has anyone with a lot of HOA's(like my self) had them corrected with a custom(wavefront) enhancement?

my doctor insists that pupil size is not an issue even with my big ol' 7mm(often) pupils(which sometimes get even bigger). another doctor told me that someone with pupils my size will always(i.e. after wavefront correction) have "some glare"Mad the same man said that even if the pupils dilate beyond the "zone" it is usually fine because of the "optics"(which i don't know much about). Confused

it's a pretty reputable clinic and when they did a wavescan the image generated looked EXACTLY like the glare bubbles i often/always see. Eek

ah, the memories of those glare bubbles pulsating smaller and larger when stopped at a stop light at night behind someone with their turning signal on(dink,dink,dink,dink).

is this the end of my nightmare?
Original Post
quote:
Originally posted by helmit:
ah, the memories of those glare bubbles pulsating smaller and larger when stopped at a stop light at night behind someone with their turning signal on(dink,dink,dink,dink).



What you described is absolutely a pupil size issue, regardless of what your "doctor" at his "reputable clinic" says. Put some alphagan or pilo in your eyes and watch the pulsating "glare" disappear. It's obvious this "doctor" doesn't know anything about "optics". Here's a question for him... if the point spread function on the post-op wavefront scan is meaningless (cancelled out by "optics"), why is he doing "wavefront corrections" using the same data? Is he saying that pre-op "optics" are somehow different from post-op "optics"???
thank you for your reply.

i'm not sure i understand the questions. you're saying that the wavescan measurements are meaningless?

my doctor said the HOA's were probably caused by the original surgery because they removed a lot of tissue and that's how my eyes reacted to it. obviously it did because i did not have these problems at all prior to surgery. also, i was in a lot of pain for two or three weeks while my vision regressed and the HOA's sunk their teeth in.

i guess that, in light of the wavefront technology, my answer to your second question is yes and that i think i agree with my doctor.

alphagan does make that s*** go away but my pupils have to be tiny- about 3mm or less. i think this is because of the HOA's. i think it is encouraging that the image generated by the wavescan looks exactly like the s*** i see everywhere b/c maybe they can correct it.

i don't blame you for putting the word "doctor" in quotes b/c some doctors just aren't worth s***- both in and outside of optometry/opthalmology.

has anyone had their HOA's corrected by a wavefront enhancement? thanks.

-helmit
quote:
... my doctor said the HOA's were probably caused by the original surgery because they removed a lot of tissue and that's how my eyes reacted to it. obviously it did because i did not have these problems at all prior to surgery. also, i was in a lot of pain for two or three weeks while my vision regressed and the HOA's sunk their teeth in.


Picking up the flap and putting it down again ALONE will alter the wavefront finding. How the flap settles over the new ablation zone will also change the vision. Secondary ablation based on the wavescan cannot guarantee elimination of all the HOAs. In fact, new ones may replace the old ones. Larger optic zones may be used which might be the real benefit, although the wavescan tecnology will get the credit.

How eyes "react" to LASIK is, of course, not something anyone can predict or adjustments would be made in advance of surgery. How your eyes will "react" to a secondary ablation is unknown. Some have benefited, some not, and some have traded HOAs. Predictability is, after all, a statement about average outcomes.
quote:
Originally posted by helmit:
thank you for your reply.

i'm not sure i understand the questions. you're saying that the wavescan measurements are meaningless?


No, I think you missed the sarcasm. (Sorry, these "doctors" really piss me off). The RMS error and PSF are very important objective measurements of visual quality. Your doctor is not being straight with you. Your pupil size is most definitely part, if not most, of your problem. And the doctor who made the comment about "optics" is just repeating something stupid he's heard or read. He is clueless.

If the data on the wavefront scans which shows how poorly you see is not a true indicator of your visual quality (due to "optics"), then why do they use wavefront data to do custom LASIK, advertising it as "correcting all the imperfections in your visual system"? (this is not really a question). They can't have it both ways. Either it relates to visual quality or it doesn't. (Of course it does!)

You said you believe your doctor. That's fine. Believe whatever you want. I wouldn't believe another word out of his mouth after he said a 7mm+ pupil is not a problem.

By the way, what is the diameter of your wavefront scan that you referred to? If it's less than your scotopic pupil size, it's not telling the whole story.
my doctor told me that it "wasn't related to pupil size."(the visual problems)


quote:
If the data on the wavefront scans which shows how poorly you see is not a true indicator of your visual quality (due to "optics"), then why do they use wavefront data to do custom LASIK, advertising it as "correcting all the imperfections in your visual system"? (this is not really a question).



I was saying that the doctor said that if the pupil dilates beyond the ablation zone it is usually fine- implying that if i get the wavefront correction done then after that even if my pupils dilate beyond the "zone," vision will be OK- which it should be b/c anything else is INSANE. Mad

i was not saying that he said the wavefront scans are irrelevent but the opposite- that they are everything(at least in my case), and that they were created from the trauma of the original surgery.

i'm thinking that if my pupils get HUGE after the wavefront "enhancement"(assuming i have it done), then i may have some glare, but it will be a different animal and not nearly as bothersome.

when i see my doctor next time i'm going to emphasize to him how big of a deal these problems are- how they are EVERYTHING, not just "problems with night vision."

well, at least i'm still kickin'.

helmit
Whether your doctor agrees or not, the collective experience of all those with larger pupils who have posted to our bulletin board attests to the fact that if one's pupils dilate beyond the effective OZ, there WILL STILL BE HOAs, and there WILL STILL BE glare, haloes, starbursts and ghosting that cause seriously aberrated night vision, and in some cases, daytime vision as well. My normal bright daylight constricted pupil sizes of OS 3.9 and OD 4.2mm are larger than my tiny 3.4mm OZ, which causes glare, haloes and "daybursts" even in bright sunlight. At 7mm+ in the dark, I have no functional night vision and my dim light, indoor vision is abysmal.

Surgery is not always the best answer, even if your surgeon insists it is so. It's sort of like the Ghetto Kitty. She is trained only to use a litter box, but not the toilet. Most surgeons are trained to do surgery, however, expecting them to suggest something other than a surgical fix is like expecting GK to use the toilet.

You might want download and print out some of the simulations created and posted in the open forum by Broken Eyes to take to your doctor. While these are only representational for some people (some of us are much worse, some much better), they can give others a fairly good idea of how and what we see.
quote:
Whether your doctor agrees or not, the collective experience of all those with larger pupils who have posted to our bulletin board attests to the fact that if one's pupils dilate beyond the effective OZ, there WILL STILL BE HOAs, and there WILL STILL BE glare, haloes, starbursts and ghosting that cause seriously aberrated night vision, and in some cases, daytime vision as well.


well yeah if you're indoors and not under a spotlight i guess that's also "night vision." if we still lived in the stone age and were outside hunting and gathering all day then maybe it could be called "night vision." maybe if someone invents time travel they can send me back to the stone age and then i will truely have "night vision." that would be barbaric, much like my lasik experience thus far. Red Face

my pupils have to be TINY(<= 3mm) right now for my vision to be acceptable(though there are still minor aberrations even then). it's not just a matter of them being within the OZ(which is 6 or 6.5 mm) and as they get bigger the abberations get worse(glare/haloes get larger) but are no different when they go outside of the OZ- just bigger.

it seems like if getting bigger than the OZ were a problem, the abberations would become radically different when passing the zone, but they do not- they just continue to get bigger.


in response to the above quote i'm thinking yes perhaps there will still be some interference if my pupils dilate beyond the OZ after(if i get it done) the wavefront "enhancement," but it will be much less and more manageable with drops etc. i'm hoping this to be the worst case scenario. i know it could be much worse.

after reading a post i think i may have "daybursts" off of cars, etc. but did not even notice them until after reading the post(i think by Broken Eyes) and they don't bother me at all.

i guess your reply brings me to the question of enlarging the optical zone. i was told by one surgeon that he had no experience with it and that it would increase the chance of complications. is this possible, though? doctors? Confused

as far as RGP contacts are concerned i really doubt i could wear them just because i have very sensitive eyes. i tried them briefly 4 years ago and they were agonizing. the people i saw had no experience with post-RS people,though.

i had strabismus correction surgery as a child and my eyes are always naturally red i think because of that. it makes people think i do drugs, which i don't. i probably could not even wear soft contacts like i couldn't 10 years ago. i strongly doubt it was a matter of oxygen permeability. i could always try special RGPS, i guess. aren't they really expensive?

also, my doc said he didn't think any contacts would help me. not that i necessarily believe him but there's another thing.

by the way, artistwoman, out of curiosity how come you were given such a small OZ? Confused


thanks,
helmit
quote:
by the way, artistwoman, out of curiosity how come you were given such a small OZ?


The OZ was supposed to be 6mm, even though my pupils measured 7+ in the dark. Why I ended up with such a tiny OZ has never been satisfactorily explained, nor has the 200 micron thick, 10mm wide flap, nor the 200 microns of remaining stromal bed. My own explanation is that my surgeon was an irresponsible, arrogant hack.

Until/unless you have been fitted by an expert RGP fitter with post-RS experience, you will not know whether you can wear an RGP or not. If you suffer from very dry eyes, you may not be able to tolerate a lens of any kind. The majority of people who think they cannot wear RGPs have simply never been properly fitted, whether before or after surgery. The cost of RGPs varies depending on the practitioner and the type of lens. Further surgery will cost you more up front, and in the long run, could cost you far more than just money.

If you are dead set on having more surgery, I urge you to get a second opinion from a surgeon who has treated a significant number of post-RS patients with the same issues you have.
quote:
my pupils have to be TINY(<= 3mm) right now for my vision to be acceptable(though there are still minor aberrations even then). it's not just a matter of them being within the OZ(which is 6 or 6.5 mm) and as they get bigger the abberations get worse(glare/haloes get larger) but are no different when they go outside of the OZ- just bigger.


If this is so then you have aberrations within the optic zone as well. As I said before, simply lifting the flap and letting it re-settle over the ablation can alter the aberrations. This is related to the underside of the flap not contouring the stromal bed. If the ablation is optically correct, then the optical irregularities are flap related. A second ablation will alter this flap/ablation relationship. It may or may not improve the vision but it will change the vision. I would reiterate what Artistwoman said. Get a second opinion from a surgeon who has sucessfully re-treated a significant number of post-LASIK patients. The risk of complications depends on a number of factors. Enlarging the optic zone will thin the cornea further so residual stromal thickness is an issue.
Everyone who has been reading here for any length of time knows that the cosine effect is responsible for optical zones that end up smaller than the treatment zone, and the cosine effect is more pronounced (worse) as the degree of myopia increases. There's a whole thread on this subject:

http://surgicaleyes.infopop.cc/eve/forums/a/tpc/f/5686055494/m/2916016594

Skip over the discussions/debates within the thread and just read the literature.

There are other causes for various aberrations (such as non-uniform energy delivery) that exist within the optical zone, but the cosine effect is primarily responsible for the spherical aberrations (halos, starbursts) within the ablation zone.

Corneal remodeling and epithelial hyperplasia are other factors that probably play a role in why there is not a sudden sharp increase/change in aberrations from the treated to the untreated zone as the pupil dilates, even in the absence of a blend zone. Also, the cosine effect creates a form of a blend zone which softens the transition.

Now lay a flap that no longer fits back down on top of all of this and who knows what you are going to get??!!
The blend is to transition the ablation from the ablation optics to the untreated cornea, theoretically reducing spherical aberrations. If your aberrations are central, then the benefit of a blend would be in whether the flap surface is optically improved where it covers the ablation zone.
had my "stability check" today (maybe they should check my mental stability after 6 years of hellish vision). apparently i'm "stable," i guess.

i asked the doctor what the screening cutoff was for pupil size with the wavefront technology and i think she said 8.5 mm. Eek must be one hell of a "blend zone."

they didn't seem to be that concerned. i said something like "this is a big deal to me not just some nuisance...and it's been a long time." to which i got no reply. i was tempted to say "it's hell" or "it ruined my life" or something but did not. i didn't smile though and looked down when they greeted me.

i saw a topic called "good grief they're targeting children." well i was 19 when i had the initial surgery- a lamb to the slaughter. i'm 25 now. 25. my memory is pretty scant before the age of 11 or 12 which means almost half of my memories in life are with these horrid symptoms. somehow i managed to graduate from college during this time. there is no doubt in my mind that having this during these developmental years will shape my personality for the rest of my life- that's if i find resolution, of course. if i do not find resolution soon, i really don't know how much longer i can go on.

i read other people's stories on this website and know that my case is not nearly as bad as many of their's. i admire them for their courage and hope they find resolution soon- this includes you, artistwoman.

despite all of this further surgery may be my best option- my eyes are extremely sensitive, and i doubt i could tolerate hard contacts or even soft ones- except maybe the newer "ultra-wet"(sounds dirty) kind.

i will post again well before having additional surgery(if i do). thank you, artistwoman, for the emails. i will look for that building.

by the way, Dr. Hartzok, that pupil in that picture of yours looks awfully big for lasik.

-helmit
quote:
The blend is to transition the ablation from the ablation optics to the untreated cornea, theoretically reducing spherical aberrations. If your aberrations are central, then the benefit of a blend would be in whether the flap surface is optically improved where it covers the ablation zone.



i guess this demonstrates the obvious fact that the result of the surgery is very dependent on the skill of the surgeon as well as the technology used.
quote:

i guess this demonstrates the obvious fact that the result of the surgery is very dependent on the skill of the surgeon as well as the technology used.


Or whether night vision defects are considered an actual problem.

I had LASIk eight years ago. I have all the night vision problems. I had an eye exam two weeks ago. The doctor says the flaps are irregular with high and low spots. Also epithelial inclusions and scars. She proposes relifting the flap to clean out the scars and smooth the cornea. But no more LASIK. She asked, "Have you tried Alphagan?"

I said I had but preferred dilute pilocarpine. Then she asked, "Does it help?"

I said it does, shrinking much of the starbursts. Her response: "Well that means most of the problem is peripheral, not central".

To my mind that means her flap lift may not do much. Perhaps she thinks so as well as it's been two weeks and nobody has called me to schedule the surgery appointment.

Doing a medline search I can't find anything much on night vision problems. Doing a 'flap relift' search I found a dozen abstracts of relifting to remove striae. One was authored this year by my original surgeon. He wrote an early critique of LASIK results which claimed no night vision problems. His data must have included my surgery and he knew quite well about my night vision problems. The stria abstracts mostly claim good to excellent results post flap relifts. So do I believe them or should I worry that they aren't considering night vision problems?

After all, these patients are probably all 20:20 in the exam room, where the doctors control all the variables.
I hit the send button too soon. I wanted to finish by saying that in the exam room objective data is collected which can be reviewed by peers. Night vision problems are mostly subjective and can't be quantified easily. So it becomes a Catch 22. If it can't be measured by the doctor, how is he supposed to know whether the treament will help?

RGPs work for me. But I can't tolerate them long enough to use daily. I've tried everything except testosterone eyedrops, because a blood test says my hormone level is normal. Maybe that's the next thing to try.
Helmit,

A wavescan cannot tell ou how much of your cornea is flap and how much is residual stroma. According to all the topographies, interwave and wavelight scans, etc., I had 400 microns+, The reality, as the Artemis scan showed, is that my flap is 200 microns, and the remaining stroma is only 200 microns. Please don't make the mistake of thinking that a wavescan can provide you with all of the information you need to make a good decision.
How many opinions have you gathered regarding your situation? Re-treatment should only be considered, IMO, after you have gotten several opinions and, hopefully, from a doctor who has done quite a few. Wavescan technology promises a lot but some patients with the latest wavescan procedures end up here with the same complaints as patients who were lasered five years ago.

I know you are tired of your visual condition but all this very impressive technology is not a quarantee. I think you need a serious second and third surgical opinion.

Your doctor also said he didn't think contact lenses would help you. Chances are great that he has little or no experience with RGPs. Fitting the lasered eye is a kicker but, while you are at it, get an opinion on RGPs. I think Artistwoman gave you some names of fitters in your area. You mentioned the expense of RGPs. How much did you pay for LASIK and how much will an irreversible and unguaranteed second surgery cost? If the second surgery leaves you with unsatisfactory vision, you could still end up needing RGPs.
quote:
How many opinions have you gathered regarding your situation? Re-treatment should only be considered, IMO, after you have gotten several opinions and, hopefully, from a doctor who has done quite a few. Wavescan technology promises a lot but some patients with the latest wavescan procedures end up here with the same complaints as patients who were lasered five years ago.


I have only had one opinion from a surgeon on a custom enhancement and he seems confident that he can help me. He has done 40-50 such procedures. I have an appointment with another surgeon for a 2nd opinion which hopefully my insurance will cover but if not, no big deal.

quote:
Your doctor also said he didn't think contact lenses would help you. Chances are great that he has little or no experience with RGPs. Fitting the lasered eye is a kicker but, while you are at it, get an opinion on RGPs. I think Artistwoman gave you some names of fitters in your area. You mentioned the expense of RGPs. How much did you pay for LASIK and how much will an irreversible and unguaranteed second surgery cost? If the second surgery leaves you with unsatisfactory vision, you could still end up needing RGPs.


I did mention the expense of RGPs but just as kind of an off-hand comment. Money is not that big of an issue- after all this is my VISION, which to a large extent is my LIFE.

I still strongly doubt that I could tolerate RGPs from a comfort perspective, as I cannot even tolerate soft contacts. And I do not think it is an oxygen permeability issue. But I guess I might as well hear the optometrist out, so I will probably make an appointment next week.

I will repeat my question from above- does loss of Best Correctable Visual Acuity mean you cannot correct it by any means? Or is there still some way to correct it? With hard contacts?

Thank you very much.
got my 2nd opinion yesterday.

the surgeon gave me the green light so to speak.
he was not affiliated with the company that performed my surgeries, but had heard of the surgeon that may perform my "enhancement"(God).

they performed another wavescan which again produced images that are striklingly similar to the awful aberrations i experience.

i dunno though- my vision has been so awful for so long it's almost like being abused by someone and then going back to that same person for help. almost.

he assured me i have plenty of corneal thickness even for another surgery after this one should better technology become available(which it undoubtably will) and said the worst case scenario would be to fit me with a pair of RGP's if the surgery didn't work or made things even worse(but it shouldn't). i do have large eyeballs- big corneas- which is an advantage.

that brings me to another question, maybe for doctors. well, first of all they will not do an optical zone larger than 6 or 6.5 mm, correct? how can that be constant for everyone? say someone(like myself) has eyes that are 25% bigger than the average eye- couldn't the zone then be 25% bigger? proportionate? that seems logical though i do not know much about optics.

he said ablating farter out than 6 or 6.5 mm would remove more tissue with an uncertain benefit to vision. he also said that people have come in with night vision like me BEFORE any lasik and have ended up better AFTER "custom" lasik- Confused - no way IN HELL can i believe that. ah well, just take it with a grain of salt i guess. thanks.

helmit
I do know one person, whoes night vision was improved after usual LASIK (even not wavefront). But she had really bad night vision, multiple images, starbursts all her life, and she had very specific cornea defect which was improved by refractive surgery. So, this is very rare, I suppose but happens sometime...
Helmit, the size of your eyes is not important. What is important is your residual sickness under the flap, and the thickness of the flap if surface treatment is considered. Please do not make any decision about further surgery without Artemis scan which is able to measure the thickness of each layer in your cornea.
Hey all,

I'm new here so I thought I'd say hi, first post ever. I'm also very tired so I am going to keep this short.

I have been experiencing night vision problems like many of you and will only undergo another surgery as a last resort. Currently I am most interested in RGP lenses. I was wondering if any of you know a good doctor in my area (Champaign, IL) that may be able to help fit me. Thanks a lot.
well i had it done- the "enhancement"(God) with the wavefront technology of course. about 4 months ago now- my how time flies.

so far my total HOAs have been reduced only 25-30%, not the 95-100% i and my doctor had hoped for. the number has been slowly creeping down about .01 per month since one month out so it is possible it could keep going down- seems unlikely it could get over 40-50% but i have to think positively and hope for the best.

i had it done in one eye. the vision seems better in that eye in medium to well lit environments and after the use of alphagan than it was before the procedure. the blob of aberrations is only slightly smaller in the treated eye than in the untreated eye in dim environments without the use of alphagan.

i can say that if my pupils become small enough my vision is perfect in the wavefront "enhanced" eye whereas in the other eye no matter how small the pupil gets there are still some aberrations.

it didn't make my acuity any worse- in fact made it slightly better- even though i was already "20/15" on old snellan.

so i am very disappointed, let down, etc.- something new and different. this summer will mark the 7 year anniversary of my visual hell. but hey it might keep improving. still kickin'. still have all four limbs.

i will try a hard lense in the other eye- really doubt i can tolerate it, though.

i am being put on a waiting list for a new computer algorithm for removing tissue which will probably take years and even then i will not just jump into it.

was it worth 30 microns and $500? i don't think so.
Last week I had my 5th or 6th second opinion. This place has a glitzy website with a lot of testimonials from newcasters and athletes that I've seen on TV. The doctor says I have about 650 microns in each eye. He was surprised considering I've had two procedures on one eye. "Awesome corneas" was the term he used.

Then he said visx was the only laser that he would use on me but they were just getting it. In fact my wife saw it being delivered. So he said I could wait 6 months to give him time to see what the visx can do or he could send me to another place that has been using the visx laser for about a year. And he said that pupil size is not a factor for starbursts and halos.

So now I have an appointment for this other place, which has a much smaller website and no athlete testimonials.
Helmit,

I'm sorry your most recent experiment produced unsatisfactory results for you. There are extremely few reports of further surgery fixing anyone satisfactorily. Surgeons who boast of great retreatment results in those with GASH tend not to be particularly interested in what the patient has to say about it...

Kevin,

Before you trust the numbers pulled off a topography, or arrived at through simple calculations, GET AN ARTEMIS SCAN. According to my topographies, my corneas were fine, too, until the Artemis showed that I had a 200 micron flap and only 200 microns of stroma beneath it.

Any surgeon who tells you that pupil size doesn't affect starbursts and halos is either woefully ignorant or lying. If pupil size were not a factor, that pilo you've been using would have been of no consequence. True, for some of us, the issues are in the tissue, and not related to pupil size. (Neither pilo nor alphagan reduced my massive glare, starbursts and haloes.) But for those who DO *see* benefit from constricting their pupils, their experience negates your most recent op's opinion.
quote:
There are extremely few reports of further surgery fixing anyone satisfactorily.


That may be true now but wavefront is very new- it's only been in use for 2 years now. 2 or 3 years from now it may be a different story. just trying to be hopeful.

Kevin- if I were you I would wait, depending on how much HOA's you have. You saw what happened with me and my surgeon was tops.

...

Any good RGP fitters in the DC area, preferably northern VA? I will be there on an extended stay. Thanks!
I have no issue with being hopeful, but from the number of people who email me with poor results from Wavefront retreatments, it's tough to be optimistic. Not only have many of them seen no improvement, their complications are worse now than they were before retreatment.

Retreating an unpredictable surgery with another round of unpredictable surgery doesn't strike me as a sound approach to the issues.

*****************

Within two hours of DC, in Chambersburg, PA, is Dr Hartzok, VSRN's executive director, who has worked with quite a few patients in that area. Email him for information at dhartzok@visionsurgeryrehab.org.

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