Custom Lasik 6 years after Lasik, vision bad again

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Custom Lasik 6 years after Lasik, vision bad again

Postby GeneralPatientInquiry » Wed Jun 14, 2006 5:16 am

I had LASIK done to both eyes at the same time for nearsightedness (my eyes were pretty bad, but no stigmatisms). After the procedure I saw crystal clear, but had trouble with driving at night (halos, glare, etc.). I wore low prescription glasses just at night.I've gone to all my scheduled eye exams post-op and regular exams as expected (every year). It is now 6 years later, and my vision has deteriorated significantly (within the last year).

I went back to the eye surgeon who did my LASIK and he did all kinds of test and eye drops, but gave no real good explanation as to why my sight, after all this time, is getting bad again (though, not as bad as they were, but after spending $5,000.00 on the procedure and insurance not covering any of it, I am disappointed.). He wants to do something called "Custom LASIK" on me. Do you have any information on this, for people like me who had the procedure done so long ago? Most people who get the "touch-ups" haven't had so much time lapse between being able to see then not being able to see and dependant on glasses again.

Or am I wrong? If I do elect to have the procedure done, is it likely to correct my vision as well as the halos, etc. for good?
Another concern is it will cost a total of $700.00 for this custom lasik, is this normal? I don't remember getting any guarantees, but I do remember my doctor saying it was a permanent procedure, and I wouldn't need to wear glasses again until I reached about 40, then maybe I'd need reading glasses. I guess I should of gotten that statement in writing.

Thanks for any information you can provide me. I feel totally in the dark. No pun intended. -

Sherri
This post is a reprint of a previously requested inquiry received by USAEyes.org via email.
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Postby LasikExpert » Wed Jun 14, 2006 5:24 am

Sherri,

It would be very helpful to know your current prescription and your prescription before surgery. Regression is a known limitation of refractive surgery, but normally will occur within the first three months, not six years later. LASIK is a permanent change to the eye, but your eye will change after surgery just as it was changing before surgery. Depending upon your pre and postop prescription, what you are experiencing could be something expected, or unusual.

You may also be experiencing a response related to hormonal changes. Are you pregnant? You seem too young for menopause. Have you changed your exercise routine lately? A change in medication or health in any other way? These and other factors can all contribute to vision changes. You would not want to have permanent surgery to correct a temporary problem. Rule out all the other possibilities first.

Custom LASIK is a common name for wavefront-guided LASIK. We have a detailed article on wavefront-guided refractive surgery at Custom Wavefront Lasik.

Some patients who have had night vision problems after refractive surgery have had a significant improvement in their symptoms after wavefront-guided retreatments. This may be an added benefit, but your doctor would need to evaluate and explain if this is a probability.

Before you have surgery, I highly recommend that you receive a reasonable explanation as to why you have had this change occur. If your doctor doesn't know why you are experiencing these changes - even if it is just natural changes and normal - then you really don't know what will happen in the future.

It would appear that your doctor is charging a little less than what it actually costs him to provide you the surgery. The laser manufacturer charges a $250 usage fee every time the doctor presses the button, plus the normal disposables will cost a few hundred. That is not even considering the cost of staff. In the this regard, the dollar amount would seem fair.

A second opinion is not a bad idea in a situation like this. To be honest, except for an understanding of why the changes have occurred, nothing indicates terribly unusual circumstances, but a second opinion would give you the peace of mind that you are well informed and making the best decision for you.

If needed, you should also read:
Lasik and Pregnancy
Lasik Regression
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Postby dmd » Fri Aug 04, 2006 5:43 pm

I'm not the original poster, but I'm in somewhat the same situation. I had Lasik (with TLC) in 1999. My original prescription was around -13 both eyes. After Lasik I was about -1; six months later they did it again and I was down to 0, but with about .75 astigmatism OD. I've had to wear glasses since then for the astigmatism (I've never been able to tolerate contacts), but at least I no longer have the huge -13 lenses.

My problem is that since 1999 I've had really bad haze/glare at night. Sometimes the only way I can drive at night is by turning on the dome light in my car to get my pupils to constrict enough for the glare to diminish.

I went back to TLC a few weeks ago and they did a scan and created customvue lenses for me to look through. These don't seem to do anything at all for me though - everything just looks extremely distorted through them. So, I'm not sure what I should be asking when I go back to see them - if those lenses didn't work, presumably it's not HOAs causing my problem?
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-13.00 D in 1999 and Night Vision Problems

Postby LasikExpert » Fri Aug 04, 2006 6:30 pm

DMD,

"PreVue Lenses" do not always reflect the actual outcome, and your problem may not relate as much with wavefront as it does to topography.

Poor night vision is commonly caused by a difference in the refractive error at the middle of the cornea compared to the outer edges of the cornea. In wavefront terms, this is Spherical Aberration.

When you had surgery for that whopping 13.00 diopters of myopia (nearsighted, shortsighted) vision back in 1999, an optical ablation zone of 6.0mm, 5.5mm, or even 5.0mm was common. The laser used was probably a broadbeam laser with a limited ability to enlarge the transition zone from the area of full correction to the upper surface of your cornea.

The 13.00 D of correction would have required at least 150 microns of tissue removal. This would have been removed in the central optical ablation zone. Let’s assume that the transition zone was expanded 1.0mm from the optical zone. In the distance of 1.0mm your cornea is sculpted up 150 microns. That is one heck of an angle. That angle will catch light and refract it differently than any other area of the cornea. The uncorrected surface of the cornea is 13.00 D myopic. The corrected surface is plano (no refractive error). The transition zone is at a sharp angle. You have what amounts to being a “hole” in your cornea, and none of this would make any difference except for the size of your naturally dilated pupil.

One must remember that not all light passing through the cornea makes it to the retina and is “seen”. Some light is blocked by the iris (colored portion of the eye). In a well it environment the pupil constricts in size and only light passing through the fully corrected optical zone of the cornea reaches the retina. This light is well focused and vision should be good. When the pupil enlarges larger than the optical ablation zone, some of the light hitting the transition zone and the uncorrected periphery is reaches the retina and is mixed in with the focused light. This commonly causes blur, halos around light sources, and/or starbursting in a low light environment. We have a detailed article about Lasik and Pupil Size that you may want to read.

When you turn on the dome light of your car at night, this introduces enough ambient light that your pupils reduce in size slightly. That is enough to block light passing through the undercorrected area of the cornea from reaching the retina and being seen. Another method to achieve this result is the use of eye drops that reduce the size of your pupil. Pilocarpine works well, but maybe a bit too well and can cause headaches and other problems. Alphagan P is a glaucoma medicine that also reduces the size of the pupils, but less severely than pilocarpine. A drop in each eye in the evening may be enough to get you through the night without vision problems.

The surgical resolution to the problem seems obvious: enlarge the optical treatment zone. That is much easier said than done. For all their sophistication, excimer lasers are not designed to precisely expand an optical treatment zone. Yes, they can and have done this very well for some patients, but not for all. With your extreme original refractive error, this would be quite a task.

Wavefront-guided ablations take an analysis of the manner by which light travels through the eye and convert that to a map of what tissue should be removed and where. For most patients, a wavefront-guided ablation is superior to a conventional ablation. That may not be true in your case. You spherical aberration is probably so high that today’s technology would not be as accurate as needed. At the very least, multiple surgeries would seem necessary.

A topography-guided ablation may be more appropriate. Think of your corneas as shaped like a dormant volcano with the center depressed. What you want is to remove the high ridges without removing the center. That really is more about topography than wavefront. It may be that a topography-guided conventional ablation first, followed by a wavefront-guided ablation would be appropriate. It is at least something to discuss with your surgeon.

There is no way to predict the final outcome, except that it will not be a 20-Minute Miracle. You may get significant improvement in night vision, but it is hard to predict how much, if any. Surgery to resolve this problem is probably an appropriate option, but using something like Alphagan P or custom fitted contact lenses are appropriate options as well.
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Postby dmd » Fri Aug 04, 2006 7:15 pm

Thank you!
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Postby sunshellsea » Tue Nov 07, 2006 4:40 am

I had Lasik done at TLC almost 6 years ago and now am considering an enhancement. I was interested in the custom vue as well, but they say the prefer to do the conventional because it removes less tissue? Is this true?
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Postby LasikExpert » Tue Nov 07, 2006 5:20 am

Wavefront-guided laser ablation (CustomVue, LADARVision, Zyopitx, Allegretto) requires more tissue than conventional ablation, however the majority of patients who are eligible for wavefront-guided have better outcomes than with conventional. You may want to read Lasik Wavefront.

As your doctor the specific reason why s/he believes conventional is required. It may be that for your particular circumstances, conventional is best.
Glenn Hagele
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