Considerations for ICL/PRK/LASEK/LASIK with HIGH Myopia

[Lightcycles]

Hi,

I have high myopia (-9) and astigmatism (-4) and just below the average thickness of corneas (530 um).
My vision can't be corrected to 20/20 using eye glasses or lenses without me getting frequent headaches and I have lived with under-corrected vision for the most of my life now (I'm 36 years old now).
A few eye doctors had qualified me as a fine candidate for IOL, PRK, LASEK or LASIK procedures.

After researching and considering different options for vision corrections I concluded on the following:

1) ICL (STAAR intra-ocular lenses)

Pros:
- fully reversible (if I don't like it)
- immediate vision recovery (15 minute outpatient procedure)
- no post-up recovery/follow-up

Cons:
- doesn't correct astigmatism yet (so I might need to perform laser correction to remove my residual astigmatism)
- has a risk of induced cataract within 5 to 10 years (especially in high myopes) and retinal detachments

2) PRK using alcohol solution (also known as modified LASEK without the flap of dead epithelium cells being placed back after the surgery) with CustomVue VISX STAR S4

Pros:
- less epithelium inflammation, faster recovery than classic PRK
- less weakening of cornea as there is no Intralese Flap
- potentially better visual outcomes than in Lasik (due to treating outer harder layer of cornea instead of inner softer layer as in Lasik)

Cons:
- potential hazing in high myopes
- none FDA-approved Mitomycin-C slowing down the healing and causing potential long-term side effects such as cornea melting
- much longer recovery than in LASIK
- unpredictable duration of recovery - some (younger) people achieve perfect vision in 1-2 weeks, some (older) people might take years to achieve comfortable vision (for reading, driving, computer work)
- long and hectic post-recovery regimen that has high impact on the final outcome (perfect or non-perfect vision), necessity of wearing sun-glasses outside for months to prevent hazing
- chances of night visual effects (halos, starbursts, double and triple vision)
- not reversible, if everything is messed up - you need an enhancement that further weakens your corneas or have to leave with messed up vision for LIFE.

3) PRK using a mechanical powered brush (classical PRK) with CustomVue VISX STAR S4

Pros:
- less weakening of cornea as there is no Intralese Flap
- potentially better visual outcomes than in Lasik (due to treating outer harder layer of cornea instead of inner softer layer as in Lasik)

Cons:
- more epithelium inflammation, slower recovery than modified (LASEK) PRK
- potential hazing in high myopes
- none FDA-approved Mitomycin-C slowing down the healing and causing potential long-term side effects such as cornea melting
- much longer recovery than in LASIK
- unpredictable duration of recovery - some (younger) people achieve perfect vision in 1-2 weeks, some (older) people might take years to achieve comfortable vision (for reading, driving, computer work)
- long and hectic post-recovery regimen that has high impact on the final outcome (perfect or non-perfect vision), necessity of wearing sun-glasses outside for months to prevent hazing
- chances of night visual effects (halos, starbursts, double and triple vision)
- not reversible, if everything is messed up - you need an enhancement that further weakens your corneas or have to live with messed up vision for LIFE.

4) Intralese CustomVue Lasik using VISX STAR S4 Iris Registration (the best combination of software/hardware currently available)

Pros:
- fast recovery (1-2 days to clear and comfortable vision if there is no complications)
- no hectic post-recovery routine (a couple of weeks of eye-drops)

Cons:
- flap complications (even with Intralese Sub Stromal (Thin) Flaps)
- higher chance of under or over-correction or induced astigmatism in high-myopes and high-astigmats due to the flap "smoothing" the treatment (ablation + transition) zone which has valleys and hills with high astigmatism correction
- higher chances of night visual effects (halos, starbursts, double and triple vision) for the same reason as above and due to the flap "edges"
- not reversible, if everything is messed up - you need an enhancement that further weakens your corneas or have to live with messed up vision for LIFE.


SO WHAT SHOULD I CONSIDER AS THE SURGERY THAT HAS HIGHEST SUCCESS OUTCOME?
ANY RECOMMENDATIONS?
It's really hard for me to choose.
And I keep on asking myself - DOES THE PRIVILEGE OF GOING AROUND IN LIFE WITHOUT GLASSES (after living with glasses for almost half of my natural lifespan) JUSTIFIES SUBJECTING ONESELF TO THOSE RISKS?
Especially IRREVERSIBLE risks of all laser vision correction procedures?

Thanks,
~LC

[tack77]

Alex, thanks for posting all your research, as you have covered a few things I hadn't ran across yet. Could you tell if your-9 is in plus or minus cylinder form ( did it come from an eyeglass prescription or an opthamologist?)

I'm kind of in the same boat and considering LASIK, but thought that ICL would be better for me, but I certainly didn't know about the cataract risk.

I was told that customvue LASIK with visx s4 was actually supposed to lessen the chances of night vision problems as compared to other LASIK procedures.

I hope you get some answers on here, I would love to hear what others have to say.

[Lightcycles]

Astigmatism (cylinder) is -4, and myopia is -9.

The ICL might speed up onset of cataract especially if you are close to the age of presbyopia (45+).

You are right CustomVue Lasik is the best in the visual outcome - but it also ablates (removes) a bit more of cornea tissue per diopter of correction than regular Lasik.
The higher degree of the vision correction you need, the larger the pupil, the larger the ablation area - the more nerves gets removed as well and the more chances that any laser procedure will leave you with dry eyes for the rest of your life.
My conclusion now is that if someone with HIGH degree of myopia can achieve acceptable vision correction with glasses - they should not go for any type of laser surgery and they should not go for ICL as there are too many risks with any of those procedures for HIGH degree myopes.

Majority of positive outcomes after Lasik is from people with mild degree of myopia and astigmatism.
The higher your myopia and the higher astigmatism - the more risks are on your plate to consider.
Besides with higher degree of correction there is a higher chance that 20/20 WILL NEVER BE reached - and you'll end up still wearing glasses (but with thinner lenses).

And think about it - even with Lasik they add additional aberrations to your cornea by placing the suction cup to increase the eye pressure (so cornea becomes hard and it's possible to make a consistent flap cut).
That's the reasons some people have NEW aberrations in eyes after Lasik and it might take up to 1-2 years (or never) for those aberrations to get decreased or fully resolved.
And until it's resolved you'll have a vision that never feels natural (or close to one you had in glasses).

PRK (or LASEK or epi-LASIK - which all are pretty much the same in duration of healing and the outcome) is the best option outhere IF YOU ARE READY FOR big vision fluctuation (and uncomfortable vision up-close) for up to a year (or forever again if you get into some post-op complications).

Neither laser surgery in existence (today) IS ETHICAL and SENSIBLE in my opinion. Removing ANY amount of cornea thickness (something that G-d gave you and me for a reason) is WEAKENING cornea FOREVER and might create big complications 15-20-25 years from now. You might enjoy GREAT vision for 25 years but at the end pay for it dearly.

~LC

[tack77]

I went today for another consultation at another reputable clinic. This one was a little different, the first consultation i went to, they did a full eye exam, then dialated my eyes and did it again, Today they checked my prescription, took measurements of my eyes, corneas and pupils and I had a one on one with the dr.

Here is my concerns now. Im -7.5 with a -1.5 astigmatism, so im not quite at your level, but pretty darn close. Both surgeons that ive talked to seem confident that im fixable and have plenty of cornea for the procedure. I didnt get any exact numbers but i did notice that thinnest cornea measurement of either eye was like 540. I told both clinics about some ulcers i had in my right eye back in 2008. At my last regular eye exam at my optometrist back in September, he said "you have some scars from those ulcers." Today when i informed the Lasik suregon of this, he took a look with that super bright light and said "no, your good, no scars. So that has me just a little concerned.

At my first consultation, the surgeon told me that there was an 8% chance that with my level of correction, I would need an enhancement. The guy today told me "I can fix that, I mean maybe not all at once, maybe you would need an enhancment later on." I asked him how about regression, and he said typically most of the regression will occur within one year.

I'm still considering it, just hopeing to hear a few success stories from high myopes like us.

[Lightcycles]

Base on what I've researched about (and seeing many successful cases in my relatives and friends) If you don't have active life style (no jumping, no isometric exercises, no boxing, no active games when you could be hit in the eye) - Intralase Lasik will probably fix all your problems and fast (you'll be able to get back to work in 1 day). If you really want to prererve all potential strength of your cornea go for PRK (LASEK). With high prescription you have they will have to use Mitomycin-C to prevent hazing and you will have a bit of uncomfortable vision for 4 to 14 days (especially for near work).

Both results above are obviously if everything is going UNCOMPLICATED (which is 95+% of the patients anyway). The younger you are and the more experienced is the surgeon the less chances you'll get into any complications and heal rather fast.

The outcome of any laser surgery depends on a few factors:
- the amount of myopia removed (the higher the less predictable is 20/20) - so your doctor was right you have about 8% of risk (1% per diopter) that you get under or over-compensated in your correction and that will require an enhancement surgery
- how experienced is the surgeon and how good is the equipment he uses (best one to date is VISX STAR S4 Iris Registration)
- how good you are in being calm and being able to stay focused on the red light during the surgery (about 70 seconds of laser treatment in your case)
- how anal you are in following the post-op instructions (drops)

- and last and not the least - how much closer to 20/20 they could correct you with lenses (or in your glasses). If you see 20/20 in your glasses (or they could correct you to 20/20 on their equipment) - there is a better chance you'll see 20/20 after the surgery if all above factors are met. This last factor can't be neglected as it reflects what your macula and brain is capable of interpreting when optics focus the image right on spot.

Look for the doctor who's confident to guarantee 20/20 if all above factors are in green.

Best,
~LC

[ScottW]

Just my experience with ICLs - I have had post-op follow-up, as the surgeons review my eye for pressure issues, contact location, vaulting, etc. So, you stil have to see the doctor several times after ICL surgery.

My vision was pretty clear after the surgery, but I had bluriness around the edges (kind of like real thick halos). Those went away after 10 days or so.

I also had to get iridotomies done, where they poke small holes in the iris with a laser. Some people have complications with this, but I have not. Some surgeons do this manually, but I'd recommend finding someone who uses a laser as it sounds like that leads to fewer issues.

ICL is reportedly reversible as they can remove the contact, but there is still some risk in that (as with any surgery). But, it's not permanent like other eye corrections.

Toric ICLs can fix astigmatism. I think Verisys (or something like that) makes these. They are different from the Visian ICLs that I got. Visian is waiting for FDA approval for their toric ICL. Also, the doctor can do a procedure during surgery to fix smaller levels of astigmatism. My doctor said he used a diamond hone (surprised me at the time), but I've heard of others doing cuts along the periphery to fix the issue. I can't recall what it's called, but it's something like IRL or ILR. Also, I've heard that LASIK can help with astigmatism, but I'm not sure if you can do that after getting ICLs (though my surgeon did mention that they could do LASIK after ICL surgery to fine tune my vision).

In my opinion (not scientific, just experience), pupil size is a larger issue for ICL surgery, and I wish I knew this before my surgery occurred. If you have large pupils, light may hit the edge of the contact and cause the starbursts and halos. I think that's what happens to me, as the starbursts and halos go away if I look at a bright light. I can actually watch the halo melt into the lightsource.