Corneal Swelling 10 Weeks Out

[kildare25]

I had LASIK 7/13/07 and the procedure went well. I am 44 so we went with mini-monovision. From the start my right eye, which required greater correction did well. Made to be slightly nearsighted is allows me to read and is 20/30 at a distance.

The problem is my left eye, which started off reasonably well (I know enough from these postings to understand the gradual healing process after surgery) but after about two weeks it took a turn for the worse. My vision in that eye got extremely blurry.

I had been using 1% Econopred Plus drops four times daily and read that it might increase IOP so I asked if there were other options. We switched to Lotemax which is supposed to be "non-glaucomatic" and a week later things were slightly better, but the doc felt things should be improving more rapidly and put me back on the Econopred.

After a week of that - now one month out - things were very blurry again, so I met with the surgeon who felt I might be in the small percentage of "steroid responders" and suggested a return to Lotemax, Cosopt to reduce any IOP, and Muro 128 5% to draw water out of the cornea.

I did see considerable improvement, back to about 20/40 in that eye at the best of times with increased blurriness in the evenings. The drops were pretty harsh on my eye after a couple weeks so I was relieved when I was told to go back to just the Lotemax three times a day. Two weeks of that kept things pretty stable.

At my last morning visit -9 weeks post op - my vision was about 20/40 and the doc felt the swelling had gone down considerably though there was still quite a bit of "intercellular" swelling, I believe he said, so he put me down to two Lotemax drops a day and said to come back in a month. That was good news.

Unfortunately, after one week of just the two drops a day my vision is as bad as it has ever been in that eye. I have read here that the "wound response" causes the swelling and does go away, but I wish I knew more about it.

Does it always go away?

Will this be a problem for six months? A year? Longer?

Is there any approach other than steroid drops that can help the healing process or is it simply wait and see?

What percentage of patients have this prolonged swelling?

This site is a great resource and has been reassuring when I was really worried about this early on. I try to be patient, but things get better and then get so much worse. I would be in real trouble if my right eye was having the same problem.

If anyone else is going through this perhaps they can shed some light or at least take comfort in that they are not alone.

Thanks!

[LasikExpert]

Does it always go away?

The corneal swelling will resolve once the wound healing response is complete.

Will this be a problem for six months? A year? Longer?

A year seems way to long. Six months should be enough, but as the doctor mentioned you are responding to steroids differently than most. The steroid eye drops are used after Lasik to control the wound response and reduce edema (swelling). Unfortunately, some people react to the steroids.

Is there any approach other than steroid drops that can help the healing process or is it simply wait and see?

There are non-steroidal anti-inflammatory (NSAIDS) that can help. It is also possible that what will be needed is tapering off the steroids and allowing the eye to go through the process without the benefit of anti-inflammatory medication.

What percentage of patients have this prolonged swelling?

We measure outcomes at six months postop when we evaluate surgeons for certification and I cannot recall a patient with corneal edema at that time.

This site is a great resource and has been reassuring when I was really worried about this early on.

Thanks for the kind words. It sounds like we are doing our job.

I try to be patient, but things get better and then get so much worse.

You are undoubtedly going to be fine long-term, but we don't "see" long-term.

I would be in real trouble if my right eye was having the same problem.

You must be doing that Lasik Salute of covering one eye, and then the other.

[kildare25]

Thanks for the reply.

At my three month check up my left eye was in even worse shape. It had gone from blurry to cloudy. Because the flap had healed sufficiently they were able to test the pressure and found that it was 32 - twice the normal 16.

It turns out that I had a "steroid response" even to the purportedly non-glaucomatic Lotemax. So they put me back on the Cosopt to recuce the pressure and prescribed Flarex, apparently the mildest steroid out there which the doc felt would not pose a risk of causing an unwanted reaction.

The next day things were very good and for three days after. Then the blurriness started creeping in.

At my appointment yesterday my pressure was down to 9 - well under normal. So I am now down to one drop of Flarex a day to control the edema and the hope is with less swelling and a return to normal pressure the vision will improve.

We did discuss NSAID's and also just getting off all drops and letting nature take its course. I'm due back in two weeks to check pressure and swelling. I'll let you know the outcome in case anyone else finds themselves with the same trouble and can see how it resolves.

Thanks for the encouragement and the time frame. I am hopeful that there won't be any more setbacks and that gradual improvement will have me seeing well in both eyes by the New Year.

Thanks again.

P.S. I am constantly doing the "Lasik salute!" My two year old daughter always laughs and salutes me back and her limited vocabulary now includes the words "eye medicine" having seen me put drops in my eyes so often.

[LasikExpert]

It sounds like my understanding of your situation is consistent with your doctor's analysis.

When next you see your doctor ask if s/he would not mind also using touch tonometry (IOP measurement) in the center of your cornea and at the edge of the cornea outside the area of the Lasik flap. I suspect that this is already being done, but if not, it may be an interesting measurement.

Sometimes after extended edema enough fluid builds within the Lasik flap interface that tonometry readings can be off. With such dramatic intraocular pressure (IOP) changes, checking center and edge may give some insight into how much edema is still causing you trouble.

I'm also sure that your doctor is checking your optic disc to be sure there is no cupping. Fortunately we can handle elevated IOP for a surprisingly long time without suffering any long-term damage.

Please keep us informed.

[kildare25]

Glenn,

I saw the doctor today and things are pretty much the same visually; excellent in my right and very poor in my left.

My eyes have maintained normal pressure - 9 in my left eye and 13 in my right. I asked about taking readings from the center and edge of the cornea, but the doc said that they use a tonometer that takes into account the variations in the thickness of the cornea. He said older tonometers measured differently at various parts of the eye, but that the ones they now use give an accurate reading from the center alone.

I also asked about cupping on the optic disc. He didn't dilate my eyes, but observed that my "cupping" was .3 which he felt was normal. He explained that cupping was the ratio of the area to the disc in the center to the total area of the disc. A central area of .8 he said (with 80% of nerve area and 20% margin) would be a cause for concern, but at about 30% I am fine.

My cornea still has edema which appears like "ground glass" to the surgeon and optometrist and that is what distorts my vision. The fact that my vision gets worse over the course of the day supports the edema theory.

They have increased my use of Flarex from one time to four times a day in the hope of reducing the edema without causing any increase in pressure. They feel confident that this dosage is light enough to avoid a steroid response and I have an appointment in two weeks to check the pressure.

So it's still a matter of waiting, which is easier to do having been assured that their is no permanent damage to my eye, but it a slow and somewhat frustrating process.

I'll keep you posted and thank you for all your helpful information.

Martin

[LasikExpert]

Thank you for keeping us informed of your progress. You are obviously a "steroid responder" and that is complicating the wound recovery, but the Lasik wound will recover and hopefully will provide the same excellent vision in both eyes.

[kildare25]

Glenn,

Well, in less than a week my pressure was up above 30, my eye was sore, and my vision was cloudy. It was worse than ever before and I couldn't see my doctor until the next day so it was a local optometrist who first checked me out.

He said there were a number of things going on with my eye: the pressure, swelling, inflammation and dryness. He also thought he could see mild DLK, but with so many variables he couldn't be sure.

The next day I saw my surgeon and he was surprised that the mild Flarex four times a day had caused such a rise in pressure. He also saw what appeared to be signs of DLK. He gave me a strong steroid drop at the office and then put me back on the Cosopt to control the pressure while staying on the Flarex four times per day. I was also to continue the Restasis morning and night in both eyes.

He was away at a convention for a week, so in five days I went back to see his partner who felt that my eye was so dry that he was unable to diagnose much else. My pressure was back down to 9, but my vision was still blurry and hazy. He inserted plugs in my ducts to keep the moisture in my eye and suggested I see the doc in three days.

That was today and he concurred that my eye was exceptionally dry. The pressure was good at 13, but he felt there must be something "toxic" to my eye in the drops I was on to cause such extreme dryness. He also said that he couldn't see the DLK with such a dry surface, but doubted that was the problem.

As the battery of steroids has not changed much (other than my IOP) for four months he has decided to change course and treat the dryness. I am now to use Blephamide ointment twice daily (morning and night), which contains a steroid and antibiotic and will keep my eye lubricated. In addition I have Lacri-Lube, an over the counter ointment to use twice daily to maintain the lubrication.

I will still take one drop of Cosopt at night to guard against a pressure increase and the Restasis at night to (eventually) improve my tear production.

I will see the doc in a week to check the progress. I am hopeful, and very glad to be trying a new regimin since the previous course was not bringing about any improvement. With all the ointment in my eye my vision will remain a bit blurry, but perhaps next week it will be possible to see some progress.

I will let you know how it goes.

As always, thanks.

Martin

[rosecmd]

Sorry you are having so much trouble, I had lasik about the same time as you and also suffered from lingering corneal edema in my left eye and very dry eyes, especially my left one. I also had more bluriness and pain and soreness in my left eye, even at 4 months. See my replies to firemom on her recent posts about dry eye in her recent posts. My major breakthrough with dry eye and lingering corneal edema was to use Alrex drops (very mild steroid) and also warm compresses on my eyes and to stop using any drops with methylcellulose in them. I can't tell you how much better my eyes are now, three weeks after starting that regimen and I noted improvements with dryness just a day or so after starting the compresses and stopping using Refresh Plus and Celuvisc. Now I use plain Refresh and Endura (both preservative-free and in individual things) and also Refresh Sever Dry Eye drops - which are the same as the Endura but in a small bottle with some kind of disappearing preservatives. I have also been on Restasis for 3 months now...although the major dry eye breakthroughs were due mainly to the other things I tried. My general morning bluriness is gone.

[kildare25]

Thanks for the information. I picked up some Endura drops today and will give them a try and will avoid methylcellulose for a while.

The ointment seems to be helping the dryness, but of course it causes blurred vision for quite some time, so it's hard to know if it is really solving the problem.

I will ask my doctor about the Alrex drops next week. Flarex is supposed to be a very light, non-glaucomatogenic steroid, but my eyes don't tolerate them well. The Alrex might be an improvement.

We'll see.

[rosecmd]

Good luck, I also dislike the ointments. Besides being hard to put in and disperse over your eyes, they do creat that blurriness and it seems unsanitary to me to apply them each time directly from the tube.

[kildare25]

Yes, the ointments are messy and low-tech, but they seem to be helping.

Saw the doctor today and the dryness is clearing up. He has said that the dryness give the surface of my eye the texture of an orange peel and described it today as "mild" rather than "severe".

I am to continue with the Blephamide and Lacrilube ointments for the next two weeks and check with him again. I will take a drop of Cosopt each night to guard against a pressure increase. (My pressure was 16 today.)

Through it all I do see some improvement in my vision - I was seeing 20/40 at the doctor today - but most of the time I'm looking through the film of the ointments.

At this point even some improvement is encouraging, so I'm optimistic.

[kildare25]

I posted Wednesday that things were going well and by Saturday things had gone wrong again.

I woke up during the night with itching in my left eye and by the time I got up Saturday morning the upper eyelid of my left eye was extremely swollen. It being Saturday of Thanksgiving weekend I could only reach the optometrist on call who suggested warm compresses.

Sunday morning things were worse, so I called again and was told that the compresses should help and to apply pressure to the tender bump on the eyelid as that would help break up the oil blockage in the "chalazion." I did that, even though it really hurt.

Monday morning the swelling was even worse, extending into the ridge of my eyebrow. By the time I could see the doctor in the afternoon the swelling had subsided somewhat, and he said that I had a stye. He has given me antibiotics to take for the next ten days while I continue the warm compresses four times a day. He has not recommended that I stop the Blephamide or the Lacrilube ointments.

This morning, Tuesday, the swelling was no better - although it's always worst in the morning. I had read on the cautions about every form of steroid I have taken that there is a risk of secondary infection, and that the punctal plugs I was given increase the risk of infection because the eye doesn't drain the old tear film as effectively.

On top of that, as rosecmd wrote, the ointments seem unsanitary and gum up the eye considerably. In any event, I have ended up with a "super stye" that is not visible along the line of lashes (as I remember them from being a kid) and has caused my entire upper eyelid to swell so much that my eye is virtually shut.

My frustration is turning to depression as everything that can go wrong is going wrong. I trust the antibiotics will knock this out and then I'll settle for anything. As long as I can kind of see without swelling, dryness, pain, or infection in my left eye I settle for that.