Your description is astute.

Tears have a composition that is rather complex. And it's the surface tension of the lipid layer that is essential for the aqueous layer to remain intact and keep your tear film from distorting your vision. Adding a higher volume of aqueous tears (or artificial tears) would seemingly be undermining the lipid layer and destabilizing the surface tension. If you have blocked Meibomian glands then I agree, you need to improve the lipid layer. Have you done anything to improve the Meibomium gland secretion? Hot compresses? Lid scrubs? Doxycycline? Do you have rosacea or any particular skin condition? Have you tried Azasite?

I have not heard lately about probing the gland orifices. The idea does not seem to be catching on. My concern for that is the potential for infection.

The Lipiflow system (I believe that is what you are referencing) is quite expensive. And it doesn't seem to be making the front page of journals so I don't know how it's being received and reception usually correlates with effectiveness.
That explains why when I was on 2 types of lubricant drops and steroid drops my eyes seemed more irritated. Yes I have tried hot compresses, lid scrubs and also doxycycline. I don't notice and lasting effect from this and although some days are better than other it seems to always be there: the visual problems never seem to go away. I was even looking into other possible problems for this such as my eyelids causing an astigmatism or the way light is refracting through my eyelids as the problem is when I blink it close my eyes. My eyelids always look quite vascular and underneigh my eyelid is bright red and has verical veins which I don't know if it is To do with the blocked glands. As for improving my lipid layer I don't know what else to do really, I have an appointment at the laser clinic next week and the eye hospital next month but not expecting much if anything to change
I don't have any refraction as the doc says I have better than 20/20 vision. I try to explain this is with my eyes wide pork and the problems I experience when I blink or partially close my eyes. The best way to describe it is when looking at a light source, the light steaks vertically down as if it's being refracted through a prism. Ghosting happens of the image in the same fashion. I had the surgery performed by optical express on aug 2012
You are having VISUAL SYMPTOMS. When a patient has visual symptoms the first thing we do is examine for a RESIDUAL refractive error - the additional lens to be added to your glasses, contact lenses or refractive surgery to fully correct your vision. I can be sick but my temperature can still be 98.6 degrees. If my doctor bases my healthiness on body temperature alone, he will tell me that I am not sick. Since refractive surgery centers are selling 20/20 uncorrected vision, they don't always examine for residual refractive errors. Perhaps your doctor was too busy to refract you. If a lens can be found that improves your vision, they don't necessarily look for it because they don't want to disappoint you. 20/20 is not "perfect" vision.

The real goal of refractive surgery is to give you a plano refraction - no sphere and no cylinder - in both eyes. A plano refraction, barring any other vision abnormality, usually yields 20/20 vision. But the converse is not necessarily true, that is, being 20/20 does not mean you have a plano refraction. The point of refraction is MORE than the determination of the refractive error; it enables the doctor to HEAR how well you are seeing. IMO, many eye doctors are not good listeners. If your doctor thinks that reading the eye chart is all there is to vision, then you need a second opinion.

By your report, you have had visual symptoms of light streaking, ghosting and daytime starbursts beginning two months after surgery. Some of these visual symptoms could be coming from corneal surface irregularities that are momentarily "filled in" by your tears. As your tear film waxes and wanes, your awareness of these aberrations increases or decreases. Everything in your history so far has been about your tear film, but I suspect there is more to it.

You need a comprehensive refraction by someone who is a good listener. Then I would suggest a corneal topography and a wavefront aberration study. You may have 20/20 vision when your tears are "just right", but corneal aberrations could be contributing to your problem.
Thanks very much for your in depth answer. I will certainly addresse this when I go next week as I am seeing a different sergeon who will hopefully be more helpful.

The last few days my eyes have felt more irritated. It doesn't feel like dry eyes though: I find I am blinking constantly and hard and don't get any relief from drops only resting my eyes. It feels more like pressure on my eye. I can actually hear a noise when blinking sometimes too:

I have read a few abstracts where people have the exact same symptoms as me both with the irritation like visual problems and it was discovered it was due to eyelid pressure on the cornea. This happened when blinking as the eyelid pressure increased. It was also worse when drops where administrated as the liquid would further increase pressure and cause a higher refraction. When I read the abstract I could really relate it it: it even said how depending on which lid was causing the pressure determined which vertical direction the ghost image would appear. I can recreate the image by pressing on either my upper or lower lid and see the image in each direction. What are your thoughts on this? And is it some thug that can be diagnosed? Many thanks for your responses
Eye lid pressure post-LASIK is not something that is addressed. Generally the lid pressure would be reduced centrally resulting in a differential pressure applied to the central corneal thickness versus the unchanged thickness peripheral to the ablation zone. There is no way to measure this so it remains theoretical but it could result in irregular astigmatism which could be analyzed with corneal topography.
But what Iv said does make sense and is a possibility. Iv just had most things already ruled out in the past 2 years with no success. Even when they test for dry eyes it only minor dry eye and can't understand why I am getting such severe symptoms with it. The at blinking abs irritation seems to be worse the same time as when I experience worse visual problems.

Regarding the topography, im guessing this would be performed during a blink to test for changes on the cornea?

I have the exact same symptoms as you and as of yet I could not find anyone describing it as well as you do. Ever since lasik done last september I have been having severe daytime glares and night time starburst and ghostings. Night vision is quite bad. But like yourself, when I opened my eyes really big the verticle lines sort of disappear. The glares are still there but the verticle smears seem to go away. These verticle smears are seen on any light source which includes phones, computers and anything that is white on a dark background. They tend to smear downwards and it goes away when my eyes are opened widely. In the morning when the eyes are really dry, my vision has less smears. But once i start to wet them, they get worst. I have seen several ophthalmologist who cannot determine what is wrong. Very saddening. I've even tried sclerals but they did not improve my symptoms

Please let me know what you have done and what you are planning to do. If you every find a way to manage it, I want to know.
I am still experiencing the same problems and had no explanation to what's causing it, every test comes back working normal limits but the light streaking and starburstung is certainly not normal.

I find by cleaning my eyelids and using hot compresses help keep my eyes feeling better and minimises problems but it's always there.
I'm convinced that it's damage to the cornea and tear film is causing a smearing of light but have never been given any diagnosis.
How do you currently manage your symptoms?
It has been well documented on this bulletin board and in many other places that irregular corneas cause these problems. LASIK can leave your corneas bumpy and irregular, which causes light to refract unnaturally. The only "fix" for this is to get fitted by an expert lens fitter for rigid gas permeable contact lenses that are individually designed for your corneas. It will definitely not go away on its own, and yes, your LASIK doctor will tell you there is nothing wrong. An accurate color topography will show the irregularities. Have you seen an unrelated second opinion doc for a complete exam?
Indeed. I too have been to 2 separate opthalmologist who have said my corneal topography looks fine.

I even visited an optometrist in dallas texas to get scleral lens customized to my eyes. Unfortunately they didn't help with the smears and the starburst.

Paul, I'm not mananging my symptoms very well. In fact, it is affecting my job quite badly. Tried omega 3 and doxycycline to improve tear film. Unfortunately, it did not help.

Paul1986, I would definitely like to get in touch with you to find out what we have in common prior to lasik or post lasik. And to find out a little more about the condition we have. As of yet, I have not come accross anyone who has normal topography and has smears like you have described.

How nearsighted were you prior to LASIK?

Was your vision correctable to 20/20 (i.e., clear!) prior to LASIK with glasses?

Did you wear contact lenses prior to LASIK?

What did Gemoules say about your vision not improving with the sclerals?

Was your vision any better at all with the sclerals?

Did Gemoules see your Orbscans?

I don't know who was advising you but you really have to look no further than the Orbscans to identify some issues.

First of all, both corneal surfaces have irregular astigmatism. This is normally correctable with rigid contact lenses unless the fit of the lenses induce their own set of visual symptoms. If the scleral lenses vault the corneal surface excessively, vision can be negatively impacted.

Secondly, the posterior corneal surface is highly irregular in both eyes. This cannot be corrected with rigid contact lenses.
Thanks Dr.Hartzok

I was moderately near sighted. Attached is my prescription prior to lasik.

Yes, my vision was correctable to 20/20 extremely clear prior to lasik. Never had any issues with vision before lasik.

I wore soft contact lenses for many many years.I was told to stop wearing contact lenses about a week before lasik.

Gemoules too was surprised his lenses didn't work with my daytime glare, starburst and the downward smears of light or light coloured objects. His lenses did help a little with the ghostings on my left eye and thus improved vision slightly, but again not my major complain. The improvement was very minor.

Gemoules did his own scans.

What can be done about the posterior corneal surface? is this correctable with surgery? or is it something that I would have to live with for the rest of my life?


Photos (1)
Actually, by refractive surgery standards, you were markedly nearsighted prior to LASIK.

The thinnest part of each cornea is about 360 microns in each eye. That overall thickness is equal to the thickness of the flap added to the thickness of the remaining stroma. If your corneal flap is 160 microns thick, that would mean the residual stroma is 200 microns. The question is, "How thick is the residual stroma?" That can only be determined by an OCT corneal scan, a Pentacam or similar imaging device. The question is important because the flap offers no structural rigidity. Only the residual stroma continues to provide structural integrity of the cornea. If the residual stroma is too thin, the posterior corneal surface can bow forward and that can effect a change in the cornea's overall refractive error and clarity.

Do you have Orbscans of each eye BEFORE your LASIK procedure?
Thank you Dr. Hartzok.

Very informative. I really do appreciate your help.

Attached on this link are my scans prior to the first lasik procedure and also the photos of my scans done with another opthalmologist early april 2015.

As far as I know, Gemoules did an OCT corneal scan. I'll write to him to see if I would be able to get the images.

If you are right, and the posterior corneal surface bows forward, can anything be done to fix my visual problems then?

Thanks again Dr. Hartzok.
Has anyone found a solution to this? I have the exact same symptoms. Dry eyes kicked in 2 months post lasik and brought starbursts which got worse over time, to the point of being present in daytime. I just ofund that i have MGD, my glands were blocked and just had lipiflow. Hopefully when the tear film normalizes 3 months after lipiflow starbursts will go away?
First of all it shouldn't take three months to experience the benefit of LipiFlow. This is from the FDA:

The LipiFlow® System met the primary study effectiveness endpoint with a statistically significant (p<0.0001) greater improvement at 2 weeks from baseline in the average number of meibomian glands yielding clear liquid secretion as compared to the Warm Compress Control. The LipiFlow® group showed a mean improvement in tear break-up time and a mean reduction in dry eye symptoms at 2 weeks from baseline with an effect greater than the Warm Compress Control. A single 12-minute treatment with the
De Novo Summary (K093937) Page 6 of 8
LipiFlow® System provided sustained effectiveness, on average, over the 4-week study duration, as shown by the mean change in meibomian gland assessment, tear break-up time and dry eye symptoms at 4 weeks from baseline.

Dry eye is certainly associated with LASIK but why would your glands suddenly become blocked and make you symptomatic? MGD should have been evaluated PRIOR to your LASIK procedure and treated at that time.
Dr. Dav0D thanks for the feedback. I agree it should have been evaluated prior to Lasik. However I've seen three different doctors and all told me my eyes looked fine. It feels like very few doctors worry about MGD or even mention it for some reasons. Fortunately I continued to research and learned about Lipiflow. The Lipiview brought back a score of 45 and 50, with nearly all glands blocked. The 3-month mark is something I have read on the web a bit and my Lipiflow doctor told me it took 3-month for full benefit on herself.

Anyways it has been a week now and my eye comfort went from 4/10 to 7.5/10 so far. No improvement on the starbursts so far however. I am hoping it will go away...this is sabotaging my sight.
Just a bit more about my symptoms: I see starbursts at night and ghosting all day. Anything white on a dark brackground will trigger ghosting. The ghosting is always downwards. Same with starbursts, it shoots down more than up. I remember being able to drive perfectly at night right after lasik. Not anymore...
The differential on tear film instability as the cause of the starbursts is fairly simple. If what you describe as starbursts fluctuate with the blink then the tear film is the culprit. However, if the starbursts mostly remain unchanged by blinking (or the application of artificial tears) then the starbursts are related to the actual procedure itself. You certainly can have BOTH factors interfering with the quality of your vision but only the tear film instability factor can be modified by blinking or artificial tear drops.

Regarding your perfect vision the night after LASIK, the procedure is basically: Cut a flap, lay it back, ablate the underlying tissue to the prescribed curvature and then lay the flap back over the ablated tissue. As with any surgical procedure, the remaining tissue is traumatized AND the actual flap tissue is being laid down onto a reduced volume of cornea, meaning it doesn't fit exactly to the new corneal curvature. As the flap eventually settles onto the ablated corneal surface it must reshape (i.e., distort) and the effect of this distortion depends in part on how much tissue was removed and the HYDRATION level present within in the flap. The flap and the underlying stroma immediately following the procedure can be somewhat edematous so what you see at first may not be exactly what you see after the corneal tissues have recovered. Of course, some patients see great at first and continue to see great. Others may have vision improve over time. In your case you report seeing great initially and now have starbursts. All of these possible outcomes are considered "normal" healing but persistent starbursts are understandably annoying. Surgeons may not be able to identify precisely why you have the starbursts (be they flap-related or stemming from within the residual stroma). If the starbursts are the result of optical surface irregularities (i.e., the flap surface), those irregularities can be identified using corneal topography. If the optical irregularities are deeper into the tissue, they are not easily identified. If the optical irregularities are on the back surface of the cornea they can be identified with a Pentacam or Orbscan. In other cases the starbursts are related to differences in the diameter of the ablation versus the diameter of your pupil. If your starbursts are WORSE IN LOW LIGHT conditions then the argument is with the discrepancy of the ablation/pupil diameters. If the starbursts (or other visual symptoms) persist in BRIGHT lighting, then the problem is stemming from the flap and/or the underlying stroma and/or the back surface of the cornea.

You report that the ghosting and starbursts are always downward. That may suggest a slight decentration of the ablation.

I know this is a lot to throw your way but since the visual disturbances are persistently uni-directional it is highly unlikely that the Lipiflow procedure will provide relief. If your symptoms abate over time, I would argue that it was due to continued healing (certainly advantageous healing) of the cornea.
Dr. Dav0D, Thanks a lot for taking the time.
The blinks do not make starbursts of ghosting go away, but using a drop does improve a lot for a few seconds.

I also had a HOA test at Lasik which told me everything is more than perfect. Then I went to get a second opinion at an other doctor which told me there is severe irregularities after what I think was a wavefront test. I did not know at the time what that meant and if dryness could result in irregularities in a wavefront test. Anyways will hope for the best. Life was great before Lasik.

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