HISTORY

I am a 34-year-old male (DOB 11/02/1966). I had radial keratotomy - 4 cut - on 03/10/1992 (left eye - OS). On 07/02/92, I had an “enhancement” - 4 additional cuts were added.

My pre-op refraction was: OS(L) -3.50 SPH.

My pre-op cycloplegic refraction was: OS(L) -3.00 - 1.00 x 165


POST RK COMPLAINTS

· The highlighted portions in Perry Binder’s letter cover what my vision was like post RK. Note that the EyeSys topography failed to reveal any significant irregular astigmatism.

As you can see from Perry Binder’s letter (1994), he thought that nothing more
Surgical could be done at that point to eliminate my symptoms.

· My post RK day glasses RX: OS(L) -1.75 + .75 x 170

· My post RK night glasses RX: OS(L) -2.25 + .50

It should be noted that these glasses helped my night vision only marginally and did
not help my day vision whatsoever.

· See letter to Casimar A. Swinger (05/96) for more description of my post RK visual symptoms.

· See Dr. Richard Abbott’s letter (1996) for even more description of what led up to my decision to have the LKP!


SURGICAL INTERVENTION (PRK)
(POST RK)

· See Dr. Nordan’s letter (06/17/1996) regarding corneal irregular astigmatism and proposed PRK plan (medically necessary).

07/12/1996 PRK attempted to try to make my corneal curvature more regular and
To correct sphere and cylinder.

· Post RK refraction before PRK procedure: OS(L) -1.25 -.75 x 167

This is the refraction the PRK was based on. It should be noted that my refraction
fluctuated tremendously since RK surgery and this was an average based on
numerous refractions.

RESULTS: Slight improvement but not nearly enough improvement to restore normal
function. Therefore, LKP was scheduled for 12/13/1996.


SURGICAL INTERVENTION (LKP)
(POST RK)
(POST PRK)


· See letter from Blue Shield (12/04/1996) approving the LKP as a medically necessary procedure.

· LKP (Lamellar Keratoplasty) (12/13/1996) surgical date!

- Surgical recovery (1st 2 days) - moderately painful.
- Visual acuity prior to suture removal - around 20/80 (with slight distortion.)

03/31/1997 (Suture removal):

- In-office procedure (all sutures out at one time).
- Not painful whatsoever.
- Vision following suture removal - somewhat myopic with mild astigmatism.

PRK indicated in a couple months!

SURGICAL INTERVENTION
(PRK AFTER LKP)

· PRK -> 05/19/1997 (5+ months post LKP)
(Nordan)

Refraction before this PRK (unknown):
-just mild myopia with mild astigmatism.


· PRK -> 05/11/2000 (3 years 5 months post LKP) (Nordan) Refraction before this PRK -1.00 + 1.75 x 180 (approximate)

· No haze developed after PRK procedures (due to the very small amounts of tissue being ablated)

PRESENT SITUATION

· Manifest refraction (07/06/2000) standard room illumination:
Planno +1.50 x 180

· Cycloplegic refraction (11/07/2000) standard room illumination: -.25 + 1.00 x 013

- Refractions have been stable since these were taken in 2000!


· Uncorrected visual acuity (standard room illumination – 6mm pupil)
20/30

· Uncorrected visual acuity (bright light 1mm - 3mm pupil) 20/20

· Am I satisfied with the result:
Yes I am. By this I mean that my vision was improved by the LKP and
subsequent PRK’s. However, I must still wear RGP lenses in low lighting
and at night. My vision during the day (with a small pupil) is very good - no
RGP’s needed. I have a very large low light and nighttime pupil, 6mm and
9mm respectively, and this is why I need to wear RGP’s under these lighting
conditions.

Even after the LKP, I still have an irregular corneal curvature. However, the
central 3mm’s are regular (asymptomatic) - which wasn’t the case before the LKP. By not having to wear RGP’s during day light hours, I have a big advantage compared to my pre-surgical state (pre LKP). Before my LKP (after my RK) I had to wear RGP’s all the time to see clearly. This was impossible to do for the following reason:

No one was able to fit me satisfactorily with RGP’s because of the
post RK corneal curvature. I could maybe get 2 hours of wear time -
which was very uncomfortable. The lenses available at the time were
not very good - it was a new subspecialty (post-refractive surgery
RGP’s). After my LKP, I can now be fitted with RGP’s. Since
I only need these lenses in low lighting conditions and at night, I can say
with certainty that I am better off now (after LKP) than I was after RK.


POST LKP & POST 2 SUBSEQUENT PRK’S

PRO’S AND CONS

PRO Eye can now be refracted with spectacles somewhat (for night vision relief -
minimal improvement – but an improvement nonetheless). Prior to LKP, spectacles did not refract at all!

PRO Day vision is excellent (1-3mm pupil). No RGP’s needed.

PRO No haze; very clear cornea.

PRO Stable refraction (except upon awakening - 2 hours).

CON Diurnal fluctuation in AM. (1st 2 hours upon awakening is always somewhat
blurry. This always clears up 1 - 2 hours after I wake.) Not sure as to the
cause. Could be that the RK incisions are still present in the stromal bed and
this is causing diurnal fluctuations from the internal eye pressure. Could also
be due to residual bed thickness (have yet to be measured).

CON Dry eyes (better with time – took 2 years postop until significant improvement! However, I still need plugs to wear RGP’s.

CON Tremendous amount of spectacle blur after removal of RGP’s. (This did not
occur before LKP.) Although before the LKP I was not able to be fitted
properly with RGP’s. Since the LKP I only wear RGP’s at night, this spectacle blur is not too much of a problem. This could be a major problem if I needed to
wear the RGP’s during the day.

CON Microkeratome used to create “button”. Not “Intralase” which Nordan uses when performing lamellar keratoplasty surgery at the present time (08/01). The use of the microkeratome and not the “Intralase” could be why I still have
irregularity of the cornea after my lamellar keratoplasty procedure.

CON Pupil somewhat larger than pre-op (in low illumination conditions).


DROP THERAPY

All 3 of these work to constrict my nighttime pupil. Alphagan P works the best.
Alphagan
Alphagan P
Rev-Eyes


ORBSCANS

Presented here for purposes of determining stability of curvature after
LKP and 2 PRK’s

* 2nd PRK -> 05/11/2000

7/6/00
7/10/00
8/2/00
8/2/00
9/6/00
9/6/00
9/6/00
2/15/01
2/15/01

- Shows irregularities (fairly stable)
- Pachymetry readings are not accurate.
- Cornea is much thicker. (However, the Artemis 3d Ultrasound will shed more
light on the pachymetry.)