Verisyse phakic intraocular lens and night vision problems

[GeneralPatientInquiry]

Mr. Hagele:

I am a 46 year-old who had a Verisyse lens implanted two weeks ago in my right eye (-13.00D, 6mm). I immediately noticed starbursts and edge glare the first night and it hasn't improved. Day vision is okay and about the same as my pre-op contact lens. At the first day post-op exam, my surgeon noted the lens was slightly off-center, but he didn't seem too concerned. At my two-week post-op exam yesterday, my surgeon was more definitive in his assessment and said the lens needed to be repositioned or removed in two weeks. He says he usually resolves these issues in 99% of cases with a repositioning procedure. He will not charge a fee, but I will have to pay for the surgery center/anesthesia (about $1,000). When I asked what happened, he indicated the lens may have moved and also that it can be difficult to center during surgery on a large pupil patient. My pupil size is just under 7mm.

If the repositioning doesn't work, then the lens will be removed. He listed additional options as 1) Epi-Laser and 2) Clear lens extraction with insertion of a lens that can focus.

My surgeon is USAEyes.org certified and an internationally noted authority on refractive surgery. My questions:
1) Is it customary for a patient to have to pay for the surgery center for the repositioning even if surgeon error was a possibility?

2) My only immediate options are repositioning or removal. Should I get a second opinion yet?

I would appreciate any other thoughts you may have.

[LasikExpert]

I’m sorry to hear of your difficulties. You do have several options.

Repositioning of the lens may resolve the problem, however edge glare and night vision problems will probably not fully resolve with centering. The optics of the Verisyse phakic intraocular lens (P-IOL) are not larger enough to cover a 7.0mm pupil. In very low light environments the pupil will be larger than the optics and light will “leak” around the edges. What is not deflected by the P-IOL’s edge will be out of focus when it reaches the retina and is “seen”. The edge deflection can cause glare and flashes. The out of focus light can cause haloes around light sources.

Refractive Lens Exchange (RLE) also known as clear lens extraction, would be an obvious option for some aged 46, however your high myopia would put you at an elevated risk of retinal detachment. Eventually you will need this same procedure when you develop cataracts, but that is a different situation. Cataracts reduce your ability to see even with glasses. There really is not much of an option. You may not develop cataracts for 20-30 years, so that is 20-30 years that you don’t need to worry about retinal detachment caused by the trauma of surgery.

Staying at the cornea makes more sense because you will not elevate the risk of retina problems. Lasik is almost probably not an option because the large amount of tissue that would need to be removed to resolve your myopia plus the thickness of the flap would mean that your cornea would probably be too thin to remain stable. A surface ablation technique like PRK, LASEK, or Epi-Lasik would probably resolve the thickness issue, but these techniques have an elevated risk of corneal haze.

Epi-lasik is probably the most appropriate choice of surface ablation techniques. By saving the epithelium the incidence of haze is believed to be reduced, but there something more you can do.

It has been found that taking 500 mg of vitamin C twice a day for at least one week before surgery plus at least two weeks after surgery reduces the probability of corneal haze to almost zero. Another important step you can take to reduce the probability of haze is to wear 100% UVA and UVB filtering sunglasses if you even think of going outside for month after surgery.

Mitomycin C can be applied to the cornea during surgery can change the healing response. This also reduces the probability of haze. Mitomycin C is strong medicine that is probably best avoided it when possible, but is appropriate when necessary.

The business side of refractive surgery is... well... business. Whatever terms and conditions a physician offers and a patient accepts are what are appropriate. It is common for physicians to charge a patient in their out-of-pocket expense including facility fees. Whether or not that is appropriate is a matter of personal opinion.

A second opinion may be wise. It is not likely that the second opinion will be much different than the opinion of a certified and internationally noted authority on refractive surgery, however there is something else a second opinion will provide: peace of mind. A second opinion doctor will affirm if you're on the right track and if you're not will be there to help you down a different path. Knowing that you are receiving appropriate advice from your primary surgeon is of tremendous value and is almost as valuable as knowing you are receiving inappropriate advice from your primary surgeon.

[GeneralPatientInquiry]

Glenn,

Thank you for your prompt and thorough response. My repositioning procedure is scheduled for June 6, which is four weeks after the original procedure. My surgeon is Dr. W (2 hour drive from here). Do you know of him? I have confidence he will guide me with the best solution.

Ideally, I would like a second opinion but my options are limited with respect to finding a surgeon in this area. I found Dr. S on your website, but doubt I could see him prior to June 6. I also know that Dr. DS previously worked with Dr. W. However, I don't believe he is certified by your organization.

Any additional thoughts are appreciated. I have posted my feedback on your website.

Sincerely,

[LasikExpert]

Anyone who has been involved in refractive surgery for more than two weeks – or ophthalmology for that matter –knows Dr. W. He is has been at the top of ophthalmology circles for years. Your confidence is well founded.

Dr. DS is not certified by our organization. Also, former business partners are seldom unbiased about each other. The truth is if anyone near Dr. W had a problem, I would be recommending they go to Dr. W or his associate Dr. KT. Perhaps what you need is to discuss your situation with Dr. W via telephone between now and time for your repositioning surgery. You may find that you would rather go straight to Epi-Lasik rather than the repositioning first, or a different type of phakic IOL.

One thing you have demonstrated is that there are no guarantees with any surgery. Even an appropriate candidate with a respected doctor can have a bad outcome. That is the unfortunate reality of any kind of surgery.

[GeneralPatientInquiry]

Glenn,

Dr. W performed my Verisyse repositioning procedure two weeks ago (6/16). I was cautiously optimistic with the results at my day 1 post-op office visit when Dr. W said he felt confident the repositioning had resolved the glare, halo and contrasting issues. He stated the problem and resolution were simple "biomechanics." The problems continued to be almost non-existent through day 2 post-op., then they returned over the next few days. The problem is marginally better than with the original procedure, but is not acceptable for driving at night. I will see Dr. W again tomorrow. I am discouraged with the results thus far. Do you think my pupil was constricted for a couple of days and temporarily hid the problems? Alternatively, do you think I just need to give some time for the healing process to help resolved the problems?

Regards,

[LasikExpert]

From my vantage, you are correct on both counts. Your pupil was probably constricted and you should give it more time. If the Verisyse needs to come out, you can have it removed at any time. Unless there is some sort of complication, there would be no reason to remove the phakic IOL early. Let me know how it goes.

[GeneralPatientInquiry]

I saw Dr. W yesterday. He said the lens is re-positioned well. He does not think it is a healing issue that will resolve the glare/halos/contrast issuer. He said, with time, my brain may adapt to the glare/halos. He also prescribed Alphagan 0.2% eye drops to constrict the pupils. He said the drops may serve as a "crutch" to get me through the adaptation period. The question of whether I use these drops on a long-term basis is an open issue. At this point, I have also developed 1.25 diopters of surgically induced astigmatism. There was no astigmatism prior to the first surgery. This may change after the sutures are removed in three months at my next appointment. Still, I am a little concerned about the new astigmatism.

Do you know of any long-term consequences of using Alphagan drops for this purpose? He promised we will resolve my issues, even if we have to remove the lens.

[LasikExpert]

Alphagan P is actually a medicine for glaucoma, which keeps your intraocular pressure at a safe level. As long as your IOP does not go too low (which is not at all likely) then you can use Alphagan P as long as required. It should reduce or eliminate the night vision problems.

It is reasonable to expect some, if not all, of the astigmatism to resolve with the removal of the sutures and healing. Astigmatism would exacerbate night vision problems and may be a part of what you are currently experiencing.

[vinceledude]

Hello sir, I have the exact same problem after my verisyse procedure. Starbursts go on and off at night or at low light. My doctor prescribed me Alphagan drops. I didn't use them yet. Would like to know if you have find a solution for your starbursts.

thanks
Vincent