CONJUNCTIVITIS POST LASIK -- BLURRED VISION

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CONJUNCTIVITIS POST LASIK -- BLURRED VISION

Postby fmb » Tue Jul 25, 2006 4:29 am

I would GREATLY appreciate the collective wisdom of this board on the following question:



1. Wife had wavefront custom LASIK with laser doing the cutting
2. Good correction in both eyes but one eye better than the other slightly
3. About 4 weeks after surgery, she contracted epidemic conjunctivitis :-( :-( --could be correlated with some sort of infection she was having at the time plus swollen lymph nodes plus sore throat
4. Lots of itching and discharge, especially on right eye -- vision blurry
5. It was a weekend so went to normal physician who prescribed GENTAK ointment
6. Vision still blurry after about 1 week of GENTAK, slight haze and blurring (she still can drive a car without glasses)
7. She went to LASIK doc who immediately prescribed ZYLET 2x daily
8. Did ZYLET for a month with basically no improvement
9. Returned to doc, hewas mostly silent, he diagnosed "ADENOVIRAL CONJUNCTIVITIS" and said that there were "viral particles" in the eye causing the blurring and said that he saw "some inflammation" since the body was reacting to the particles
10. Said recovery took time but was very very unclear about how long, etc. Prescribed TOBRADEX 2x daily & told my wife to "come back if needed" (as opposed to setting up any follow-up !)
11. Doc specifically said this was NOT DLK
12. We assume (naively perhaps) that there is no corneal scarring etc.



Some questions:

1. Does this sound like the correct course of treatment (i.e. TOBRADEX and lots of time...) ?
2. What exactly is ADENOVIRAL CONJUNCTIVITIS and how should it best be treated ?
3. Is LASIK an issue or is it more or less irrelevant to this problem?
4. How long does it take to get fixed? Two weeks of TOBRADEX plus 4 weeks of ZYLET and nothing has improved for my wife and she's getting antsy.
5. We assume that if there were corneal scarring our doc would have had the basic sense to not tell my wife to go away and come back "if needed" (am I the only one who thinks this is appalling bedside manners???)?
6. We are getting a second opinion now
7. Is this kind of vision loss permanent (it doesn't seem so from the literature but the pace of healing is glacial)

I would greatly appreciate your wisdom and help in this very worrying matter.
fmb
 
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Postby LasikExpert » Tue Jul 25, 2006 7:12 am

You have some excellent questions, however due to the problematic situation I am going to limit my responses with the exception of urging your wife get that second opinion you mentioned. I recommend seeking a see corneal specialist who is affiliated with a teaching hospital as a professor or on staff. From my research it appears that your current surgeon is responding appropriately, but viral conjunctivitis so soon after Lasik is worthy of a second opinion. Perhaps a less obvious advantage of a second opinion is that you will get some peace of mind. You will know that either your current doctor has you on the right path, or you will be with a doctor who can put you on the right path.

Adenovirus conjunctivitis is the most common form of viral conjunctivitis. Transmission can occur with contact of eye fluids and even contaminated waters such as a pool.

Topical steroids are commonly used with conjunctivitis when infiltrates are present. TobraDex tends to be used if there is concern about a steroid response, and that makes sense after refractive surgery.

There is a tremendous difference between infiltrates and permanent scaring. The second opinion will undoubtedly clear up any concern about permanent problems, however you can expect to hear again that your wife will need to be patient.

If the doctor believes that all will be fine and there is no need to schedule a return appointment, then the doctor should be sure that the patient understands that all will be fine. Not doing so can create unnecessary anxiety. If the doctor does not think all will be fine, then it seems scheduling a follow-up would seem appropriate. Without faulting or defending your wife’s doctor, it is clear that uncertainty exists on your side. Uncertainty is often a bigger problem than the problem itself.
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Postby fmb » Tue Jul 25, 2006 12:43 pm

Thanks for your response. It's very very helpful.

Mybe the question we should be asking is: is it normal for adenoviral conjunctivitis with "infiltrates" to take this long to clear up with ZYLET and then TOBRADEX?

How do these infiltrates "go away" ?

Does the body absorb them ?

I thought all these cellular structures in the body "shed" and get new cells? What is the "standard experience" (if any) for this kind of condition? My wife complains of seeing as if she has a "dirty contact lens" ? Finally, if these particles seem persistent, wouldn't the doc suggest re-lifting flap and irrigating? Does the fact that he specifically said "there is no DLK" mean anything?
fmb
 
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Postby LasikExpert » Tue Jul 25, 2006 5:53 pm

The fact that the doctor said that your wife's problem is not Diffuse Lamellar Keratitis (DLK) is important. DLK is sterile infiltrates at the interface between the Lasik flap and the underlying stroma. DLK can progress rapidly – within a few days – to corneal opacification and scaring. DLK commonly clears up within a few days of a regime of steroid eye drops. When DLK resolves completely (although it can re-occur), whereas adenovirus in the tear film has been found a decade after conjunctivitis.

Adenoviral conjunctivitis is a very different situation. The infiltrates are not sterile. The body’s response is different. The development of infiltrates and recovery are slower. Since the infiltrates would not necessarily be limited to the Lasik flap interface, a flap lift and irrigation may be of marginal help. The way ophthalmologists respond is different too. A survey of ophthalmologists found that 50% prescribed a corticosteroid and 51.6% an antibiotic, whereas 37.5% prescribed only lubrication or no topical treatment. (Multiple treatments account for the greater than 100%)

I did find in the literature at least one case study of a Lasik patient who had adenoviral conjunctivitis triggered by Lasik and who had a successful resolution after treatment.
Glenn Hagele
Volunteer Executive Director
USAEyes

Lasik Info &
Lasik Doctor Certification

I am not a doctor.
LasikExpert
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Posts: 3309
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Postby fmb » Tue Jul 25, 2006 7:10 pm

Thanks for the reply. I am encouraged by a couple of things:

- doc says no DLK

- wife can drive car etc. etc. and is not "impaired" (until she notices and then it drives her crazy!)

- doc is somewhat "taking it easy" -- I am hoping that since he is a guy with a huge reputation with published papers and is a fellow of the US Academy of Optahmology that this is a sign that things are not serious but one worries...

- your very valuable information which helps us dent the uncertainty aspect of this a bit :-)


So here are some final questions:

Is there some sort of time over which these kinds of infiltrates 'vanish'? Is it normal for the ZYLET and TOBRADEX to not have quickly resolved them ? I am sure each patient differs but was curious as to how long one would have to cope with the "dirty contact lens" type vision?

Given all the help you have given, I will certainly report back after out second opinion with another very highly regarded surgeon.
fmb
 
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Postby LasikExpert » Tue Jul 25, 2006 7:34 pm

Everything I have found about treatment indicates that it can take weeks for improvement and even then the improvement is slow and gradual.

It sounds like you have a knowledgeable surgeon. That is your best asset.
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

Postby fmb » Sat Aug 05, 2006 10:11 pm

Update:

1. We got a second opinion. The 2nd doc and his D.O. assistant separately peered into my wifes eyes with instruments and said they saw NOTHING in there. They suggested stopping TOBRADEX and waiting a couple of months. If the blurring still persisted, then it would need a "0.5 diopter" LASIK touchup. They said corneal depth was good. They mapped her eyes with a device that made a contour map of her corneas. Overall they seemed OK and only saw some residual myopia that would need a touchup at best. They did say that the swelling from the pink eye she had, had swelled up here eyes and that could be causing the blurriness in the right eye. The left eye is 20/15. They were fans of a medicine called RESTASIS and suggested that as something that could/would help. They seemed ok with doc #1 and counselled us to go back to him.

2. We went back to our doc. Here is what he said:

- good to have got the 2nd opinion
- he still saw some faint residual "scarring" on the cornea from the past infection -- he was damn sure about this
- he measured vision, 20/15 in left, 20/60 in right
- he said that the right eye was still a little inflamed
- he did NOT agree that stopping TOBRADEX in the right eye was a good idea
- he absolutely did not agree with RESTATIS and said my wife had a great tear film
- he agreed that the left eye had resolved and to stop TOBRADEX there
- he asked my wife to continue for 4 weeks on TOBRADEX in right eye 1 drop/daily then move for the next week to 1drop/every 2 days and then to go off it for 4 weeks
- after being off all meds for 4 weeks, come in to see him and then he'd see about touch ups etc.
- he mentioned that he could correct her to 20/20 in right eye with glasses (he used that optometrist instrument with the lenses) but that she would be changing so getting her glasses for the next 8 weeks makes no sense --and given that she can still drive etc. we agreed


Any thoughts, comments, words of encouragement or advice appreciated
fmb
 
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Postby LasikExpert » Mon Aug 07, 2006 6:36 pm

It's not surprising to have a difference of opinion, but generally the two doctors seem to agree. The differences seem to be a matter of degrees.

Restasis is an anti-inflamatory approved to treat dry eye. Using it at this moment may not be wise. If the tear breakup time and the tear quantity is good, Restasis would not be indicated for dry eye.

Because Restasis is an anti-inflammatory it may have been considered helpful to reduce any swelling relating to the surgery. This may be appropriate, but it seems best to allow the current treatment and healing to run its course, and then determine if an anti-inflammatory is needed.

According to the manufacturer, Restasis will not achieve full effectiveness until after about 90 days of use. Restasis would not likely help with the immediate problem.
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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