Corneal Ectasia post-Lasik

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Corneal Ectasia post-Lasik

Postby Angela » Fri Jan 12, 2007 11:34 pm

I am a 40 year old female who underwent Lasik in 2000 for significant farsightedness. At that time eyes were about +3(L) and +5.75(R). Lasik was performed with good result. Only complication at that time was a flap wrinkle which resolved with eyedrops. Vision was good for about a year - perhaps a little more. After two years had to start wearing drugstore readers, and then small rx. Eventually progressed to needing more significant rx. again in Jan. 05 (probably needed them earlier, but put it off). Filled that at +2.25(L) and +3.5(R). Tried contacts but couldn't stand them - made my eyes hurt and itch (tried 4 different types).

Several months ago I noticed eye pain, feeling of something in eye, blurriness, etc. Thought it was allergies and continued my Patanol use. This didn't get better, and my vision just got worse. Went to see eye Dr. this week and left eye had jumped from +2.25 to +4.75. Right eye stayed the same. Had a corneal scan which revealed corneal ectasia. He has now referred me to a corneal surgeon who specializes in these types of problems - but it is another week before I can see him. I have been doing research and am not liking what I am finding about this condition as it appears to be unreversible and progressive. Since I have allergies and cannot even wear soft lenses, I am very concerned that the RGP's won't work for me. Is C3-R an option and safe in the States? What about Intacs? I don't have a great immune system - so corneal transplant scares me a great deal - I think I would be at high risk for rejection.

Are other people having this problem with Lasik done early on? I am very upset about this - I was never told about this kind of complication and now my good eye is my bad eye and I fear will become much worse as the condition progresses.
Angela
 
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Postby LasikExpert » Sat Jan 13, 2007 2:08 am

I believe you should defer your worrying until after you have been examined by the corneal specialist. The preliminary diagnosis of corneal ectasia may be accurate, but seems inconsistent with your situation.

Ectasia is a forward bulging of the cornea due to weakness. In Lasik related ectasia the weakness is caused by the cornea being made too thin when reshaped by the laser. For many reasons corneal ectasia in your situations defies logic.

The forward bulging of the cornea would normally cause myopia (nearsighted, shortsighted) vision, not hyperopia (farsighted, longsighted) vision. You are experiencing a hyperopic progression.

Hyperopic Lasik removes a "ring" of corneal tissue from the mid-periphery of the cornea. This is the thickest portion of the cornea and is least likely susceptible to ectasia. It is possible, but highly unlikely that this ring would have been thinned enough to cause ectasia.

If the ring of tissue removed for hyperopic correction was thinned enough to cause ectasia, then the movement of the cornea would be forward and should cause myopic shift, not hyperopic shift.

What you have sounds more like natural regression of hyperopic correction that may be exacerbated by presbyopia. Presbyopia is when the natural lens of the eye is less able to change shape and thereby change focus. Welcome to being 40! This is when presbyopia becomes problematic and is when most people need reading glasses or bifocals. Hyperopes who are also presbyopic have a unique situation.

Before presbyopia interferes with near vision it is often possible for hyperopes to "focus around" some of the hyperopia. In 2000 – and even today - it was common for surgeons to base the amount of needed hyperopic correction on a manifest refraction (which is better one or two?) with the eyes able to change focus. It may have been that your hyperopia was actually worse than thought back in 2000, but over the preceeding years your eyes had learned to focus around part of the refractive error. When you become presbyopic, your eyes become are not as able to focus around the hyperopia.

There is also an effect with hyperopic correction that relates to the human body trying to fix what it thinks is a problem. The ring of corneal tissue removed to reduce your hyperopia is a depression in the topography of the cornea. For the lack of a better description, let’s call it a moat.

The natural cornea is not supposed to have a moat, so the cornea attempts to correct this “problem” by filling it in with epithelial cells. Epithelial cells comprise the outermost layer of cells on the cornea and are the fastest reproducing cells in the human body. Over the years the epithelium will build up cells in the moat. This long-term healing response is logical to the cornea (it’s fixing a perceived problem), but will reduce and possibly eliminate the improvement in refractive error that hyperopic Lasik provided.

The moat may still be there and if it were not for all the epithelium build-up you would have much of your original improvement. If this thickened epithelium is the problem, the surgeon may simply remove the epithelium and allow it to renew in a normal and even thickness. The process of epithelium regeneration takes a few days to weeks. Yes, in another 3-8 years the epithelium may fill in the moat again, but epithelium debridement is a relatively simple and (should be) inexpensive process.

It is also possible that the deeper layers of the cornea have built-up and filled-in that moat. If this is the case you may not receive much benefit from epithelium debridement, however enhancement surgery may be considered appropriate (only if ectasia and disease are ruled out).

Another possible reason for the change in refractive error is corneal disease – specifically keratoconus. That is another one that you will not like what you see as you research it, but keratoconus normally presents before the fourth decade of life and would undoubtedly have presented very quickly after your Lasik.

Corneal scans (probably an Orbscan) may be interpreted differently from doctor to doctor and depending upon the sensitivity of the equipment. There are additional devices that can help in a diagnosis. Your current doctor may have indications of ectasia, however they may be a unique artifact to your situation.

The pain is an unusual symptom that does not normally relate to any of the refractive problems you present. It may actually have been due to the use of Patanol.

Corneal tissue, unlike internal organs, is not a tissue that normally reacts and rejects. It is highly unlikely that you would need a corneal transplant or that a transplant would be rejected if needed.

Intacs have been proven to help resolve refractive error related to keratoconus and possibly even reduce the progression of the disease, however Intacs do not correct hyperopia. Intacs may be an appropriate therapeutic response depending upon the actual cause of your problem, but they will not reduce your need for corrective lenses.

There is currently on one surgeon in the US who does C3-R. He is located in Beverly Hills. Most of the research and application of C3-R is coming from Germany and Switzerland. If you have corneal instability problems C3-R is something you should research.

As you can see there are many possible reasons for your creep back into hyperopia and they are not necessarily ectasia. What you really need is that evaluation by the corneal specialist. . As a general rule corneal specialists are no-nonsense people who are straight to the point and will simply tell you what is wrong, what you can expect, and what you should do about it. I personally find that it is the uncertainty that makes us worry.

Please let us know what is revealed by the corneal specialist.
Last edited by LasikExpert on Fri Jun 06, 2008 5:36 pm, edited 1 time in total.
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Postby Angela » Sat Jan 13, 2007 5:42 pm

Thank you for your response. I am trying to be patient while I wait for my appointment with the corneal specialist, but my vision is quite bad right now. Even with the new lens at +4.75 I cannot read this text on this computer screen if I cover my right eye. My optometrist said he couldn't get my left eye corrected to 20/40. Everything is blurry, and I am having ghost images. I can't drive at night - lots of halos and ghosting of lights. I can't see road signs clearly, etc. All of this in a short amount of time (maybe the past 4 months). The right eye has not changed in 2 years.

Also - I forgot to mention in original post that I saw the corneal scan. The right eye looked fairly symmetric, with a distinct center area that was a purplish color - but he did mention it was undercorrected at the time of the Lasik. The left eye showed a large red area in the bottom right of the image with no distinct center where the pupil was. Obviously I don't know what the colors mean, but the two looked very different. The print-out said keratoconus under the left eye image - but he felt it was corneal ectasia and seemed very concerned - called the corneal specialist immediately while I was still standing there to make the appointment for me.

I appreciate your input - which provides me with some hope that this may be something correctable. I rely on my vision a great deal for my profession - and it is becoming very difficult to read/write, not to mention the headaches from straining to focus.
Angela
 
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Postby LasikExpert » Wed Jan 24, 2007 7:03 pm

The "hot spot" in the lower portion of the cornea can be an indication of keratoconus, a naturally occurring disease of the eye that causes forward vaulting of a portion of the cornea. Your corneal specialist will be able to determine if this is the cause of your difficulties. You may want to read our detailed article regarding keratoconus and Lasik.
Glenn Hagele
Volunteer Executive Director
USAEyes

Lasik Info &
Lasik Doctor Certification

I am not a doctor.
LasikExpert
Site Admin
 
Posts: 3309
Joined: Fri May 12, 2006 6:43 am
Location: California


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