enhancement problems

[marion]

Hi, Glenn, I need some suggeastions and have a lot of background on this one to give you.

I had epi-lasik last July. My initial prescription was
Right eye -6.25 +1.25
Left eye -8.50 +2.50

We corrected the left eye for monovision. I've been happy with the mono vision, but the distance eye was never good and then regressed. I ended up with
Right eye -1.25 +.50
Left eye -2.25 +.50
although at my last visit, the tech said that my chart showed that right before the enhancement my right eye was -1.50 +.75 or even 1.00. I suppose it fluctuates depending on who does the exam and how much they ask you to squint/guess.

My surgeon recommended we enhance the distance eye and see if I still liked monovision and if I didn't, we'd correct that one as well. This seemd sensible since I was looking to possibly enhance both and if lucky, would only have to do one.

On December 27, I had a PRK enhancement on the right eye. My vision was awful at first as expected. I had one great day of vision about 5 days after the bandage contact came out and it's been awful ever since. I test at 20/25 or -.25 at 2 weeks, -.50 at 8 weeks. My astigmatism has been from .50 to .75 at my visits.

But I don't feel like I have 20/25. The thing is I can't really see anything clearly out of the right eye alone or both eyes together. I've lost all ranges of vision, middle and distance and now I don't even read so well out of my monovision eye since I think the two worked together before the enhancement. I'm getting tired of seeing poorly and having people ask me why I'm always squinting!

My best corrected vision is equally blurry. If I squint I see a bit better and I see better in darken rooms or with sunglasses. Putting in drops doesn't improve a thing - not even for a few seconds. The eye doc said my eyes didn't really seem to be all that dry although he recommended a thicker eye drop which didn't help and made my eyes feel sore. I went back to the preservative-free refresh.

The eye doctor gives me the "It's too early" speech which I've unfortunately heard before, but it's two and a half months and I'm pretty sure it's getting worse! This very kind and sympathetic eye doctor who does all the follow-ups has just quit (second one since last July) and I've only seen the surgeon once since surgery at which point I expressed my frustration at the poor vision and he said "You're 20/25, you have good vision." Great bedside manner, huh?

My next appointment is in 3 weeks with the surgeon since pretty much no one else works there now. What should I ask to get answers? This is the surgeon I complained about before because he has to be asked things directly and only then he will answer. I'd like to know what we do with this blurry vision. Is it HOA? Is that correctable? I'd sure hate to have another enhancement since this one made it worse. I guess my next option is to correct the monovision eye for distance, hope for a better result and that the two eyes will work together to compensate for the poor right eye. In any case, I'm not even considering either eye until I've passed the 6 month mark on this right one.

Any advice or ideas on this? I'm preparing for my appointment and I appreciate that you give unbiased answers since it's not YOUR work that didn't turn out!

[LasikExpert]

...I appreciate that you give unbiased answers since it's not YOUR work that didn't turn out!

Even if it was my work, or the work of an affiliated Lasik surgeon, I'd try to be unbiased. My bias is objectivity.

The fact that lenses do not clear your vision indicates that this is a quality of vision issue, not quantity of vision issue. Your refractive error is almost eliminated and your refractions (which is better, one or two?) are almost within normal human fluctuation for visual acuity.

You probably can identify the 20/25 line of recognizable black letters on a white background in a controlled environment. That does not mean that your real world vision is what you seek. A contrast sensitivity test may be a better measurement, along with a wavefront diagnostic and any other test that examination may find appropriate.

What is interesting is that your vision improves in low light environments. This indicates that the refractive error in the center of your cornea may be different than the refractive error at the periphery. The light passing through the outer edge of the cornea is better focused. This would likely be represented in a wavefront diagnostic as Spherical Aberration. Remember that Higher Order Aberrations (HOA) are a measurement of an aberration, not the cause of the aberration.

In the absence of any observable or measurable abnormality, you will probably need to wait until six months postop until you do anything more. In other words, it is a healing issue and the healing won't be considered complete until about six months postop. If you continue to have quality of vision problems at that time, then I highly recommend a second opinion from a corneal specialist.

I suspect that your surgeon will be able to provide some insight into what is causing the problem.

[DryEye]

Glenn:

You stated above "Remember that Higher Order Aberrations (HOA) are a measurement of an aberration, not the cause of the aberration."

What tests tell one the causes of the aberrations?

Thanks

[marion]

Your refractive error is almost eliminated and your refractions (which is better, one or two?) are almost within normal human fluctuation for visual acuity. You probably can identify the 20/25 line of recognizable black letters on a white background in a controlled environment. That does not mean that your real world vision is what you seek.

That's the difficulty. His machines say that my vision is good. My eyes say differently. At this point, I can rattle the letters off from memory while sitting here in my living room. I've looked at the same test for nine months.

A contrast sensitivity test may be a better measurement, along with a wavefront diagnostic and any other test that examination may find appropriate.

How does one tactfully request more testing when the surgeon doesn't bring it up? It seems so presumptious when he is the expert, but he always acts like everything is turning out great.

Remember that Higher Order Aberrations (HOA) are a measurement of an aberration, not the cause of the aberration.

Is there a correction for this type of aberration? Contacts or glasses don't seem to be a solution. How do you correct uncorectable vision? As you can tell, I'm getting worried.

In the absence of any observable or measurable abnormality, you will probably need to wait until six months postop until you do anything more. In other words, it is a healing issue and the healing won't be considered complete until about six months postop. If you continue to have quality of vision problems at that time, then I highly recommend a second opinion from a corneal specialist.

So it sounds like I should ask my surgeon to perform these tests now and if he can't find anything wrong, wait until July and then find another doctor. I wonder if the reason he doesn't perform these tests is because it's a really small practice and maybe he doesn't have the equipment. Is this standard equipment?

[LasikExpert]

What tests tell one the causes of the aberrations?

A comprehensive examination by a competent doctor may determine the cause. As an example, a person may have a wavefront diagnositc that shows high HOAs, but the wavefront diagnostic does not determine that the problem is dry eyes.

[LasikExpert]

That's the difficulty. His machines say that my vision is good. My eyes say differently.

Not every vision limitation can be objectively measured. If machines could figure it all out, we would not need to tell the doctor which is better, one or two.

How does one tactfully request more testing when the surgeon doesn't bring it up?

Ask if the doctor will refer you to a specialist who may have available additional diagnostic equimpment or specific expertise. That is a reasonable request in this kind of situation.

Your doctor undoubtedly wants to know what is wrong too. Not only for you, but also if he should have another case like this in the future. If you see a specialist who diagnoses and treats the problem, you get the result you want and your doctor becomes more knowledgeable.

It seems so presumptious when he is the expert, but he always acts like everything is turning out great.

Then there may be a disconnect between the doctor and the patient.

Is there a correction for this type of aberration? Contacts or glasses don't seem to be a solution. How do you correct uncorectable vision?

Since the cause of the problem has not been diagnosed, it is impossible for me to say.

As you can tell, I'm getting worried.

This is another indication that a second opinion is in order.

So it sounds like I should ask my surgeon to perform these tests now and if he can't find anything wrong, wait until July and then find another doctor.

I recommend that you discuss the idea of a second opinion at your next exam. Your doctor may think it is a good idea now, or may agree that July would make more sense. Seek your doctor's advice.

I wonder if the reason he doesn't perform these tests is because it's a really small practice and maybe he doesn't have the equipment. Is this standard equipment?

Not every practice has the same equipment, and not every eye doctor has the same abilities. I normally recommend contacting the ophthalmology department at a university affiliated teaching hospital when seeking a second opinion. One of my reasons for this is that teaching hospitals often have sub-specialists and specialized equipment.

[marion]

Ask if the doctor will refer you to a specialist who may have available additional diagnostic equimpment or specific expertise. That is a reasonable request in this kind of situation.

I recommend that you discuss the idea of a second opinion at your next exam. Your doctor may think it is a good idea now, or may agree that July would make more sense. Seek your doctor's advice.

Not every practice has the same equipment, and not every eye doctor has the same abilities. I normally recommend contacting the ophthalmology department at a university affiliated teaching hospital when seeking a second opinion. One of my reasons for this is that teaching hospitals often have sub-specialists and specialized equipment.

Interestingly, my surgeon IS an adjunct professor of the ophthalmology dept of the local large university. He just happens to practice out of his own clinic. I'll take your advice and ask if he thinks perhaps going somewhere with more specialized equipment would be appropriate at this time. He most likely knows what is available at the university.

After my appointment, I'll report back. I'm just awfully sorry I had this enhancement.