After DLK, why does eye get worse?

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After DLK, why does eye get worse?

Postby alicia » Sun Jul 16, 2006 11:33 am

Hi. I had LASIK on June 9 (a Friday) in a big established center with a good reputation. The doctor said he's done 30,000 eyes before me. I was nearsighted before the operation and have good health, etc. A very common and uncomplicated case...

The next day, my vision was terribly blurry and my eyes hurt and I had to wear sunglasses in the house. Ugh. Not the "you'll go to work the next day" I had read about. They call all their LASIK patients on the first day post-op and I reported that things weren't good and they said, "keep up with your eye drops" so I did. The next day WE called to report things had not improved. They said, "keep using those drops" referring to the steroids, antibiotics, and tears.

Monday, I was diagnosed at my first post-op visit (3 days post-op) with DLK. The doctor said my left eye was "stage 3" and my right eye (which had considerably more pain and haziness) a "stage 3 plus." I'm not sure exactly what he meant by "3 plus." My vision at the time was 20/70 (left) and 20/150 (right). Not exactly what I wanted after LASIK.

He irrigated both eyes (OUCH) and sent me home with increased steroid drops which I continued taking for two weeks or so and then they weaned me off those. I saw the doctor often during this period. The DLK was reduced to a stage 2 (left) and stage 3 (right) two days after the irrigation and with the drops it dropped to both being stage 1 by the end of the week or beginning of the next.

Finally, one week post-op, the doctors were able to correct (via glasses, sigh) my vision well enough for me to legally drive.

Each time I go in for check-ups, they check my vision and update my glasses if necessary. As the DLK subsided, my vision got better and I could use less and less correction for my glasses.

However, at my last visit, my right eye had gotten noticably worse. It went from about 20/50 uncorrected to about 20/80 or so.

We are hoping for an "enhancement" (as a kid we called these things "do-overs.") in the fall. Is that feasible?

Why would my vision get worse on this last visit? How long should I expect these fluctuations? Would the DLK occur again if they give me an "enhancement?"

alicia
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Postby LasikExpert » Sun Jul 16, 2006 6:13 pm

The possibility of DLK (See Diffuse Lamellar Keratitis, DLK, Sands of Sahara) always exists with anyone who has had Lasik, IntraLasik, or any corneal lamellar procedure. The probability that DLK will occur is relatively low, however the probability that DLL will reoccurr in someone who has previously experienced DLK is higher than if the patient had not experienced DLK. If you have trauma to the eye or a sudden degradation in vision - and you know exactly what that looks like - you will want to contact your doctor immediately.

The common method to resolve DLK is with steroid eye drops. Because your DLK was so advanced on the third day, the doctor obviously felt lifting the flap, cleaning away the cells, and irrigating the area was necessary. This is not always the case. If the DLK is diagnosed and treated within the first 36(ish) hours, irrigation is commonly not required.

DLK is an inflammatory response to sterile cells underneath the Lasik flap. Steroids are an anti-inflammatory. These two will fight each other until the steroids finally win and all DLK inflammation is resolved. A concern with an extended use of steroids is an increase in intraocular pressure (IOP). If the IOP is raised too long, damage to the optic nerve can occur. You doctor will want to monitor your IOP and/or add IOP lowering medication to your steroid regime.

At the same time as you have DLK, you have normal surgery related inflammation. The steroids will work as an anti-inflammatory on the normal inflammation too. Because of the hyperinflammation caused by DLK, you won't pay much attention to the normal inflammation. In fact, it is impossible to know what inflammation is normal and what is DLK until the DLK is fully resolved.

Now that the DLK has fully resolved, your normal inflammation has had a chanced to resolve. This was the period where you were using increasingly lower strength glasses. Now that the eyes have settled down, your refractive error is stable yet not quite perfect. It is possible that the DLK affected the final refractive error, but it is more probable that your final refractive error is what you would have received with or without DLK.

Stage 3 DLK is when you have many solid opacities and are at the edge of corneal scaring. Stage 4 is when the flap starts to destroy itself and scars appear. This is also known as flap melt.

Because your doctor described your DLK as Stage 3 Plus, I assume that there was evidence of scaring, but not much or what the doctor saw was not clearly identifiable as DLK related scaring. It is possible that this caused your final refractive error to be less than ideal. It is not likely that you suffered flap melt if your vision is well corrected with glasses. Flap melt is irregular, can cause multiple images, does not correct well with glasses, and often requires the use of rigid gas permeable (RGP) contact lenses.

Your vision corrected with glasses is the best vision quality you can expect to achieve with regular enhancement surgery. If you have scaring or other issues, different procedures and/or treatments may be combined with enhancement surgery to provide a satisfactory result. You will need to talk with your doctor about these details.

It is possible that the DLK could occur with enhancement surgery (do-over, as you say), but due to your previous experience with DLK your doctor will probably put you on a full regime of steroid drops, agressively treating you as if you had DLK. Consider this a pre-emptive strike against DLK.
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