Was I doomed from the start?

[Vincent]

Hello Everyone,

I had LASIK ~5 months ago and have come to the conclusion that I was not accurately informed of the risks that my eyes presented to a LASIK surgeon. I chose to get LASIK because my future career requires it. I am attempting to join the Air Force and I needed better visual acuity in order to join the specific part of the Air Force that I am interested in.

My preoperative information: OD: -7.50,-.50 OS: -8.00,-.50
Corneal thickness was around 535 in each eye
Scotopic pupil size was 8.0x8.2 OD and 8.1x8.3 OS

I had Intralase VISX Customvue with a STAR S4 Laser. My optical zone was 6.0x6.2mm with a blend out to 8.00mm. My LASIK flap was 9.00mm and 100um thick. I currently have ~310um of cornea left under the flap. My current prescription (which has still been fluctuating) is around -.50,-50 OD and -50,-.25 OS. I am seeing 20/20 -2 in both eyes, however it is a struggle for me to read those letters. I can realistically read the 20/30 line in both eyes without struggling and guessing a lot. I have dry eye, but it is not as severe as other stories that I have read. I currently only have dry eye in the morning upon waking. I am currently being treated with Restasis and I have seen encouraging results.

As one could guess from looking at measurements, I have large halos and starbursts at night. These symptoms have not fluctuated whatsoever in the past 5 months. They have been with me since day 1 after surgery. I see them mostly at night. They dissipate when I turn the car interior light on, turn my house lights on -- basically anything that decreases the size of my pupil. I also see minor starbursts during the day emanating from car headlights when turned on and from certain bulbs indoors. I am much less concerned with the daytime starbursting as I don't have a huge problem with them. I have tried Alphagan and my starbursts and halos dissipated considerably. They did not completely disappear, especially those coming from lights in the distance, but I saw a significant reduction. I know Alphagan is a good solution for my problem, however there are a few reasons why I am reluctant to use it.

First of all, I cannot be reliant upon an eye drop to join the military. Having to use Alphagan daily would basically render my surgery pointless because I would be moving from dependence on glasses/contacts to dependence upon Alphagan. Furthermore, many of the studies on Pubmed show that Alphagan does have a rebound effect (which I experienced) and that the myotic effect of Alphagan decreases as one uses the drug more consistently.

I am most upset because it seems like I was destined to have problems. I have read the article on pupil size and LASIK. I realize that you cannot predict who exactly will have night problems, but it is fair to say that I was a high risk patient. When I spoke to my surgeon about this I was told that I should not worry about this problem, that technology has advanced with a blend zone to counter problems and that my vision would be much better than the vision I could achieve with glasses or contacts. I went into surgery thinking that I might not achieve 20/20 vision and I accepted that. I was ready to use glasses/contacts again, but at no point did I think I would end up with serious GASH that could not be corrected with glasses/soft contacts.

I am hoping someone can answer the following questions for me:

Was there any way I could have had a larger optical zone with a different laser? I have read that Allegreto goes out to 8.00 (optical zone). i realize that LASIK would not be suitable, but could I have had PRK with an Allegreto laser coupled with the use of mitomycin c to reduce the chance of haze?

Was I doomed from the start? I realize RS is not perfect and I thought I understood the major risks. That said, it seems like I was a very high risk candidate. It seems like LASIK/PRK is a great surgery for the right patient. Should I have been turned away or at least counseled and told that I am a high risk candidate because of my large pupils and large correction?

Would a Visian ICL been more appropriate? I realize this is a more invasive surgery, but does it counter the problems that LASIK/PRK presents to people with large pupils and large correction needs?

What are my options now? Hard contact lenses are also not allowed in the military so I am exploring more surgery options. Is it actually possible for me to get PRK on the LASIK flap with a laser that has a larger optical zone to correct my remaining HOAs? I realize doctors cannot correct HOAs in isolation, so assuming I regress even further to -1.00 or greater is this a possibility?

Thank you for taking the time to read my post. I appreciate any advice.

[Vincent]

LASIKExpert do you have any comments? Thanks.

[LasikExpert]

Was there any way I could have had a larger optical zone with a different laser? I have read that Allegreto goes out to 8.00 (optical zone). i realize that LASIK would not be suitable, but could I have had PRK with an Allegreto laser coupled with the use of mitomycin c to reduce the chance of haze?

Lasik enhancement would likely be appropriate. You may also be able to have PRK on the Lasik flap. Undoubtedly Mitomycin C (MMC) would be used to reduce the probability of corneal haze with PRK on the flap.

Was I doomed from the start?

Most certainly you were at a higher risk of problems than someone with a lower prescription to be corrected. The large pupils is something to be considered (read Lasik and large pupils), but I'm actually more inclined to think the problem relates to how flat your corena is after surgery. The problem of halos in daytime indicates that your cornea may be very flat and that is contributing to your problem. A larger pupil just means more light through a flat cornea is reaching the retina and is "seen".

Should I have been turned away or at least counseled and told that I am a high risk candidate because of my large pupils and large correction?

You absolutely should have been advised that you had a higher than normal risk of vision difficulties, but at the same time there have been many patients with large pupils and large corrections that do not have halo problems.

Would a Visian ICL been more appropriate? I realize this is a more invasive surgery, but does it counter the problems that LASIK/PRK presents to people with large pupils and large correction needs?

As a general rule a phakic intraocular lens (PIOL) is a good alternative to Lasik for someone with high refractive error, but much would depend upon the unique properties of your eyes. I suspect edge glare from the PIOL would have been a real risk with such large pupils.

What are my options now?

The first is to determine if the residual refractive error can be fully corrected and if this reduces or eliminates the problems. Even a 0.50 D refractive error can cause blur that may present as halos around light sources at night. Soft contacts, glasses, or rigid gas permeable (RGP) lenses should be tried, and in that order. If you can get relief, then enhancement surgery may resolve the problem.

You can have Lasik on the flap that is as large as the flap itself, but regular enhancement surgery is not necessarily going to be that helpful if the problem cannot be corrected with lenses first.

If your corneas are especially flat, an RGP may help or even laser surgery to add curvature to the cornea. Whatever you do, get a second opinion from a competent doctor first.

[Vincent]

If your corneas are especially flat, an RGP may help or even laser surgery to add curvature to the cornea. Whatever you do, get a second opinion from a competent doctor first.

Thanks for the response. I have tried to read up on flat corneas, but I have not been able to find the definition of a flat cornea. On my orbscan my Sim K in OD is: Max 36.8D @62 deg and Min 36.3D @ 152. OS is 36.8D @ 74 deg and Min 36.2D @ 164 deg. Is this considered especially flat? Corneal flatness makes sense to me because I have daybursting in bright sunglight when my pupils are very small. I also used Alphagan tonight and it shrank my pupils dramtically. Even under dark conditions they looked as small as they usually do during bright sunlight. I would say my starbursts went away to only 15% of their usual size, but the halos did not change at all. Shrinking my pupils obviously is not going to fix anything if the the problem lies in my flat corneas. What are your thoughts Glenn? Would a competent doctor be concerned with my post op Sim K values? I am going to see a corneal specialist as soon as I have the chance to get another opinion.

Thanks again.

[LasikExpert]

For years the industry commonly abided by the "Rule of 36". The concept was that refractive surgery that reduced the curvature of the cornea, or K reading, below 36 diopters would make the cornea too flat and could result in vision quality problems. As you can see, your surgeon did not exceed the rule of 36, but apparently your corneas are flat enough that your vision is affected. Several doctors I know have revised thier protocol to the Rule of 39, to create a greater margin for error. While 36 has provided acceptable results for most, obviously not for all.