quote:
If a well-fitted, rigid contact lens eliminates the visual frustration, then you know the problem is optical and primarily on the corneal surface.


Can you explain what this means? What are the implications if it's on the corneal surface? Is that vs. being in deeper corneal layers? Optical meaning related to vision correction, not the flap?

Sorry I don't understand all the lingo. Smile
If the corneal surface has "waviness" (i.e., aberrations), a rigid contact lens will cover those corneal aberrations with an optically correct (non-aberrated) surface. By covering corneal surface irregularities in this way, the rigid contact lens becomes a diagnostic tool to ascertain the degree to which those surface irregularities are impacting your vision.

If a rigid contact lens eases your visual frustrations, those frustrations are then proven to be optical and, in particular, at the corneal surface level as opposed to an optical problem in the deeper layers of the cornea. In your case, if the problem is swelling in the deeper cornea layers, then a rigid contact lens will have minimal effect. Surface irregularities, scarring and other deeper corneal issues - ALL ARE OPTICAL - but we typically assume that most post-LASIK corneal problems are at the surface. Surface aberrations can be seen with corneal topography but dryness can distort those findings. Even if the corneal topography findings look good, it doesn't rule out the corneal surface as the culprit. (Aberrometers measure the total optical distortions throughout the entire corneal thickness, helpful in a general sense but not particularly localizing as to where the aberrations exist.)

The art of rigid contact lens fitting is vanishing; one reason so many patients have turned to LASIK and other surgical procedures. Fitting post-LASIK patients with a rigid contact lens is specialized. However, for the purpose of determining if the corneal surface is the major factor in your frustration, the rigid lens does not have to be as precise - it merely has to be tolerated long enough to get your impression of improved vision. In your case, being only mildly nearsighted pre-LASIK makes it easier for an experienced contact lens fitter to find something in the office for the test. (It helps if the fitter has worked with other LASIK patients and or does ortho-keratology.) The better the fit, the better the diagnostic impression.

If the flap is the problem, re-lifting (re-floating) it will only improve your vision to the extent that the flap can be put back down without wrinkles or waves. Again, the fact that you were so minimally nearsighted pre-LASIK is helpful.

I know this is a lot to think about but sorting out post-LASIK vision complications is not simple. There are so many variables. Ten patients with almost identical pre-op findings can have LASIK on the same day by the same surgeon and come out with mostly happy patients while two may be unhappy and one totally frustrated. My position on this remains: Until we can figure out WHY patients deemed "great" candidates for LASIK have bad outcomes, we can not effectively screen them out of the process. This means we have to take long, serious looks (RESEARCH!) at post-LASIK problem patients, looking for factors that may be missing in the pre-op analysis.
Thank you for explaining, that all makes total sense.

From all angles, I guess it seems like the flap re-float is worth a shot. Then if that does nothing I can begin working through all these other possibilities one at a time.

I do think dryness is a factor b/c there is some fluctuation where the vision gets even worse, and usually the left (good) eye feels dry at the same time (it is not on steroids or Restasis). But oddly the dryness never seems to affect the vision in my left eye much.

I keep thinking if it were just the vision and I didn't have so much pain/discomfort maybe I could live with it. But both is just so horrible. The last few days especially have been really bad b/c of allergens in the air.

This does not make me any less scared that I might be permanently stuck with the pain and poor vision, but it helps a ton to better understand it.

There is a dr. 3 hours away from me who specializes in post-LASIK vision correction, though he said he won't see patients until 6 mos. post surgery. If this doesn't work I will probably end up going there this summer.

If you think of anything else that I should think about, ask or know before the procedure Fri. please let me know.

Thank you!
You have two issues, blur and discomfort, and the causal factors are not necessarily related.

I do not understand the need for an OD to wait six months post-op to assess your case, particularly if you are trying to determine if surface aberrations are to blame in advance of a flap re-lift. At this time you are looking for a diagnosis for a condition that has been significant for you since surgery.
I got the impression that he specializes in fitting for contact lenses to correct vision problems resulting from vision correction surgery, but that he doesn't do post-surgery diagnosis/treatment relating to surgery complications. So, he would see me after everything is stabilized and we know what kind of vision outcome I'm "stuck with" then he would work to achieve best possible vision correction with RGPs or sclerals or whatever. Maybe he's just too busy to take on the post-surgery diagnosis patients? Though I did consult with him via email about my complications and he also was generally favorable about the idea of trying a flap re-float in my situation. He said that's a pretty routine step that some of his patients have tried before he ultimately ends up seeing them. (sigh - this could be me in 3 months)

Anyway I don't think I need to travel 3 hours at this point for treatment of what is going on now b/c there are plenty of docs in town. As mentioned, I've already had 2 ODs look at my eyes (in addition to 3 different surgeons and a corneal specialist at the laser clinic - it's a big clinic obviously). Only one of the DOs said he saw the "waves" whereas everyone else says the cornea looks fine (I recognize the others have more of an interest in saying that of course).

Both DOs think flap lift might help with one or more of my problems - whether it's surface aberrations or something deeper. It sounds like you don't disagree, right? (Though I know, it also might not help at all.)

Both have also said there is probably more than one problem and it's hard to separate them to "fix" them. Since I had bad edema post surgery it could be logical that a tiny bit is still underlying in deeper layer; since I had a flap wrinkle it could be there are aberrations interfering with vision; it has also been suggested that there could be a thin layer of cells proliferating under the cornea (which I guess if they're not clustered they can't always be seen with slit lamp) and the cell growth could have happened during the phase when I had the edema, which means I would not be able to SEE the difference when one went away and the other began ... and since I have dry eye that could be exacerbating any and all of the above.

One of the DOs said to wait until 3-6 months for flap re-float (I'm at 13 weeks now - the one who said wait is the one who thinks there are "waves" and he did the aberrometry so I mostly am going with his recommendaton). The other DO said do it as soon as possible. Obviously I took the more conservative route of waiting.

I certainly understand and agree with your position about the way this surgery is marketed: it's obvious that people who are ideal candidates can have horrible, unexplained outcomes and they minimize this when they are selling the procedure. Though I'm also not sure anyone could have ever explained this to me in a way that would have truly captured how horrible it feels. So would it have deterred me to hear more about the negatives? Who knows.

As far as treating my complications, it seems a lot of this is subjective and trial and error, which sucks and can be discouraging, but for the moment I'm geared up for the work and the fight of trying to see well again!
Were the "waves" something visualized by corneal topography? What we are looking for is depicted with topography.

Throughout the history of LASIK is a running thread - "Well. The flaps look great." Such statements are meaningless if based on simple slit lamp observation by the doctor. (Most things visible at the slit lamp are not minor or subtle.) Aberrometry can pick up those irregularities but cannot localize the problem as being on the corneal surface.

This is what I mean about LASIK complications. Ideally we can run tests and deliver a diagnose for a problem before proceeding with a treatment plan. While technology certainly is amazing, it loses luster when it fails to differentiate a problem. Having been in practice for thirty-five years I have come to except that subjective impressions by a doctor (i.e., best guess) are still a part of eye care. However, subjective impression is more palatable when dealing with pathologies as opposed to elective procedures where patients have higher expectations.

If there is concern for cell growth beneath the flap, then I would think this would be visible to some degree with a slit lamp. The surgeon will irrigate the underside of the flap at the time of the re-lift to remove any cells. Whatever the case, let us know how you are doing.
Yes, the OD who saw "waves" did aberrometry and topography and he showed me what he meant in all the pictures, so he is basing that on more than just slit lamp exam. It is ever so slightly different from the good eye, though there actually are more HOAs in the good eye, but they are farther out from visual axis I think.

The LASIK surgery center doesn't have the equipment to do aberrometry in the local office (they have another clinic out of town that has it) so that plus the desire for 2nd opinion is how I found the OD who says he saw "waves."

However, he also said it the waves were far enough toward the edge of the visual field that he is surprised it's having such a big impact on vision, but that it's possible.

He encouraged me to give it another month or so to see if it improved on its own, which I did and it did not get even the tiniest bit better. In fact, I'd say the blurriness and ghosting has stabilized at the worse end of the spectrum of what it was when it was fluctuating.
I have a really good update: This time they were able to correct my vision with a lens!

I'm wearing a soft contact lens on my right eye and the two eyes see the same now. It felt so amazing to be able to read road signs again on the way home!!

The corneal specialist thinks there was still some residual inflammation, as previously speculated, so that's probably what was getting in the way of refraction before. She thinks now the Lotemax has worked to resolve it, so we can tell my remaining vision problems are the result of 1 diopter under correction.

I was actually really pleased with how incredibly thorough they were about re-checking everything and they did not hesitate to acknowledge that I'm under corrected. So I'm not getting any kind of CYA vibe from them. Smile Which I was worried might happen after reading so much about surgeons not wanting to admit to under correcting. They seemed to have no qualms whatsoever about saying, it's not good enough and we can fix it.

So, I'm supposed to wear this contact lens for a week, see how things are going and they will probably at that point schedule me for a second lasik procedure to correct the right eye to match the left.

Which is scary to me now that I've been through what I've been through. But if I can have perfect vision when it's all said and done at least one thing will go right.

And since there's no flap cutting that should mean an easier recovery than the first time around. Plus it's just the one eye. They also will give me stronger pain drops this time, knowing that I had more than the usual amount of pain last time. But they said I may not need them.

This doesn't address the remaining discomfort, which they think is due to the dry eye. My right (uncomfortable) eye is now drier than my left. Left tears stay 8-9 seconds while the right eye is still only more like 6 seconds. It's been just past 2 months on Restasis and I guess this is still within normal time frame for dry eye to be a side effect.

So, I'm hopeful and encouraged to know that the vision problems I've been having are not anything catastrophic or permanent.

I guess I could stay with just a contact lens rather than doing the second surgery. What would be the pros and cons of that? Now that I have dry eyes, wearing a contact lens probably isn't the best thing anyway. Plus all of this would be for nothing if I'm still dealing with contacts. Though I guess some of the same risks are there with treating the eye a second time.

What a ride this is.
By the way, I appreciate all the questions you asked and your input about the explanations I was being given re: inflammation, cell growth, etc.

It just wasn't adding up, which is why I was feeling skeptical about the re-float working and posted here in the first place, and your additional questions only fueled my skepticism. So I walked in there today with half a mind to walk out if things still weren't making sense and if they couldn't explain it all better.

Luckily they did.
So, I am just realizing the contact lens they gave me is only -.50 even though when I was in the office they verbally stated that I need 1 diopter correction to balance the two eyes.

Now I'm confused. Why would the contact lens prescription not match the difference they say needs to be corrected?

What is the smallest amount they can correct with LASIK if I do the enhancement?

More important than balancing the two eyes is the fact that even with this small correction my right eye goes from not being able to read signs while driving or identify faces at a distance to being able to see clearly again. So independent of the left eye, I think the right eye really is under corrected.

Are there specific questions I need to ask the dr. to make sense out of this?
???

quote:
they verbally stated that I need 1 diopter correction to balance the two eyes.


Throughout the posts nothing was mentioned about a 1.00 diopter imbalance and nothing was mentioned about performing an enhancement. All that was said was that they would attempt to relieve the blur by re-floating the flap. When did you learn about the imbalance? Looking over the posts, the right eye was reported to have 0.25 diopter of astigmatism. (Jan. 7, 11:08)

A one diopter imbalance is a highly significant finding. What is your actual prescription? Did they give you the numbers?

Did they re-lift the flap? Often a bandage contact lens is placed on the eye after surgery. They might have used a -0.50 lens because it's thin.

With all the docs you've seen, why didn't this imbalance figure prominently in the discussion?
That's weird, one of my posts must not have shown up or something. I can see it there now though.

Do you see a post from Fri January 10 2014 01:39 PM that starts with "I have a really good update" - if so that stated about the 1 diopter correction and explained how they were able to correct my vision with a lens so they are recommending a second lasik procedure.

They didn't lift the flap (thought that was implied by the update).

I will repost this update. Sorry for the confusion. That's so strange if it isn't showing up for everyone. Smile
[/QUOTE]When did you learn about the imbalance? Looking over the posts, the right eye was reported to have 0.25 diopter of astigmatism. (Jan. 7, 11:08)
With all the docs you've seen, why didn't this imbalance figure prominently in the discussion?[/QUOTE]

Until the visit on Friday, January 10, the only imbalance anyone noted was a .25 astigmatism in one eye and they did say my right was seeing 20/20 while left was seeing 20/15.

This was also the first time refraction actually worked to clear up the vision in my right eye.

That's why it never came up before because everyone was still just trying to figure out what the heck was causing uncorrectable blurriness.
REPOSTING THIS since it seems maybe it didn't show up?

quote:
Originally posted by oneblurryeye:
I have a really good update: This time they were able to correct my vision with a lens!

I'm wearing a soft contact lens on my right eye and the two eyes see the same now. It felt so amazing to be able to read road signs again on the way home!!

The corneal specialist thinks there was still some residual inflammation, as previously speculated, so that's probably what was getting in the way of refraction before. She thinks now the Lotemax has worked to resolve it, so we can tell my remaining vision problems are the result of 1 diopter under correction.

I was actually really pleased with how incredibly thorough they were about re-checking everything and they did not hesitate to acknowledge that I'm under corrected. So I'm not getting any kind of CYA vibe from them. Smile Which I was worried might happen after reading so much about surgeons not wanting to admit to under correcting. They seemed to have no qualms whatsoever about saying, it's not good enough and we can fix it.

So, I'm supposed to wear this contact lens for a week, see how things are going and they will probably at that point schedule me for a second lasik procedure to correct the right eye to match the left.

Which is scary to me now that I've been through what I've been through. But if I can have perfect vision when it's all said and done at least one thing will go right.

And since there's no flap cutting that should mean an easier recovery than the first time around. Plus it's just the one eye. They also will give me stronger pain drops this time, knowing that I had more than the usual amount of pain last time. But they said I may not need them.

This doesn't address the remaining discomfort, which they think is due to the dry eye. My right (uncomfortable) eye is now drier than my left. Left tears stay 8-9 seconds while the right eye is still only more like 6 seconds. It's been just past 2 months on Restasis and I guess this is still within normal time frame for dry eye to be a side effect.

So, I'm hopeful and encouraged to know that the vision problems I've been having are not anything catastrophic or permanent.

I guess I could stay with just a contact lens rather than doing the second surgery. What would be the pros and cons of that? Now that I have dry eyes, wearing a contact lens probably isn't the best thing anyway. Plus all of this would be for nothing if I'm still dealing with contacts. Though I guess some of the same risks are there with treating the eye a second time.

What a ride this is.
So, does it make sense that having the inflammation before would have interfered with refraction and measuring my correction?

I'm sorry for not having the #s from the appointment Friday. Will definitely post back with that tomorrow when I get them.

This is all new to me and a constant learning process so I don't always think to ask the right things at the appointments.

Even though I went in there with a list of questions, most of them were related to the flap lift since I thought we'd be doing that.
Also (sorry I keep thinking of things to add) I think the doc told me previously that I actually also have slight astigmatism on left eye, too, but that it is canceled out by slight farsightedness so that I'm plano in that eye. (Again, sorry I don't have the #s at hand right this second.)

The left eye is totally fine, sees perfectly near and far. I'm just mentioning this since we are talking about imbalance.

But whether or not there's an imbalance, the right eye OBVIOUSLY is benefitting from this -.50 lens. Last night, for the first time in 3 months, I was able to tell which kid was mine on a sports field without shutting one eye. It was such a relief!
I was typing what is below before I realized that you added to your post.

Sorry I missed that part but it's odd that no one discovered the imbalance for all these months. A one diopter imbalance would not have developed overnight. While there have been advancements in LASIK technology, there is still no guarantee that the visual system will respond to refractive surgery in perfectly predictable fashion.

I can't explain, with a 1.00 diopter imbalance, why they would have given you a -0.50 lens. Unless, your prescription is -0.50 in the right eye and +0.50 in the left and, for some reason, they choose not to provide the full indicated correction for the imbalance. It's hard sometimes to second guess other docs' actions.

By all means let us know what you find out today.
Okay, I just got confirmation that the imbalance between the two eyes is -.50 not 1.00 diopter. That was a miscommunication on their part.

So, that is the change they would make with the enhancement.

I'm waiting for them to check and email me the refractive numbers from Friday. Will still post those when I get them.

There's no doubt this -.50 correction is making a dramatic improvement in my vision. I know there's no guarantee the second surgery will fix this perfectly and I might end up with a lens after all. But it's likely it will fix it, whereas not doing the surgery means I'm guaranteed to keep wearing a contact lens or glasses.

Prior to Friday when they detected the imbalance, I had not been refracted for about 6 weeks. Could this be regression? As mentioned, I did feel like my vision had "settled" at the worse end of what I had been experiencing all along.

If regression, is it better to wait longer for the enhancement?
I guess part of the problem here is that I have not seen clearly from day 1. So until recently any part of assessing my results that is subjective has been, quite literally, clouded and blurred by my complications (wrinkle, edema, swelling).

Now that those problems are resolved, we are seeing a different picture. But the measurements taken by the machines can't be wrong, can they?

They said the -.50 enhancement will take me to 20/15 so is this just that I need to be at 20/15 to be able to see well? I don't understand that.
Well, ugh, they didn't reply with all the #s when I asked for my UCVA.

They just wrote that a -.50 correction takes me to 20/20 "plus a few letters" so they recommend the .50 diopter enhancement, which is the minimum they will do.

Probably they are assuming I'm too ignorant to understand all the #s so they're dumbing it down for me. :/

Tomorrow when I see the other OD I'll get complete #s from him and he will also do aberrometry. I also will be seeing a different OD next week and will have his #s to compare, too.

So ultimately I will have 3 different doctors' offices checking refraction.

How important is the auto-refractor machine results vs. the subjective exam results? If the auto refractor says 0 can it be wrong?

Because I just really don't think I've regressed. I feel like this has been underlying all along, but every time they show me the print out it's been 0 so they're not making it up. But I guess we'll see tomorrow if it's different from the last visit.
quote:
How important is the auto-refractor machine results vs. the subjective exam results? If the auto refractor says 0 can it be wrong?

Because I just really don't think I've regressed. I feel like this has been underlying all along, but every time they show me the print out it's been 0 so they're not making it up. But I guess we'll see tomorrow if it's different from the last visit.


Now I think you are getting to it. If everyone has been relying on auto-refraction then, yes, the undercorrection could have been the problem all along. When a patient has a problem with their vision, the first thing to do is REFRACT THE PATIENT. I suspect that more and more eye care providers rely on auto-refractors because they are no brainers, i.e., no experience required. In my practice, I have seen numerous post-LASIK patients with recent records from their previous doctors indicating great refractive outcomes but my own examination reveals under or overcorrection. I don't own an auto-refractor because they are so limited in their output. The process of refraction is not solely about determining the "sphere, cylinder and axis". Subjective refractions differentiate the QUALITY of vision. The crispness of the patient's response, the depth of the lens bracketing, the consistency of the patient's answers - all these nuances of VISION (not to mention accuracy) are completely left out of the examination when an auto-refractor in employed. And for young doctors with limited experience, their growth as practitioners will be stunted. They will never realize the limitations and lack of insight into their patients' vision.

So... YES - the auto-refractor can be wrong. And doctors who have little experience with (or patience with!) subjective refraction can be wrong. However, subjective refraction is the ONLY way an eye doctor gets to HEAR WHAT THE PATIENT SEES.

Regression? In my opinion, the term means nothing at all. It's a way to explain away the inaccuracy and unpredictability of refractive surgery. These are elective procedures, much is promised, and when outcomes fall short, instead of chalking it up to the limits of technology, it's called regression.
Thank you and that makes total sense. In addition to the auto refractor, they have refracted me at each visit, but it had been about 6 weeks - and at that time I still had some inflammation. So this all supports what they are saying about how and why my case has developed the way it has. They have been totally listening to my complaints about vision quality, not blowing me off at all, but it took until now for my eyes to reach a point where we could pinpoint how to correct the vision quality.

Now I just have to decide, should I do this second surgery or not?

On the one hand, I feel like the "damage" has been done in that they've already cut the flap and I've got the dry eye. My right eye vision sucks and I've got numerous reasons to try to avoid lenses (headaches, allergies and now dryness). My left eye is great so at least I've got that going for me no matter what. My logical side says might as well give it a shot to get the better vision out of this whole mess.

On the other hand, am I asking for more trouble? Will the laser correction miss the -.50 mark and leave me overcorrected? Is that worse than this? If it misses the mark and leaves me under corrected I guess then I'd still be closer to both eyes being even, so that wouldn't really be bad.

Nobody knows the answer, of course. Guess I'll just be going in circles until I decide to pull the trigger or not.
The vision in your right eye "sucks" WITH a lens correction? Vision that can be corrected with a standard spectacle lens or contact lens is not "bad" vision; it is just a refractive error. Yes, everyone wants to be free of devices to correct refractive error but to their credit, glasses and contact lenses do not alter the actual eye. Refractive surgery that results in an over or under correction disappoints, but if the residual refractive error can once again be corrected acceptably with a spectacle lens then you still have your vision. But not all refractive surgery disappointments result in vision that can be corrected with a spectacle lens, resulting in truly heartbreaking cases and the patient will have to live with the outcome.

Should you chase a 0.50 diopter imbalance with an enhancement? Would it be accurate? Would it increase the dryness? Your situation confronts LASIK patients quite often. Do you "go for it" or not? You can have all the opinions in the world but there is no guarantee.

You didn't get a perfect outcome. Was the surgeon at fault? The equipment? No one can know since there are INHERENT inaccuracies in plastic surgery and LASIK is plastic surgery. Can a second surgery get it just right so you can put this behind you? Reassurances can be offered based on your surgeon's experience but they are just that, reassurances.

VRSN primarily assists patients with loss of vision that CANNOT be corrected with spectacle lenses. Our goal is to help patients recover the QUALITY of their vision. We are not opposed to second surgeries but it is not for VSRN to reassure patients facing second surgeries when the first surgery has already failed the patient's expectations.
The right eye vision sucks until I put on the contact lens.

Just got back from OD#1 and his findings are in agreement with surgery center.

R eye -.50 nearsighted with -.50 astigmatism
L eye plano

He also says my flap still looks the same with decentralized "waves" and given that plus the under correction, his advice is to go ahead with the enhancement, knowing that if I am over corrected I will still need a lens. He feels that in my specific case the extremely small correction and the fact that retreating may actually result in a smoother flap makes it less likely that I'd have any additional problems.

Will see OD#2 on Monday and see if he concurs.

I know VSRN isn't here to reassure me of anything regarding another surgery. Smile My hope in posting here is to just make sure I'm balancing what the drs. are saying and asking all the right questions along the way to make a decision.
Hey, oneblurryeye, what was the result? Did you get the enhancement?

I got LASIK a week ago and while my left eye (my dominant eye) is basically perfect my right eye is definitely significantly blurry (both at distance and while reading up close). While I understand there is a significant amount of healing to be done, I'm fairly certain the prescription that was input for my right eye was off and it's not really a result of improper healing or anything else. Basically, when I was getting measured for my prescription the day of the surgery, the left eye was perfect and crisp, but the right eye was not exactly perfect and crisp and there was a discernible difference in visual quality in comparison to my left eye and when both eyes were open and looking at the letters, it felt slightly "off" or imbalanced, a feeling I NEVER had with my glasses (i.e. with glasses, each eye both when closing one or with both open felt balanced). I should have been more adamant about this feeling of "offness" when they brushed it off as normal.

While I'm sure they're going to tell me to wait it out and I'm fine with doing so, I know deep down that we simply input the incorrect prescription into the laser/computer. This time I'm going to consult with separate optometrists/opthamologists to get a 100% accurate prescription on my eye and I'm going to test it out with glasses/contacts PRIOR to having the surgery (something I should have done the first time around and am kind of surprised isn't standard protocol to avoid this very issue) to make sure it really is the correct prescription.

Dr. DavOD Hartzok--does this sound like a reasonable approach to you? Have you heard of stories like this before?
Authority11,

It's my contention that REFRACTION is not accurately assessed in many pre-op and post-op examinations.

I have been an optometrist for quite awhile now. On numerous occasions I have heard my colleagues criticized as being mere "refractionists" as though it's a highly simplistic procedure, something "my assistant learned in three weeks", etc. The fact that REFRACTION occupies such a lowly rung on the eye care ladder of procedures is unfortunate and naive. When a patient complains of blurred vision, the first thing we do is a REFRACTION. If we can refract the patient to their previous level of clarity, then we have ruled out numerous other possibilities for their loss of vision. IF the refraction fails to restore the patient's vision, then we need to look further into their problem. But what if the refraction is performed poorly, if it is inaccurate? The practitioner proceeds to examine further based on erroneous findings, makes erroneous diagnoses and performs erroneous treatments - all because the refraction was inaccurate.

When refraction is performed in a COMPREHENSIVE manner by an experienced practitioner it involves much more than the determination of a sphere and cylinder: It's the way an eye doctor gets to HEAR how his patient sees. We can assess the quality of vision by listening to the subtleness of the patient's response. You must be a refractionist to appreciate refraction and an EXPERIENCED refractionist to truly embrace its significance. With experience, refraction is not some low-level procedure that spits out a prescription for glasses. Indeed, being a good refractionist allows one to be a good eye doctor.

If your refraction was inaccurate from the get-go, it is most unfortunate. But (and this is just my opinion from years of examining patients and communicating with them in this forum) when patients enter a REFRACTIVE surgery practice, I think it's scandalous that the refractions performed are not double and triple checked by more than one provider. REFRACTION in a refractive surgical practice should be be a major FOCUS of the pre-operative workup and the post-operative followup.
quote:
Originally posted by Dr. DavOD Hartzok:
Authority11,

It's my contention that REFRACTION is not accurately assessed in many pre-op and post-op examinations.

I have been an optometrist for quite awhile now. On numerous occasions I have heard my colleagues criticized as being mere "refractionists" as though it's a highly simplistic procedure, something "my assistant learned in three weeks", etc. The fact that REFRACTION occupies such a lowly rung on the eye care ladder of procedures is unfortunate and naive. When a patient complains of blurred vision, the first thing we do is a REFRACTION. If we can refract the patient to their previous level of clarity, then we have ruled out numerous other possibilities for their loss of vision. IF the refraction fails to restore the patient's vision, then we need to look further into their problem. But what if the refraction is performed poorly, if it is inaccurate? The practitioner proceeds to examine further based on erroneous findings, makes erroneous diagnoses and performs erroneous treatments - all because the refraction was inaccurate.

When refraction is performed in a COMPREHENSIVE manner by an experienced practitioner it involves much more than the determination of a sphere and cylinder: It's the way an eye doctor gets to HEAR how his patient sees. We can assess the quality of vision by listening to the subtleness of the patient's response. You must be a refractionist to appreciate refraction and an EXPERIENCED refractionist to truly embrace its significance. With experience, refraction is not some low-level procedure that spits out a prescription for glasses. Indeed, being a good refractionist allows one to be a good eye doctor.

If your refraction was inaccurate from the get-go, it is most unfortunate. But (and this is just my opinion from years of examining patients and communicating with them in this forum) when patients enter a REFRACTIVE surgery practice, I think it's scandalous that the refractions performed are not double and triple checked by more than one provider. REFRACTION in a refractive surgical practice should be be a major FOCUS of the pre-operative workup and the post-operative followup.


Dr. DavOD,

I 100% agree. The refraction tests (and all the other computerized tests) in both of the places I consulted with before choosing which practice to have the surgery with were ALL done by assistant, nonprofessional staff. Thinking back on it now, it was incredibly stupid for me not to request the actual doctor performing the surgery to figure out why the refraction on my right eye wasn't matching the quality on my left eye. At the very least, I should have requested one of the optometrists they have on staff to get a 2nd opinion! I think it's ludicrous when I think about it more and more. Whenever I went to the optometrist, the OPTOMETRIST himself/herself performed the refraction and was there to listen to all my reactions and issues when presented with various measurements. And that was just when I was getting measured for an easily correctible and reversible procedure! I think it's insane that I subjected myself to testing done by a non-professional for inputs on a nearly irreversible procedure and I'm definitely partially to blame for that, but is absurd that the professionals aren't taking the measurements for LASIK.

I'm sure it's not done like this at every place, but I know it's done this way at at least a few.

In any case, prior to when I go in for the enhancement, you can better believe that I'm having the prescription triple checked, verified by a third party optometrist and then testing of the prescription via REAL life simulation via wearing a contact lens/glasses lens of this prescription (I'm a firm believer that while refraction is the best method for determining a prescription, it is simply impossible to be 100% comfortable with the prescription until you've worn it out in the real world and not simply in an isolated room with letters on the wall).

I really appreciate you taking the time to respond!

I have a post-op appointment on the 12th and will report back with their responses and any updates on the progress of my eye.
With respect to my comments about refraction, most patients' disappointment with their refractive surgery outcome is NOT because of inaccurate refraction but because (1) it is not always possible to alter the shape of a cornea to provide the exact prescription determined by the refraction and (2) high order aberrations can develop as a side-effect of the procedure.

The newest approach to making eyeglasses is to carve the lens material into precise, prescription-unique curves as opposed to molding and grinding. Carving a precise set of curves into a chunk of plastic is way more predictable than working with living tissue.
Hi, my apologies for not seeing these last few replies until now.

First, Authority11, I'm sorry for what you are dealing with. Hopefully your vision will continue to change. Mine has. For what it's worth, I remember saying the same thing before my procedure about what I was seeing not "looking right" for my prescription and they also assured me that was normal, and indeed it was. My prescription is fine and is not the problem I'm dealing with. I do think it's very common for technicians to take all the pre-op measurements, but there should have a been a dr. double checking it, too. At the clinic where I went there was not only a corneal specialist checking over it all before surgery, but my optometrist also does co-managed care of all LASIK patients and he was there double checking it, too. Anyway, please post an update when you can.

As for my update, I have good and bad news.

The good news is I did NOT do an enhancement (thanks to all the great advice about that) even though all of the drs., including my second opinion optometrist, all recommended it - though to be fair, they didn't pressure or rush me at all and told me there would be no harm in waiting. Well, I'm glad I didn't rush b/c my prescription continued to change!

I am now 20/15 in both eyes at 6 months post-op. My right eye only has .25 astigmatism so the smallest possible amount.

Somewhere around a month ago, there was a noticeable sharpening of my vision in the right eye.

The bad news is I still have quite a lot of pain and discomfort, especially in my right eye that has had so many healing problems, and on the days/hours when my eye gets drier and more painful my vision also diminishes temporarily. So I wear glasses when that happens (usually late in the day or after a lot of computer time).

So, at least I can breathe easy on the whole enhancement thing (that decision has been so stressful) and now focus on treating my eye condition only.

Today at my 6 month appt. the dr. recommended discontinuing the Restasis (I've been on it the whole time) because he sees significant inflammation in my lower lids - actually worse than a few months ago - so doesn't think the Restasis is helping me (which I gather is common). He told me to call if I see any change after stopping it, but likely what he will do is switch me to a routine to treat MGD in a few weeks (he didn't want to overlap it with the Restasis in order to isolate how each medication change affects my eyes - seems sensible).

So, now I'm doing artificial tears as needed, taking fish oil supplements, and using Lastacaft and OcuSoft lid scrub for eye allergies as needed (hopefully allergy season over soon).

He did mention one far-fetched idea: that maybe I could have a slight "gap" at one edge of the LASIK flap that could be a source of pain, because on staining he said the edge around the R eye flap shows up as slightly thicker than the L eye, but he said it's not an unusual amount of staining and normally wouldn't be associated with anything a patient can feel. So he thinks it's unlikely. I kinda wish he hadn't mentioned it if he doesn't think it's likely. :/

Dr. Hartzok, have you heard of anything like that? He said if that's it I would need a flap re-float still.

It's weird how relieved I am just to know there is no reason to mess with the flap again, despite the other problems I still have, so the very suggestion of something different that could lead to touching the flap makes me worried!

Thanks so much!
You are now six months post-LASIK, right? I would not expect any staining around the edge of the flap. And, if there is staining, then it certainly could be causing discomfort. The way to differentiate that is to add a drop of anesthetic (like, proparacaine) to the eye and see if your discomfort is relieved. If it is, then we can assume that the staining area is the cause of your discomfort.
Okay, I just read about some super bad things about staining at the flap edge and the possibility of epithelial ingrowth. But if it was that, wouldn't my vision would be getting worse or staying bad, not getting so much better?

Then I also read some things that say that the staining might just be damaged areas of the tissue that will never heal. Which sounds better than the ingrowth for sure, not that it sounds good.

Is there anything else the staining would highlight? Scar tissue? Could it be that b/c the right eye has healed sooo much slower than the left that it is beginning to finally heal?

Half of what I read about this was scientific journal excerpts and over my head.
Okay, tell me if this is wrong or right the way I am interpreting what I have read about epithelial defects:

One way it goes is that epithelial ingrowth can start centrally and early during or right after the primary procedure (from the laser or irrigation introducing them). This usually resolves over time because the cells don't proliferate, though if they migrate this can cause severe problems. It may be asymptomatic or it might be accompanied with edema (which I had), blurry vision (which I had) and irregular astigmatism (which I had but now we know was temporary). As it resolves, vision improves.

Another scenario is that epithelial ingrowth starts on the periphery of the flap and migrates inward. I read that this would usually result in vision deteriorating over time (which mine has not - it's only gotten better over the last 3 months).

All the drs. I have seen (2 different surgeons, 1 corneal specialist, 2 optometrists) over the past 6 months for my problems have all said they didn't see any evidence of epithelial ingrowth. Even so, they considered the possibility that it was there and just not visible, since I still had such poor vision quality a few months ago - and they almost did a flap lift then.

However, BCVA improved between month 3-4 and they were able to correct vision with a lens at month 4. Now at month 6 my vision is 20/15 in both eyes with only .25 astigmatism in the one "bad" eye. Pain/discomfort still present, but much less than it was 2 months ago.

So, given the above if I had or have epithelial ingrowth it seems like it is likely to be mild and resolving, right? Could I have had ingrowth early on and the improvements I've experienced coincide with the ingrowth resolving gradually?

I'm expecting to hear something back tomorrow from my optometrist who is consulting with the corneal specialist (who has been out of town these past few days) about my case tomorrow morning. Hopefully they will ask me to come in for another exam at the surgery center so they can check things too.

Would the anesthetic not help resolve discomfort from dry eye too? How does that help to differentiate dry eye vs. something else?

Isn't it possible that my eyes just hurt b/c they are dry? The pain also gets better for about 5 min. when I put in artificial tears so that's always made me think it's the dry eye that hurts.

The scary-sounding thing related to the epithelial ingrowth that I don't understand is "flap melt" and what that looks like or means or how you would know its happening. It's mentioned all over these articles, but I haven't found a clear explanation of it in layman's terms. Can you explain it?

Now I'm totally in a panic all over again.

Which seems nuts b/c my vision is so great right now that I started to finally get some enjoyment from this whole mess being able to see so clearly.
Hi Oneblurryeye,
I am the one that actually started this thread. I am now almost 11 months post op. Our symptoms sound very, very similar! Just for some history. I have been to my optometrist multiple times after the surgery to get refracted. I trust him very much and it looks like my final outcome is:

Left +0.25x-0.5
Right 0x-0.5

I am also right eye dominant and 42 years old. So as you would expect I see slightly better for distance in my left eye and slightly better close up in my right eye. I wish the prescriptions were swapped since my right eye is dominant. Sometimes in low light the astigmatism in the right eye bothers me. Regardless the last time I went to see a corneal specialist I was 20x15 in both eyes.

But since the day of the surgery my right eye has not felt normal. So I have been back to the surgeon, who is also a corneal specialist, many times. I have been to my optemetrist many times. I also went to see 2 seperate corneal specialist that do not do LASIK. Those 2 non-LASIK related doctors puts some crazy dye in my eyes. The kind that stains your eyelids an looks like you went to a goth concert. The bottom section of my right eye stains! This is where I usually feel the discomfort. But they can't figure out why it does that. So everyones solution so far is lubrication, lubrication, lubrication!!! But I am like you. I put the drops in and it feels good for a few minutes, but thats it.

It also doesn't bother me all the time. I think it happens when it dries out a bit. It just sends my eye into a tailspin. The problem is that I work in front of a computer all day. I think this really dries them out. Because on weekends when I am outdoors or just hanging around, my eyes don't bother me as much.

Nobody has diagnosed me with MGD. But I am doing the same as you right now.
1. Flaxseed/Fish oil pills
2. Drops as needed
3. Occusoft scrubs

I have read that the flax/fish oil may take 3 months to work. I have been on them for 2 months now. Not sure I can tell a difference. I also have plugs in both eyes in the lower lids. Not sure if that really helps either! When I go to all of these doctors they all say my eyes don't look very dry. I have had Schirmers test that come back normal. They have said that I am producing enough tears, but they may be poor quality. But noone has tested that.

Also noone has mentioned the epithelial ingrowth to me. They always say the flaps look perfect. So I am at a loss at this point. I go back to the surgeon next month for my 1 year follow up. I am going to ask him about that though. I am also going to tell him he needs to use the crazy dye that the other doctors used that showed staining. He does use drops, but I don't think they are the same kind.

Sorry I am not much help, but I just found it interesting that we both seem to have the same symptoms. Maybe one of us can figure it out and post it on this forum. But I am kind of resigning myself that I may have to live like this now.

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