Bill

A CAUTIONARY TALE

I had LASIK surgery on my eyes just over a year ago (Jan. 6, 1999). At that time I was 58 years old, and had been wearing glasses since I was eight years old. I was one of the early contact-lens wearers, getting my first pair of hard contacts in 1958, and graduating to soft lenses in the 1970s. I was a successful contact-lens wearer, but often wore my glasses (later bifocals) when it was more convenient. I was -8.5 in my left eye and -11 in my right eye at the time of the surgery.

I suppose I got caught up in the advertising hype that seemed to intensify on the airwaves and in the print media in 1998. It sounded almost too good to be true -- a few minutes of painless surgery, a few days to recover, and no more myopia for life! I decided 50 years was long enough to wear glasses, and that I would do something nice for myself by getting rid of them. However, as with so many things that sound too good to be true -- it was.

I spent considerable time checking out the local ophthalmologists who performed the operation. I eventually chose a man who I still feel is probably the best surgeon available locally. I do quibble with the counselling sessions and risk assessment in his office, however. After the preliminary eye examination and screening, the surgeon said, Congratulations", that I was a fine candidate for the procedure. I naturally enquired about the risk involved. Most of the discussion (with the vision counsellor) seemed to revolve around the percentage of people who achieved 20/20, 20/40 etc. vision. As to the possibility of permanent damage occurring, the counsellor dismissed the possibility out of hand, saying "...it just isn't going to happen". I do not recall the possibility of decreased low-light vision being mentioned. "Starbursts" and "dry eyes" were mentioned in passing, but in the context of temporary reactions (a few days implied), with the dry eyes being alleviated by temporary use of eye drops. I was aware of the obvious fact that I would still wear reading glasses after the surgery. I had worn them over my contacts for some years.

In the days following the initial surgery, I was in considerable pain -- my eyes were extremely dry and irritated. After about a week with no improvement, the surgeon prescribed a topical steroid, which I used in decreasing amounts for the next two months. He said the problem was pre-existing blepharitis (inflamation of the eyelids caused by oily secretions from glands in the eyelids). I was advised to clean my eyelids daily with baby shampoo, a regime I still follow today. Although the blepharitis had never caused me any problem before (I didn't even know it existed), the surgeon said it was now causing an eye reaction, presumably stimulated by the surgery. In retrospect, I raise the point that because the blepharitis must have been obvious during the screening eye exam, why was I still considered a good candidate for the surgical procedure? Surely the more conservative course would have been to clear up the blepharitis first, then proceed with the LASIK surgery? The result for me was several weeks of acute pain and discomfort caused by the reaction.

However, I optimistically kept the main goal in sight; to eventually heal and to be able to see without glasses. The vision in my left eye was pretty good from the start. It did regress temporarily, then came back, stabilizing at about 20/30 after six months. My right eye was much more variable, ranging from about 20/200 to 20/40, depending on the day of the exam. The surgeon suggested enhancement, and I was certainly in agreement, hoping to get the right eye up to the acuity of the left. My eyes were very dry during this six-month period, and I was using eyedrops about every hour, and more frequently when trying to read. I had new reading glasses made a few months after the surgery, but the letters seen by my right eye were always slightly hazy, even with prescription glasses. I remarked on this to the surgeon and to his assistant, who had now taken over my follow-up examinations. The assistant maintained that my vision would improve as healing continued. He said that my right eye could not be completely corrected for sharp acuity at the moment, even with glasses, but that the enhancement would help. At this time I was still under the impression that the lack of clarity in my right eye was caused by a remaining degree of myopia in that eye.

I had the enhancement of my right eye done on July 12, 1999, six months after the initial surgery. According to the chart readings, my right eye had stabilized to about 20/50 at that stage, although things still looked hazy to me through the right eye. After the enhancement, I noticed almost immediately that the hazyness was worse, most noticeable in the middle distances, where hazyness had been less pronounced before the enhancement. I now had markedly hazy vision at all distances with my right eye. I was told that this would improve with healing.

In October, after two more unsuccessful attempts to obtain reading glasses to allow me to read clearly with my right eye, the surgeon's assistant rather casually gave me the devastating (to me at least) news: my right eye could never be corrected with glasses to the acuity of my left eye, or to what it had been with glasses prior to the surgery. In a subsequent visit, he explained that the fibers of the cornea had not interdigitated properly during the healing process. Although the cornea looked clear, this improper interdigitation caused the hazyness, and it could not be corrected with glasses. I asked specifically if this was what was called "irregular astigmatism", and was told "no", that there was no specific term for the situation other than "loss of best corrected vision". I was told that it happened in about 1-2% of surgical cases, more often in people with a high degree of myopia.

I eventually saw the surgeon again, and he said that there was still an "interface" between the cornea and the flap, because healing had not welded the collagen fibers tightly enough together to eliminate the interface. I assume that the surgeon and his assistant are both saying essentially the same thing, just phrasing it slightly differently. In any case, the surgeon said that nothing can be done about the situation. He said that there is a good chance that the hazyness in my right eye will eventually improve, although it may take another one or two years! I hope he isn't just putting me off by holding out something for me to hope for. He did say, however, that even if the right eye improves, its acuity will probably never be as good as the left. He said that the "dry eyes" condition should also get better in "one or two years".

In summary, my current problems are these:

1) The usual post-LASIK problems, frustrating but marginally manageable, of poor night vision and poor low-light vision, "starbursts" around lights at night, and a slight loss of contrast. However, I consider these to be less serious problems than the next two.

2) More serious is the continued discomfort from "dry eyes". I had never had any noticeable dryness in my eyes before the surgery. I have subsequently learned that dry eyes are a very common reaction to the surgery (a response to the corneal nerves being cut), and can result in a life-time condition. I have had this problem for over a year now, with no sign of natural abatement. The possibility of this as a long-term consequence was certainly never mentioned to me during the screening/counselling. I am now wearing punctal plugs in my upper tear ducts (lower duct plugs proved unsatisfactory), which help, but I still use eyedrops for added relief, especially when reading, as my eyes rapidly become dry and scratchy after only a short period of time reading. Without the plugs I was using eyedrops every hour to maintain a degree of comfort, and every 10-15 minutes when reading. I now use eyedrops about every half hour while reading.

3) The most serious post-surgical complication -- the one that has caused a dramatic alteration for the worse in my life-style -- is the loss of clarity of vision in my right eye, especially for purposes of reading. Apparently my right eye now tests(!) about 20/30 or 20/40. Despite those attractive readings, the bottom line is that I simply can't see clearly with my right eye! The problem is most noticeable when reading (even using prescription reading glasses). Letters seen with my left eye are clear and distinct; letters seen with my right eye are fuzzy and markedly indistinct. The result of this clear left eye - hazy right eye is slightly indistinct letters when reading with both eyes, an imbalance that causes noticeable eye strain. I now frequently have a headache after an attempt at prolonged reading. I never had headaches when reading before LASIK surgery. Moreover, I now cannot read very small print (e.g., a dictionary) at all without the aid of a magnifying glass. Very small letters just fuzz together.

I am a university professor, involved full-time in teaching and research. Before the surgery I could read (with reading glasses/bifocals, of course) for days on end without any discomfort. Lengthy reading sessions were (and still are) absolutely necessary for my work, as well as a valued recreational pleasure. All my life I have relished reading; now I avoid it. The eye strain caused by the lack of acuity, compounded by the discomfort of dry eyes make reading an uncomfortable, unpleasant task for me. I estimate my teaching and research reading has decreased 50% in the last year. My recreational reading has declined even more. I haven't read a book in comfort for over a year.

The maddening thing is, of course, that I need not have had the surgery done in the first place. I could see perfectly well before the surgery with glasses/contact lenses. The surgery was entirely elective; but oh, how seductive was the promise of glasses-free vision for the first time since childhood! I recall signing a form just before going in for the surgery, which I'm sure must have been the consent form (although I was not given a copy). As we all know, these consent forms agree to release the doctors from any conceivable consequence. So what are my complaints about the current process for people like me? Overall, I feel that there is often a misrepresentation of the degree of risk involved. I believe there was in my case.

1) Patients should be told, orally and clearly, during the screening consultations of the likelihood, not just the slight possibility (if they are mentioned at all), of such things as chronic dry eyes, reduced night-vision, etc.

2) Patients should be told of the possibility (probability?) of healing problems in cases of high myopia that can reduce corneal clarity. I had absolutely no idea that this could be a consequence of the surgery. Had I known that there was even a 1% chance that the surgery would render me permanently unable to read clearly and comfortably, I would not have had it done.

3) In my personal situation, the somewhat reduced corneal clarity which developed after the initial surgery was(?), or should have been, recognized, and therefore the enhancement should not have been performed on the grounds that it could make the uncorrectable hazyness even worse (which it did). I was completely unaware that this situation existed, and had I been informed, I would definitly not have had the enhancement done.

It has been said that we do not know what we have until we have lost it. In my case, I have lost the capacity to read with ease and comfort. As someone else said, "Once your cornea has been cut, there is no going back".