Considering second surgery for nighttime halos, etc

[sean_r]

Hi all,

Had LASEK about 11 months ago. Experienced halos/starbursts and mild double vision in right eye once eyes healed and my eyesight normalized. (Otherwise, no issues - daytime vision is around 20/20 and eyes are not dry in a material way.)

Doctor had me try Alphagan P, but that did not seem to help at all.

Current recommendation is to have my right eye re-treated. The doctor cut me a "preVUE" lens to look through, which is supposed to mimic what my (re-)corrected vision will be post op. If I get the alignment right, the preVUE lens does eliminate my right eye's double vision and it essentially eliminated the starburst I was seeing in the exam room (the test was to look at a disc of light in a dark room). Somewhat discouragingly, the lens does not reduce the halo I see surrounding a streetlight when I tried it out at home.

Anyway, according to my doctor, the reason I have nighttime issues is surgically induced astigmatism. Apparently the tests they administered prior to the procedure showed I had an astigmatism, when in fact I did not. Thus the laser was out of alignment when it went to work.

I'm wondering if there are two simultaneous issues here: double vision/starbursts from the induced astigmatism AND halos from large pupil/ablation zone mismatch.

I'm scheduled for my re-treatment later this month, but I'm not sure I should go through with it, as it's not obvious to me all my issues will be addressed. If in fact the halos are being caused by pupil size/ablation zone mismatch, it seems like I should be trying a different laser, one that is sized appropriately for me.

On that note, should I be seeking a second opinion? If so, I am located in Northern California and would appreciate any referrals - I can't find many surgeons in the area that do LASEK (my procedure was performed in NY).

Any and all input welcome and appreciated!

Sean

[LasikExpert]

It does not appear that your starbursts are due to a pupil size / ablation zone mismatch. Alphagan P would have resolved the problem if this was the issue.

It appears the real problem is that the first surgery attempted to correct astigmatism that did not exist. Astigmatism is when the cornea is not spherical like the top of a ball, but is elliptical like the back of a spoon. The tip of the spoon is the astigmatism. During surgery the laser sculpts the cornea to remove the tip and make the cornea more spherical. Since you didn't actually have a tip to remove, the laser scuplted a hole. That is going to cause serious vision problems.

The preVUE lenses will approximate your vision after surgery. I suspect that a normalization of your aberrated cornea will provide improvement, but it is very difficult to predict.

You are very fortunate that you had the surface ablation technique LASEK, not the conventional Lasik. You don't need to deal with a Lasik flap and the fine tuning that will be necessary to re-sculpt your cornea will be less complicated. That was a wise decision.

[sean_r]

Thank you!

I see your point regarding pupil size / ablation zone mismatch and the Alphagan. After some introspection, it occurred to me that my thinking followed these lines: the mismatch is so great that Alphagan was ineffective. I understand there's a second medication available that is more powerful, which I have yet to try.

By way of update, I spoke with someone in the doctor's office today and they clarified that the astigmatism was only induced in my right eye. However, my left eye also experiences nighttime halos. So confusing!

The doctor's recommendation is to cut a new preVUE lens before the procedure, just to be thorough, and to proceed with re-correcting my right eye. They apparently believe that fixing my right eye will lead to the elimination of these nighttime issues for both eyes.

I'm going to move forward with the procedure, though I'm still rather skeptical my issues will ultimately be addressed.

Any thoughts/reactions to the above?

Thank you for the compliment regarding using LASEK instead of LASIK. I think I underestimated the risks associated with nighttime issues, but I at least got the procedure selection correct.

Sean

[LasikExpert]

I understand there's a second medication available that is more powerful, which I have yet to try.

You are probably refering to Pilocarpine.

I'm going to move forward with the procedure, though I'm still rather skeptical my issues will ultimately be addressed.

The difference between an optimist and a skeptic is that the skeptic is better informed! Be sure to update us on your progress.

[sean_r]

Will do, thanks again!

[jazzy_jeff_1986]

Hi,

I hope your re-treatment will elimnate the issues You have. I have quite similar problem like You. The difference is I had re-treatment (EPI LASIK) to ged rid of night vision problems 10 moths ago. They have enlarged my zone, but on the other it looks like the treatment induced astigmatism, which I never had before. According to refractometer it is around -0.75 D, so not that serious, but I can feel it easily every day and it's frustrating. I am wondering what to do. My daily distance vision is very good, but reading from computer screen or books is not that good (letters are fuzzy etc.). I'm not sure if third surgery is not too risky. Keep us informed!

[sean_r]

So, here's my update.

Came in to the doctor's office today (one day prior to scheduled enhancement procedure). To recap, my PreVue lens did not really address my nighttime issues when I tried it at home. (It did fine in a bright disc test in the exam room.) My doctor's new opinion (as of this morning) is that the lens was a poor fit and that we should not laser my eye using the scan that made the lens.

He also revised the probability of improved symptoms from 92% to 50%, the probability of no improvement from the procedure from 5% to 30%, and the probability of worsened symptoms from 3% to 20%. This little maneuver was not appreciated, particularly since I just flew across the country to have this enhancement done. Frustrating.

Of note, these revised probabilities take as a given a perfectly tuned PreVue lens. (If after trying we cannot cut a lens that works, at some point we will give up.)

Because my issue appears to be "subjective" and not "objective" (meaning that altering the quantifiable variables won't fix me), the doctor had me flip through the images taken by the (I believe) Wavefront scanner. The idea was find an image that matched the halos/nighttime artifacts I see. I did my best (the task was not easy) and a new PreVue lens was cut for me this afternoon.

Sadly, this lens does not appear to do the trick as I tried it outside this evening and still see halos/starbursts. So the plan is to go back in tomorrow so they can cut yet another lens (even better would be a bunch of lenses that I can compare). Another one of the doctors in the office said he'd never seen someone go through more than three lenses, but at this rate, I can definitely see myself going through a dozen.

Because I do have some residual refractive error/induced astigmatism in my right eye, I am inclined to move forward with the second surgery on my right eye assuming I can find a good PreVue lens. I don't want to be too much of a skeptic, but I do wonder if my doctor is low-balling the odds of improved symptoms (which he puts at 50%) to discourage me from moving forward for his own sake (he's not getting paid for this procedure). I should ask him what happens if there's no improvement or if my symptoms worsen. Would we try a third procedure?

The doctor admitted he himself is not sure what exactly is causing my nighttime issues, which isn't very encouraging. But finding a good PreVue lens would really ease my mind and make me comfortable with taking the risk of a second surgery.

What do you all think? What would you do in my situation, as I've described it?

Sean

[Vincent]

Hi Sean,

I'm not a doctor, just another patient with similar problems so take my advice with a grain of salt. I have similar problems to you. I have starbursts from pupil size/ablation zone mismatch and halos from overly flattened corneas (36K). The last part of your post seems to be very ominous - your doctor doesn't even know what is causing the problems. If he isn't positive what's causing the problem then how is he supposed to fix it? It seems like he's just making a somewhat educated guess. He's not going to have to live with your eyes if your vision gets worse. I haven't read a single success story of someone going in for a 2nd surgery with major halos and starbursts and coming out happy. I hate to be negative because I would love for there to be an answer to our problems, but it doesn't seem like there is at this time. You can look through these boards and other refractive surgery forums and I'm sure you'll see that success stories to fix higher order aberrations seem to be few and far between (if any really exist).

It seems like some people have some success with topography guided ablation, but that is not available in the United States and is only performed by a few surgeons in the world. It might be worth it to do a bit more research into this or consider waiting until more advanced technology comes to the United States. Have you tried RGP contacts? Clearly the point of the surgery was to get rid of contacts, but you might be able to rectify your problems with lenses rather than further surgery. There is also no risk of more permanent damage. Good luck with whatever you do.

[sean_r]

Thank you for your feedback, Vincent. Really appreciate it.

I read through the first link that Google served me when I searched for topography-guided ablation: http://www.revophth.com/content/c/35282/

Seems very interesting. Towards the end of the article, the variability of wavefront scans is discussed. This, I think, is the heart of the issue. Frankly, the whole 'guess and check' process to find the right PreVue lens just seems silly. This is supposed to be a precise, technical and instrument-driven procedure. Based on my limited understanding, it seems topography-guided ablation could be a step in the right direction.

To answer your question, I have not tried any contact lenses yet. I have also not really investigated using these. I would be open to using a pair of eyeglasses at night, but my guess is that this is not an option given HOAs are the cause of my nighttime issues? Either way, I like your approach of finding a stop-gap solution until such time as I identify a new surgeon (with a new technology; topography?) who can better diagnose my situation and provide a lower-risk treatment.

Assuming I decide to not get an enhancement from my current doctor, what next steps should I be taking? Are there specialists who focus on addressing HOAs and other complications from refractive surgeries? I'm definitely open to flying to Europe or heading to Canada if that's what is necessary.

I'm heading back to the doctor to try a new lens (hopefully more than one) today. I'll continue to keep you all updated. Thanks again for reading and contributing your thoughts.

Sean

[sean_r]

Hello everyone.

Just to close the loop, I ended up not having an enhancement procedure from my original doctor. We were unable to find a PreVue lens that did anything to reduce my nighttime issues. I also just didn't have a good "gut" feel.

As mentioned in prior posts, I'm keen to try a different technology, specifically a topography-guided procedure. I'm going to travel to Vancouver to see a doctor up there who has experience treating patients with my profile of problems (he claims 500+ such cases). He is confident he will be able to help me. If I decide to have the procedure, it will be on my right eye at first.

Anyway, I just wanted to provide an update.

Sean

[cemong]

Just an update . Some of my friends who are in the same boat as you had recently had their eyes treated by topography guided - trans PRK ablation in singapore and their results are very ,very good they said. Also, they have this machine called topography oculus 5m to scan corneal irregularity that cause halos, glare, etc. you might want to check it out. Its pretty common in singapore to treat post lasik halos and glare.