an opinion on stromal haze, corneal surface irregularities and/or epithelial breakdown. A second surgery would ablate the scarred anterior stroma - at least part of it - and, if the corneal hazing effect can be controlled following the procedure, your contrast would be improved. The other benefit would be a larger ablation diameter. PRK removes less tissue than LASIK so, unless you have very thin corneas, you probably have plenty of tissue for a second procedure. Based on all that you said above, a second procedure may very well be to your benefit. Ablating a little deeper into the stroma would remove previous hazing and the slightly deeper stroma is less subject to post-operative hazing. Surgeons today usually follow the PRK procedure with a Mitomycin C treatment to prevent or reduce hazing. Ask your surgeon about this as well. Some patients are more subject to post-operative hazing than others and you should consider every option to prevent this. This is why you need to know about the extent of stromal haze that you have. The number 0.38 (0.038mm?) may be a reference to ablating 38 microns of tissue - not unreasonable for widening the ablation diameter and reducing any previous haze. |
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Vision Surgery Rehab Network VSRN.atinfopop.com http://visionsurgeryrehab.evecommunity.com Ask the doctors Complications/Dry Eyes/Pain Lasik Complications - Need help!!
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