Surgery Dilemma

[NYCitidude]

Hey Glenn,

This site was so helpful in my quest to free my dependence from glasses/contacts. I'm facing a huge dilemma of what I should do. Please help! Here is a bit of background on me and my eyes.

I'm a 26 year old male with high myopia and slight astigmatism.

My scripts are L -8.5D -0.5, R -8.5D -0.5. My best corrected vision acuity is 20/15 using both eyes and 20/20 with each 1 eye.

Cornea thickness: L 558, R 556.

Pupil size in a dimly lit environment ranges from 7-8 mm.

The steepness of my cornea or K values are L 41.4D, R 42.8D.

The first time I went for a lasik consultation was 4 years ago and was told b/c of my high script and relatively thin cornea, I should not consider lasik at that time and should either wait for better technology or explore an alternative. So I gave up the idea for 4 years and decided to revisit again late last year. I went to 2 more consultations and this time was told that I'm a great candidate. I got very excited and contributed money to my flexible spending account to do the surgery next year. But I remained a bit skeptical given the surgeons economic incentive. Whenever I asked the surgeons does risk increase with my high prescription, they only say they don’t see it as a problem as they have done patients with much higher prescriptions. So I started doing my own research and found this website, which has been so useful in educating me on the subject in a very objective way (pretty hard to come by in this field). I then went to a recommended doctor (who use to do surgery but not anymore so his economic incentive is less of an issue) for an independent screening and advice. I passed his initial screening but he noted two issues.

1) My upper lashes are pointed down and in towards my eyes (which are common in some Asian eyes), so at times they scrape my cornea, which has caused some dryness and little marks on the surface. I was told this is not a big issue and can be corrected with an incision on my eye lids to change the directions of where my lashes are pointing. Have anyone else had this problem and done anything about it?

2) The bigger problem that can't be resolved is that the curvature of my cornea is relatively flat. The K value is 41D-42D. And post surgery, Lasik or PRK, my cornea will be flattened further by 7-8D, down to 33 or 34 D, which the doctor said is getting the borderline of cornea’s stability. The surgeon can use conventional laser, not wavefront guided, to remove less tissue, but that can leave higher High Order Aberrations, which doesn’t help my vision acuity either.

The doctor then referred me to another surgeon for a final screening. This surgeon is affiliated with a prestigious university and said he turns away 60% of his patients, which I am comforted given his conservatism. He confirmed that I'm a candidate with elevated risk to not achieve my BCVA, given my high script, large pupil, and flat cornea. He would recommend lasik with intralase as long as I understand I'm a higher risk candidate. He said people in my situation probably will not achieve their BCVA and will seeing 20/25. I asked him about night vision issues, and he said that is a bigger unknown as research remains inconclusive (Steve Shallhorn did research on pupil size and night vision problems and showed pupil size is not the main cause). He also recommended phakic IOL but suggested for me to wait until the FDA approves the 3rd type that is under trials. what is this 3rd type? He thinks this new IOL will replace high myopic laser surgery.

I have read the article on this site regarding phakic IOL and like the fact that it is reversible but understand that it is an more invasive procedure (with higher % of surgical complication?).

Is phakic IOL a better alternative for me than Lasik/PRK? What is the typical cost for this procedure, I can imagine it being much more than Lasik/PRK. Is this surgery for limiting on one’s lifestyle than say PRK? Will a trauma to the eye have a worse impact when there is an implanted IOL than PRK? Where can I find more info on this procedure?

Also I know permanent night vision problems associated with lasik/PRK have limited treatment, if any given the irreversible nature of the surgery. I know I have higher risk to this problem, but how high of a risk is this for me? I don’t think I can tolerate an outcome where my vision is worse than what I have now to the point where I can’t live normally and causes a real disability (that can’t be treated with anything else).

Thanks so much for your help!

[LasikExpert]

The prediction that you may not be able to see better than 20/25 or even 20/40 may not be because the refractive error can not corrected. It may be because the quality of your vision after a laser-based correction surgery would be so low that the best you could see would be 20/25-40. If this occurs, you would not be able to correct the vision problems with contacts or glasses.

The physics of laser vision correction are the same to matter what type of laser, technique, or flap creation. After surgery the center of your cornea will be relatively flat. Due to your large pupil size, a significant portion of the cornea will be under-corrected or uncorrected when you are in low light environment. This can cause halos, starbursts, and other vision quality problems.

A phakic IOL does seem to be a more appropriate option. It is more invasive and has its own set of limitations, however it will not flatten your cornea and can be removed (removed, not reversed, as some changes are permament).

Knowing that you are at a high risk of complications is not the same as living the rest of your life with vision limitations. Keep searching for alternatives.

[beingbobbyorr]

He also recommended phakic IOL but suggested for me to wait until the FDA approves the 3rd type that is under trials. what is this 3rd type? He thinks this new IOL will replace high myopic laser surgery.

I hope he's not talking about the Toric ICL that is available outside the USA, and still awaiting FDA approval. Most ICL surgeons I've spoken with don't seem too thrilled about it (too worried about post-surgical rotation).

I have read the article on this site regarding phakic IOL and like the fact that it is reversible but understand that it is an more invasive procedure (with higher % of surgical complication?).

The ICL can be taken out, but the reversal of the Peripheral Iridotomy is highly surgeon-dependent (something they want to avoid, as 'stitching it back up' is more complicated than a lot of other ocular surgeries, including the PIOL surgery itself).

What is the typical cost for this procedure?

In greater Los Angeles, I've seen ICL surgery (I'm not interested in the Verisyse lens) go for $6,500 to $10,000 for a pair of eyes. The lower figures generally do not include any post-ICL Lasik/PRK to do touch-up fine-tuning. The higher figures do include that if exercised within the 12-18 month 'warranty period'.

Is this surgery for limiting on one’s lifestyle than say PRK? Will a trauma to the eye have a worse impact when there is an implanted IOL than PRK? Where can I find more info on this procedure?

As a hockey player (albeit adult beer-league) I'm interested in this, too. See question #16 at:

http://iclquestions.angelfire.com/

The ICL surgeons wave their hands at this and say "No problem", but frankly I'm doubtful whether this has been validated by analysis or testing. The NHL team ophthamologists I've contacted express either (a) a lack of experience with (opinion about) PIOL technology, or (b) reservations about foreign objects inside the eye, especially so close to the still-resident natural lens. I was surprised to learn that a Florida Panthers defenseman, Brandon Mezei, has had RLE surgery (but he doesn't have to worry about the natural lens anymore).

Also I know permanent night vision problems associated with lasik/PRK have limited treatment, if any given the irreversible nature of the surgery. I know I have higher risk to this problem, but how high of a risk is this for me? I don’t think I can tolerate an outcome where my vision is worse than what I have now to the point where I can’t live normally and causes a real disability (that can’t be treated with anything else).

PILIs (Peripheral Iridotomy Leak Images) and Halos seem to be the dirty little secret of ICLs. I had to scour the Internet to find out about these, the doctors having said nothing to me about it.

I'll be updating http://iclquestions.angelfire.com/ soon to add more questions to grill the doctors on these subjects.

[LasikExpert]

PILIs (Peripheral Iridotomy Leak Images) and Halos seem to be the dirty little secret of ICLs. I had to scour the Internet to find out about these, the doctors having said nothing to me about it.

A very important point.

[NYCitidude]

Thanks Glenn for your feedback. I care about the quality of vision and would not want to sacrifice quality, knowing that I have higher risk of complications/significantly lower quality of vision given the charateristics of my eyes. I am willing to wait longer to such for better/lower risk alternatives for me even if it means wearing glasses/contacts for the time being. I have decided against lasik/prk even though I have already contributed money to my healthcare spending account for this year. If I fix the problem with my lashes and can start wearing contacts full time, I'd be ok with that.

Beingbobby, thanks for your response. I started to look more into PIOL and am coming out to the conclusion that it is a more complicated procedure (than lasik/prk), is more costly, and also has its own set of drawbacks and risks as it is a surgery nontheless (an even more complicated one). It is also a relatively new procedure so the long term effects remains unknown.

I am now revisiting the idea of Ortho-K. I know that is more ideal for people with low to moderate myopia (<6D). I have -8.25D, which I believe is still possible but would need to use off-lable contacts. I am going in for a consultation tomorrow. What are your views on using Ortho-K for my situation? It is non-surgical and given its reversibility, it is safer than any surgical alternatives (lasik/PIOL). Now, the question is really whether it can fully correct my degree of myopia. Night vision problems probably remain if the correct optical zone is smaller than my fully naturally dilated pupils, correct?

[LasikExpert]

Night vision problems probably remain if the correct[ed] optical zone is smaller than my fully naturally dilated pupils, correct?

With your relatively high myopia it seems likely that your night vision would be the same or worse after any corneal vision correction that does not fully correct the entire optical zone.

[DryEye]

"With your relatively high myopia it seems likely that your night vision would be the same or worse after any corneal vision correction that does not fully correct the entire optical zone."

Isn't that true with everyone in regards to how the machines treat the center of the cornea the most and then blend out the rest of the cornea?

Doesn't it make the most sense to expand everyone's treatment zone (assuming enough cornea is available) so that it best mimics wearing a contact lens?

It should reduce the amount of enhancements performed.

[LasikExpert]

Our article on Lasik and pupil size goes into great detail about this issue.

The size of the fully corrected optical ablation zone is limited by current technology. Some lasers are able to create a blend zone up to about 11.0mm, but the optical ablation zone is limited to about 6.0mm, smaller for astigmatic correction.

The manufacturers undoubtedly have the ability to upgrade their lasers so they have a larger optical zone, but the vast majority of patients have a naturally dilated pupil size of about 6.0mm, so there is an imbalance of the cost of research and developmnet against the number of people who would beneifit.

At this point, people with unusually large pupils and higher refractive error or flatter corneas may want to reconsider laser assisted corneal refractive surgery.

[beingbobbyorr]

I started to look more into PIOL and am coming out to the conclusion that it is a more complicated procedure (than lasik/prk)

Actually, I think it's a remarkably simple procedure (at least the ICL; the Verisyse not so much). Physicians will (rightly) assert that it's a more invasive procedure (than Lasik/PRK) -- which is true when you crack the eyeball & expose the interior chambers to the air -- but I know I feel more comfortable with a 3mm incision in the base of my cornea (to add to my eye) than I would with a flap popping open 80% of my cornea (to burn stroma tissue I'll never get back) . . . . but that's just a personal opinion about degrees of queasiness.

is more costly,

The first thing I do at every refractive surgery consultation is tell them I only want the cost info on paper (I don't want to hear anything verbally). Then, afterwards, I throw away that sheet of paper. I don't want to compare docs or procedures based on cost. Not that I want to overspend, but (a) I figure competition alone will keep prices more or less within spitting distance of one another, and (b) my eyes are the one area of my life that I will pony up to go "Rolls Royce" on.

It is also a relatively new procedure so the long term effects remains unknown.

It's been done in Europe (& Canada?) since the mid-90's. Grill the PIOL surgeon about whether his opinion(s) on the various risks/rewards reflect a knowledge of those longer-term databases. Could the FDA restrict American doctors from making comments based on anything other than the ~2003 FDA trial study?

I am now revisiting the idea of Ortho-K.

I have eyes that appear to be in your ballpark (-7.5, -9.0, almost no astigmatism, 590-600 micron cornea thickness), and I've seen 15 refractive surgeons (many of the best of LA & Beverly Hills), but not one of them even mentioned this Ortho-K. What are we missing here, Glenn? Did NYCitidude find some uber-doctor who uncovered a state-of-the-art technique that's flown under the radar, or did he wander into the refractive surgery ghetto?