Post-Lasik - Visual Distortion of Light when Eyelids cover Cornea/Iris

Hi folks,

I got lasik three months ago and developed facial pain in my forehead.

After some mystery and a million scans, it has been determined that I have a visual distortion thats encouraging me to keep my eyelids 'open' and off my cornea/iris. This is in addition to the usual halo and glare 'GASH'syndromes. The best description of the effect is in the following image:

http://imgur.com/vNlKD8G

So essentially, I'm consciously/subconsciously constantly raising my forehead/brow/eyelid to keep my vision clear of this blur.

Two optometrists that I'm working with have suggested that the weight of my eyelids or the 'tear prism' at the top eyelid is causing this on my new irregular post-lasik cornea.

Has anyone seen this? My poor forehead is pretty tired!
Original Post
LASIK alters the relationship between patients' corneas and their eyelids. Lid posture can alter the degree of GASH. If your facial pain is truly related to lid posture (as opposed to some underlying nerve pain) then the only solution is to wear rigid contact lenses. RGPs would clear your vision by canceling the effect of the irregular corneal optics.
Thank you Dr. DavOD and Barbara.

The first suggested a lid surgery, which I'm not in favour of.

The second, who is a family friend, wants to pursue RGP lens. She is not sure which kind or who fits them. Do you have any particular recommendations on what type of lens to pursue?
Post-LASIK vision distortion is typically a corneal problem. Even if raising your lids reduces the distortion, there is no guarantee that lid surgery could replicate that same lid position.

I would offer another opinion on the visual benefit of raising your eyelids: The normal upper lid position (at your age) tends to cover the upper one-fourth to one-third of your cornea. And, being young, you also tend to have larger pupils that are covered superiorly by the lid. Post-LASIK patients with large pupils have more GASH than those with smallish pupils. When you raise your eyelids, you are allowing more light to pass into your eye which causes your pupil to constrict and it is the constriction of the pupil that is reducing the GASH.

I think the upper lid tear prism is a thoughtful idea as to your specific complaint, but it won't solve GASH issues associated with large pupils and any irregularity secondary to the ablation.
Sorry... just saw the last line of your post.

This topic has been discussed since the beginning of time on this BB: There is no KIND or BRAND of RGP lenses. On post-LASIK corneas the work is all custom. There is no measurement device, no simple formula, nothing that works for all patients. Anyone who gains success with a specific brand or off-the-shelf lens is lucky more than the device is effective. It's all about optimization and optimization is patient-specific.
Canadaeyes,

I believe that I sent you a referral to one of the best fitters in Canada some time ago. My opinion still stands. Without an expert fitter, you will likely not be successful with RGP lenses. If you need the information again, let me know and I'll resend.
This is the same visual problems I am having. That downward smear of light I notice it more and more and just as much through the day off any bright light source.
I have not been given any diagnosis of this and therefore not given any way to rectify this as no body understands the problem.
How can I explain this issue to an opthamologist and what I can do to resolve this?
I have been experiencing it for 3 years now and it is really getting me down
Any help would be appreciated
Can I ask what scans would be needed to determine if it is the tear prism or eyelid that's causing these vision problems? I too feel I keep my eyelids open to avoid these visual distortion.

I am having exactly the same problems and my corneal scans are coming back normal so I am not given any possible solution to my problems

Can anybody help?
Paul1986...

The upper lid tear prism (which is what your are referencing from Canadeyes posts) is generally never a problem. See my post above - August 16, 3:38 PM. Patients often assume that their problem sounds exactly like someone else's problem and that someone else's solution is their solution.

Several years ago I was at a seminar given by a neuro-ophthalmologist. He presented seven cases that had been sent to him accompanied by "normal" (as read by a radiologist) CT scans. However, in all seven cases the patients had a lesion visible on their CT scan that explained the patient's condition. All that was needed was a competent interpretation of the CT scan.

Similarly, today's ocular technology can provide answers that eye doctors, even those in refractive surgery centers, fail to accurately appreciate.

Corneal topography results (as you mentioned in your post above - August 29 12:31) may look fine to someone who "doesn't have anything to do with LASIK" but not fine to another practitioner. It would be helpful to see those scans. It would also be helpful to see Orbscan or Pentacam analyses. Do you have anything available that we can look at?
Thanks for your reply

No I wasn't assuming that it was the same problem as mine, it just seems to be a very uncommon problem having the light streaking when blinking and the tear prism and eyelid seeem to be things that haven't been looked into for me. I am awaiting another appointment so will attach any scans I have from there. Are the orbscans the same as wavefront scans? I know the clinic I go too only have this and topography scans.
Thanks for any help I'm just really struggling at the moment and being told my eyes are fine is really wearing thin now.
Paul1986,

Wavefront scans interpret the path of light rays entering the eye. Effectively, wavefront details the type and intensity of distortions of light passing through the cornea and physiologic lens. Orbscans primarily show us the optical integrity of the corneal surfaces - both anterior and posterior. From the Orbscan, we can infer the effect on one's vision and assign the effect on specific surfaces. From the wavefront analysis, we can get an accurate picture of the distortions present but we can NOT assign those distortions exactly to any one corneal surface. We can learn something about your condition from both techniques. They actually complement each other. The more data the better.
Hi everyone,

Its been months since I posted but I wanted to update you on my findings. I have seen tons of doctors on this streaking matter - none have the answer.

On my pain/strain front, this is still a daily problem. Thankfully, it appears to be fading, but still very problematic. I have been working with behavioural/developmental optometrists (met with numerous to get second opinions). All have found fusion and accommodation issues, which I'm addressing with a treatment plan.

The light streak issue is still a problem. I now have fitted scleral lenses and they do not resolve the streak issue. I have also consulted with Dr. Gemoules who confirms that he has heard of this problem with other patients and sclerals do not seem to solve it. Truthfully - I can deal with the streaks if the strain goes down.

I have had a myriad of alternative corneal surgeons and optometrists take and review my scans, but none have detected the source of these vertical streaks.

For additional information, it may be helpful to note that I am overcorrected into hyperopia.
Have you had any updates regRding the light streaking issues? Was anything showing on the pentacam scans?

I too have got no further with this issue. On recent refraction I am slightly myopic and small astigmatism. They have suggested a enhancement may be possible but have really no idea what effect this will have on the light streaking issues.
Thanks for your reply

I am currently awaiting the pentacam and wavefront scans I have requested, I hope this shows some understanding to why I am getting these problems.

My refraction when I last was seen was left eye- sph -0.75, cyl -0.5 and right eye -0.25, -0.5

I asked about the amount of HOA and they said this was a total of 0.9 if this makes sense and this isn't very high.

I have been given glasses to this precription and although I see slightly clearer my eyes are still aching most the day off any light and the light streaking I experience when blinking adds further to this.

One doctor suggested that the lasik flap could potentially cause light to refract or reflect at the flap interface and this might be exagirated when blinking and the eyelid moving over this surface.

All I know is I didn't have it straight after surgery and it started about 2-3 months after during the healing process and it is exactly the same in both eyes?
Paulf1986,

It sounds like more than one problem. Anything that changes with the blink is normally related to the tear film fluctuating, as in dry eye, although there could be some corneal surface irregularity.

The second issue is the eye aching. Is the aching less of a problem in the morning when you first wake up? Were you on steroid eye drops BEFORE the aching began? Have you used any steroid eye drops SINCE the aching began?

Regarding light reflections or refractions at the flap interface - that would be a constant if present and only responsive to alterations in lighting, not blinking.
The aching is normally less of a problem in the morning and more later in the evening when concentrating or watching television.

The vision is sometimes worse in the morning as My eyes used to be quite dry after surgery and Although my eyes don't feel dry through the day and my TBUT and schrimer tests are within normal range, I continue to wake through the night/morning with dry eyes almost impossible to open unless I administer drops. Sometimes this determins how my eyes feel first thing in the morning.

As it is over 3 years now since the surgery and have noticed the light problems continuously after the first 2-3 months, do you still think this could be tear film issues or more of an underlying cause. Could the dry eye I did previously experience have caused some lasting effects that aren't really visible on scans and under slit lamp?
Many thanks for your time
Regarding any steroid drops these where only administered during the first few months after surgery.

Another question is that usually people that have vision affected by tear film issues notice improvement when administering artificial tears, I seem to be affected the opposite and light streaking and issues around bright lights seems a lot worse, does any of this make sense?
quote:
Originally posted by Paulf1986:
The aching is normally less of a problem in the morning and more later in the evening when concentrating or watching television.


In this regard... I would suggest Lotemax drops (mild anti-inflammatory) every twelve hours for a few weeks and see if the aching and dryness resolves.

quote:
Another question is that usually people that have vision affected by tear film issues notice improvement when administering artificial tears, I seem to be affected the opposite and light streaking and issues around bright lights seems a lot worse, does any of this make sense?


Some artificial tears supplements are very thick. Can you remember which ones you have tried?
Thanks I will give them drops a try and see how I get on.

The problems I have isn't specific with any type of drops even if my eyes just tear then I seem to notice all the visual disturbances and light steaking to a higher degree especially when blinking.

I understand tear film quality can affect optics but It's like light is refracted in a totally different way through my cornea when my eyes are wet with tears/artificial drops.

Do you have and idea what would cause these issues?
quote:
Originally posted by Paulf1986:
I understand tear film quality can affect optics but It's like light is refracted in a totally different way through my cornea when my eyes are wet with tears/artificial drops. Do you have and idea what would cause these issues?


Excessive wetness can negatively impact vision. What we need is a evenly-thick tear film that reconstitutes itself almost immediately after each blink. Do you have any office notes from all your visits as well as the scans you requested?
I have requested my full notes and scans so should have those available in next few days to email you.

One specialist on another site suggested it may have something to do with transition between the treated and untreated zones of the cornea or some sort of interaction between the tear film and the lasik flap. Would any of these be possible?

I do get a lot of daytime glare and starbursting even when it's bright day light and my pupils are tiny so I don't know if this is related to the steaking also.
Paulf1986,

While the vast majority of refractive surgeries are satisfactory for patients, when surgery is not satisfactory the number of causes to sort out can be legion. In many cases it is not just one thing. Because there are so many possibilities to consider, I think post-surgical consultations tend to be superficial and quick to explain causality. It takes ten times more effort to sort out a patient's post-surgical complications than it did to pronounce that same patient a good candidate for surgery.

I'll be anxious to see your records.
I have same problem with streaks and beams what you guys have. Have it 3 years and nothing want change. It seems like on the pictures
http://imageshack.com/i/p7PJX6FZj
https://imageshack.com/i/p8qvtxrnp
I didn't have Lasik Surgery for Myophia, but i had laser treatment on my retina. I think, i had holes in retina. 3 months after laser i started to see floaters, streaks, beams. Also, when i open my eyes wide, all goes away and i see almost clearly. I was examined by many doctors and they cant find anything wrong. Only one doctor said i have irregular astigmatism, so i tried contact lenses but it didnt help. It's really annoying, it's hard to live with that. Any solutions ?
I cant tell what kind of contact lenses i tried, i forgot to ask. I was wearing it maybe 1 minute. My doctor said i should wear it minimum 3 hours, becouse my cornea need to get flatten. I have appointment with optometris in Thursday, maybe he will tell me more. What kind of lenses should i try ??
Hello. I was trying hard and soft contact lenses today and it doesnt work. Optometrist thinks i could have something wrong with my natural lenses. He mentioned something about internal astigmatism in my eyes. He told me, that my lenses can causes internal astigmatism in eyes, becouse when he was examining me, he still was seeing astigmatism with contact lenses. He said, that maybe laser could damaged lens fibres. I hope, you can understand me, becouse my english is not enough;/.

Dr. Davod i dont have a contact with specialist who treated me. 4 years ago Doctor said to me " all is ok", so i gave up with this Doctor. I was thinking about vitreous and vitrectomy, becouse almost all people who have this problem in internet, have floaters. I know someone, who had same laser treatment on retina and after this treatment she was starting to see same visual problems like mine, first floaters, then streaks. I had appointment with vitrectomy specialist and he said, that vitreous cant give symptoms like mine. Dr Davod, you think vitreous can causes my vision problems??? What do you think about lenses, is it possibble, that laser could damaged my leneses ?

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