Eye strain/ Headaches worsened after TransPRK

Hi I wanted to share my story about my eyes and hope someone can help me.

Until I was 16 years old I never wore glasses. But at that age I noticed that my vision was getting worse at all distances but more noticeable far away, I couldn’t read subtitles on the television anymore. Until I got glasses I never had issues with tired eyes or pain behind and around my eyes.

I got my eyes checked by an optometrist and she said I had astigmatism. My prescription measured with cycloplegic drops was:

Left eye: Spere: -0,25 Cyl: -1,25 axis 80

Right eye: Sphere: -0,25 Cyl -1,5 axis 100

The hospital told me that the optician had to measure again to give me the glasses prescription. They gave me glasses with the prescription of:

Left eye: Sphere: -0,75 Cyl -1,25 axis 80

Right eye: Sphere -0,75 Cyl -1,5 axis 100

This is the first time I felt a tired feeling around my eyes when I wore my glasses for the first time. I Didn’t wear my glasses all the time since my vision wasn’t that bad. I remember I could see much sharper without glasses if I rested my eyes for a longer time. After 6 months I got used to the glasses and I didn’t feel much tiredness or strain anymore. It was pretty much okay for a couple years.

Then I lost my glasses and got new ones with a slightly different prescription. I believe 0,25 or 0,5 more cylinder. I remember it took a very long time until I was used to these glasses again. For a couple months I had some tiredness and headaches again but this went away finally. In the next summer I didn’t wear my glasses for approximately 3 weeks because I did a lot of outdoor activities where glasses were not an option. When I had to study again I put on my glasses and the headaches returned but they were worse now. Especially when looking close up I felt a lot of strain. It was so bad I had to give up on college and quit. I was 19 years old at the time. I felt contact lenses were a lot more comfortable and relieved the strain a bit. But these lenses gave me eye lid infections so I wasn’t able to wear contact lenses anymore. I went back to the optician twice but they said my glasses were fine and I just had to adapt to it.

In April 2017 I decided to have laser eye surgery because I thought having a prescription that stays the same forever will give my eyes the chance to fully adapt and eliminate my headaches. The other reason was I couldn’t wear contact lenses but I’m a very active person who likes to do water sports where I’m not able to wear glasses.

I was a good candidate for TransPRK but my doctor said my glasses were a little bit too  much minus in the past. So he decided to treat a lower prescription than in my glasses.

The lasered prescription was:

Left eye: Sphere: -0,5 Cyl: -1,25 axis 73

Right eye: Sphere: -0,5 Cyl: -1,5 axis 110

After the surgery I got very intense eye strain and I was not able to watch tv or read for months. It turned out I was overcorrected and my prescription measured with cycloplegic drops is now:

Left eye: Sphere: +0,75 Cyl: 0

Right eye: Sphere: +1,00 Cyl: 0

For the first 5 months after surgery I didn’t wear any glasses because my doctor said it would regress but this never happened. After 5 months I got glasses with the prescription of L: +0,75 R: +1,00. I remember my eyes got a little bit used to the overcorrection after 5 months and the eye strain was not that bad anymore but still present especially around my right eye. When I put on these glasses the strain became worse again. And my vision in the distance was worse than without glasses. My near vision was better.

After a couple months my vision in the distance cleared and my headaches and eye strain were not as bad anymore but still there. I got an extra +0,25 in my glasses in both eyes because the doctor at my second opinion said my eyes were still in a locked up accommodation. After the change in glasses my headaches were more intense again, after 2 weeks I changed back to L: +0,75 R:+1,00. I still had trouble seeing up close but I waited another couple months. The eye strain/ headaches became a little more manageable in the months after but didn’t go away. Then I went to an optician who gave me prism glasses. I felt like these glasses helped a little to see more comfortable in the distance but didn’t help nearby. And I had to get used to them again and headaches became worse the first weeks. She gave me prism because my left eye was a little higher than my right eye.

After 2 months I went for a 5th or 6th  opinion at the hospital (I lost count). I already checked everything else that had to be medically checked but we came to the conclusion that the cause of the pain is 100% from my eyes.

At the hospital my eyes were measured again with cycloplegic drops. The result was now:

Left eye: Sphere: +1,25 Cyl: 0

Right eye : Sphere: +1,75 Cyl: 0

They told me to get rid of the prism glasses because my eyes could do this on their own they said. I was being told to wear glasses with the prescription given above. They also said my eyes were not working together well.

So here we go again another change. The eye strain and headaches worsened again but this time the pain became as bad as it was the first months after my surgery. I noticed my vision nearby was better but in the distance it was blurry. It is now 2 and a half months since I got these glasses and the strain/pain is less than the first weeks but still there. It gets worse when I do a lot of close up work like typing this on the computer. The vision up close is better but still not as sharp as it was before my surgery. The positive thing is that my vision in the distance is now sharper than 2 months ago so I can let go of some accommodation. But it is still so painful sometimes that it is hard to function normally.

 

The strain is completely gone when I wake up in the morning after a long night of sleep but kicks back in as soon as I open my eyes. But it depends on how well I rested my eyes for the past week. Also my vision in the distance is much better in the morning than it is in the evening. Studying is almost impossible, also riding a bike and driving is really hard. The best thing I can do is staring in the distance. My life is completely messed up right now. I use a towel during the day to cover my eyes and make my vision pitch black to have instant relief. My vision is not perfect I see a little bit of ghosting when I look on a screen from close up. Especially in my right eye above and under white letters on a dark background it is noticeable. This could be because I also have haze since the surgery which is slowly fading away.

Dry eyes was also a big thing but after 1,5 years after the surgery it is now a lot better.

Now 1 year and 10 months after the surgery and still having headaches/ eye strain every day.

 

So my question is if anyone here experiences same issues and how or if they found a solution?

-Does it maybe take 1 or 2 years with these glasses I now have to let my brain adapt to my eyes?

-has the small ghosting caused by the haze anything to do with my eyestrain?

-Do I maybe have an even larger amount of farsightedness than is measured until now?

-Are contact lenses a better option than glasses because they don’t enlarge the image like plus glasses do?

-Is there any other thing I have to get checked?

-Any tips or recommendations?

Original Post

"When I had to study again I put on my glasses and the headaches returned but they were worse now. Especially when looking close up I felt a lot of strain. It was so bad I had to give up on college and quit. I was 19 years old at the time."

Based on all that you have written I would guess that you were significantly exophoric combined with being farsighted. The accommodation necessary to focus your eyes helped adjust for the exophoria. As you became slightly older your farsightedness naturally lessened, the extra accommodation was no longer needed and your eyestrain due to the exophoria increased. Getting glasses at that point did nothing to relieve the exophoria.

"After the surgery I got very intense eye strain and I was not able to watch tv or read for months. It turned out I was overcorrected ..."

Again, not surprising based on your history. You were probably always farsighted but the full degree of your farsightedness was not manifest because you were over-accommodating to help with the exophoria. Corneal refractive surgery alters the natural and acquired balance between accommodation and convergence. This also happened when you got contact lenses. ("I felt contact lenses were a lot more comfortable and relieved the strain a bit".) This was a "telling" event as to the underlying binocularity issue.

"Then I went to an optician who gave me prism glasses. I felt like these glasses helped a little to see more comfortable in the distance but didn’t help nearby."

Another "telling" event and your optician was picking up on the exophoria. The prism corrected the distance exophoria but, because we all require additional convergence at near points, the glasses didn't benefit reading.

"She gave me prism because my left eye was a little higher than my right eye."

This examiner picked up another feature of your binocularity issue. The "hyperphoria" was either a natural component (that had bothered you for some time) or it was induced by your visual system trying to coordinate and align your two eyes over the years.

-Does it maybe take 1 or 2 years with these glasses I now have to let my brain adapt to my eyes?

No, it should not take years for your brain to adapt to your glasses. On the contrary, the goal of prescribing vision correction is to provide a correction which relieves the underlying vision issues. Your present prescription is not doing what is necessary to relieve your eyestrain.

-has the small ghosting caused by the haze anything to do with my eyestrain?

Ghosting exacerbates the struggle to attain and maintain binocularity.

-Do I maybe have an even larger amount of farsightedness than is measured until now?

It's quite possible. I imagine what is happening in your country is the same as here in the USA where the art of refraction is dying. Many examiners do not or cannot render anything more than a simple sphere, cylinder and axis. The term "vision analysis" means a comprehensive examination of the visual system which is NOT limited to that simple sphere, cylinder and axis but examines for ocular alignment and accommodation issues. Your underlying binocularity problem was not diagnosed in spite of visits to numerous practitioners. A few figured out that something was going on (hence the prism) but didn't quite pull it all together. The visual system is highly dynamic and it can take awhile to iron out underlying issues that have been there for years.

-Are contact lenses a better option than glasses because they don’t enlarge the image like plus glasses do?

Image size is not the issue in your case. And, if necessary, the contact lenses cannot provide any prism correction. If everything was great up until your refractive surgery, then a contact lens might be suggested. But because your visual problem preceded the refractive surgery, you have to look back at the entire visual system to discern what approach is needed.

Hello Dr. Davod Hartzok,

first of all I want to thank you very much for Answering! I really appreciate the help you give here on the internet to all these people, I have a lot of respect for you!

I notice when I wear my glasses for a longer time the pain and strain gets less. I have been wearing my +1.25 and +1,75 glasses for 2,5 months and it feels a bit better. Every time I change anything, even 0.25 , the real discomfort kicks back in. Also being outside the whole day helps a lot. 

Your part about the exophoria makes a lot of sense about my situation in the past. That should be the reason why I’m overcorrected by the surgery. Would you suggest getting prism glasses for my hyperphoria and exophoria. Or get glasses with a higher amount of + plus correction for reading or distance as well? Again I’m pretty scared to change anything because this alway causes more pain at first.

How much time is needed for my eyes to adjust to my glasses I now have before trying a new prescription? Do I have to give these glasses more time?

Are there any other treatments for exophoria and hyperphoria besides prism glasses? My orthoptist at the hospital is against prism glasses but my optician isn’t. This is very confusing.

The haze is not noticeable when the light is bright but I still get headaches so I guess this has nothing to do with my strain, maybe only at night when I do see it it. The haze is almost gone by the way, it was way worse one year ago. But is there a way to speed this up or get rid of the haze and all of the ghosting caused by it?

Did my minus cylinder before my surgery also help with dealing with the exophoria?

would an enhancement to get rid of my farsightedness be a good idea? Preferably I don’t want this because I don’t want to take any risk with my eyes anymore.

You said the prism glasses corrected my exophoria in the distance but not nearby. How should I correct the exophoria nearby?

I don’t know if you can answer all my questions since you didn’t examine my eyes yourself. I try to describe it as best as I can. If still nothing helps I’m willing to travel great distance to search for help. Also the USA. Or maybe you have suggestions for doctors specialised in binocularity close to the netherlands?

 

 

When any one of us read something, say at 16", our eyes must converge (turn in) to that point where we are reading. Our focus (accommodation) must also be just enough for our vision to be clear at that distance. The relationship between convergence and focusing is a conditioned (learned) response, a coordination of our eyes.

One way to think about this is how we move our arms while walking versus running. Our left arm moves forward while our right leg moves forward. At the same time, our right arm is moving back. How much back and forth movement of our arms depends on how fast we walk and if we are running, and taking bigger strides, our arms move further forward and back. We don't think about it; it's just a built-in coordination.

Now imagine wearing ankle weights or steel-toed work boots. The added weight will alter our arm movement. As we walk with those weights or with those shoes our arm movements will have to swing differently until it becomes natural to us. Until then we would find walking a bit awkward.

Every time we change the lens strength in your glasses, it alters the relationship between how much you must accommodate (focus) relative to the needed convergence. If your natural relationship between the two is unaltered for many years and you achieve some degree of comfort, great. But, as our prescription changes, as we age, if we opt for refractive surgery or contact lenses ... any change that can alter the previous balance between focusing and convergence can be difficult particularly for someone who's coordination is already challenged. (You now know more than many eye doctors!)

This is why surgeons should never view refractive surgery as a sure cure for all things visual and should first endeavor to solve any underlying visual coordination issues. This of course presumes the examiner can first diagnose the particular problem and why many of these "subtle" issues are overlooked prior to refractive surgery.

In your case ... 

Changing your prescription even 0.25 diopter seems to throw things out of balance which is the reason your glasses prescription needs to be changed carefully. At the same time, the degree of exophoria may indicate prism to help you but that too should be added sparingly. Hyperphoria, on the other hand, needs to be examined for very carefully and even 0.50 prism diopter of vertical hyperphoria can be very problematic. In practice, I don't actually measure hyperphoria ... I measure "vertical fixation disparity" which is the actual amount of vertical imbalance for which you are unable to compensate. Our visual systems are not designed to deal with even small amounts of vertical fixation disparity but, incredibly, most practitioners neglect to examine for it. Vertical fixation disparity is measured outside of the phoropter (the device with all the lenses in it, the "better one or two" thing.) Your prescription needs to be mounted in a trial frame. The examiner then uses polarizing lenses and has you view a similarly polarized eye chart where the fixation disparity can be measured. The examiner should then be able to measure the precise amount of prism needed and that amount is what gets built into your glasses. At this same time any horizontal fixation disparity can also be determined.

Of all the prism that I find necessary to prescribe for my patients - prism that corrects vertical fixation disparity is far and away the most common because it seems to impact the patient most severely, leading to chronic discomfort and eyestrain.

You may want to check with your prescriber and find out if he or she is set up to examine for fixation disparity (OUT OF THE PHOROPTER!). The normal refraction (sphere, cylinder and axis) can also be determined more effectively in such a manner as well.

Refraction can be tedious and many practitioners delegate it to underlings who are not educated to the necessary degree. A complete and comprehensive refractive analysis can take time ... even twenty minutes or longer ... to get the two eyes relaxed enough to give consistent responses to the lenses. The visual system is highly dynamic and so must be the examination. Forty seconds on the right eye followed by forty seconds on the left eye with no analysis of BOTH EYES SIMULTANEOUSLY is the product of an examiner who does not understand the visual system. It is also becoming the norm.

"My orthoptist at the hospital is against prism glasses but my optician isn’t. This is very confusing."

I agree ... this is confusing. Ask each one about fixation disparity testing. (Remember, it's a process, an analysis, and not just a simple test.) If one of them identifies with what I am suggesting, then let him or her do the examination.

"The haze is not noticeable when the light is bright but I still get headaches so I guess this has nothing to do with my strain, maybe only at night when I do see it it. The haze is almost gone by the way, it was way worse one year ago. But is there a way to speed this up or get rid of the haze and all of the ghosting caused by it?

The haze is probably directly related to the actual procedure and may fade over time as you seem to appreciate. There is no way to speed up the process at this point.

Did my minus cylinder before my surgery also help with dealing with the exophoria?

Your pre-operative cylinder was "against the rule" which generated some degree of base-in prism and yes, that may have helped with the exophoria when reading. (By the way ... the orthoptist who is not in favor of prism should be able to recognize this possibility and the fact that, post-surgery, your glasses are no longer generating the base-in prism.)

BTW ... your farsighted lenses can generate some base-out prism when reading which is NOT what you need, so using some horizontal prism may help offset this. The goal is to solve the underlying visual problem and give you comfortable, functional vision.

Would an enhancement to get rid of my farsightedness be a good idea. Preferably I don’t want this because I don’t want to take any risk with my eyes anymore.

An enhancement will probably create more haze which is not good thing because it makes ocular coordination less precise. Also, your prescription will still change as you age and you can't chase that with more surgery.

You said the prism glasses corrected my exophoria in the distance but not nearby. How should I correct the exophoria nearby?

This points out the difference somewhat between exophoria and horizontal fixation disparity and why the latter is more critical. While we may measure much more exophoria at near than far, the amount of correction for fixation disparity is typically smaller than the measured exophoria. The fixation disparity represents your inability to align your two eyes by a subtle amount and that subtle amount may be just enough to correct the near as well. In other words, while the difference in measured exophoria between near and distance may be significant, the difference in measured fixation disparity is often negligible.

I don’t know if you can answer all my questions since you didn’t examine my eyes yourself. I try to describe it as best as I can. If still nothing helps I’m willing to travel great distance to search for help. Also the USA. Or maybe you have suggestions for doctors specialised in binocularity close to the netherlands?

Answering questions without actually examining you always carries with it some shortcomings. I have been in practice a long time (maybe too long!) but you've done an excellent job describing your visual frustrations and much of what you are experiencing is something I encounter frequently in my practice.

You mentioned an orthoptist and an optician. In the USA an orthoptist is generally a technician associated with an eye muscle surgeon. An optician is someone who dispenses (but does not prescribe) glasses. An optometrist here examines for (hopefully) all things visual / optical and diagnoses and treats eye conditions medically. In the Netherlands, your "optician" may actually perform refractions and be capable of rendering the necessary analysis you need. (Based on what you said about prism, I would expect the orthoptist to have recognized the need for prism and not be reluctant to use it when necessary ... so I too am a bit confused.)

Any examiner who can relate to what I have written here is a good bet. Here in the US not everyone performs the kind of analysis I am suggesting either. Increasingly, comprehensive refractive analysis is a dying art.

Thank you so much for your comprehensive answer! 

I think I meant an optometrist when I said optician. I will discuss this conversation with my orthoptist and will keep you updated about my situation whether I’m feeling better or not.

kind regards,

Mitch

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