Blurred & Double Vision

[PatientAnonymous]

I had surgery 12 days ago. The doc did not tell me exactly which procedure he will use, all I know is that it was not any procedure involving creation of a flap. He said it is something close to PRK but not exactly PRK. Since surgery the doctor checked my eyes twice, and he did not said anything went wrong, but I see double with my right eye and my vision is blurred in both eyes. I’m scared that my vision is not going to improve in the next period because I see no change in the last few days.

Symptoms:

Left Eye: I can see clearly at about 15cm, but beyond that vision is blurred. Right after surgery it was worse than my right eye, but now it’s better.

Right Eye: I can see clearly at about 12cm, beyond that if I look at text on an [LCD monitor]/[page of a book] as the distance grows I start to see double (vertically). At a distance of arm’s length lines are exactly doubled, meaning I can see the actual text and a dim ~33% opaque text just below the actual text. Right after surgery for a few days I did not notice any double vision; it started seeing double after 3-4 days.

I made a test; I took two A4 pages, and put them together at the edge close enough to see between the pages. If I look through the gap between the pages, turn that pages along z-axis 360 degrees, line doubling disappears when the small gap is almost horizontal. In my opinion this might be astigmatism and it won’t go away by itself.

Assuming that epithelial cells did not grow back yet and surface of the eye is not smooth, is there a chance that my eye is still healing and the refractive error I’m experiencing is gone go away?

Thanks in advance!

[LasikExpert]

Your test with the two sheets of paper was brilliant!

All of your symptoms are consistent with postoperative inflammation and healing, especially if you had PRK, LASEK, or Epi-Lasik. Your mention of the epithalial cell healing indicates strongly that these are the types of surgery you had, often called surface ablation.

Report all of your symptoms to your surgeon, follow the treatment routine, and expect continued positive changes for the next 2-4 weeks. If at any time you have a sudden deterioration in your vision, contact your doctor.

[PatientAnonymous]

Exactly 3 weeks after assumed PRK. I see little to no improvement when it comes to double vision in my right eye. I’m getting very worried, the doctor examined my eyes said I won’t need any enhancements. When I said that I see double with my right eye he replied that it will go away. I’m concerned because I’m not experiencing big fluctuations in my vision, I am starting to see better at a distance but double vision in my right eye is all the same. I need more than words, something like actual facts, that PRK can induce temporary relatively long lasting double vision. Oh I’m depressed!

[LasikExpert]

To help you understand what is happening with your healing process, you may ask your doctor to create a surface scan of your cornea, commonly called an Orbscan. The doctor may have already done this, but did not show you the results. On the Orbscan you will be able to see the corneal imperfections that contribute to the doubled vision in one eye. A series of Orbscans can show you how the imperfections are resolving, even if you don't immediately experience vision improvement. You may want to read this technical article about the Orbscan.

I suspect the doctor sees the issue as wholely one of epithelial growth needing more time to complete and that is why the doctor is not concerned. Perhaps you being able to see the changes from visit to visit may help with your anxiety about your result.

[ArlingtonNewEyes]

A couple of questions. Regarding the OP situation (and mine -double vision post-PRK):

1. Is there definitive reason to believe the eye heals properly; or, is it rather the brain that "fixes" the double image? I tend to assume the latter, which really isn't a happy-maker.

2. Since it's somewhat annoying and distracting from work, is there anything that can be done in the mean time that mitigate the poor vision caused by double image? E.g., temporary lens, patch, "pinhole glasses"/partial-blinders? Does it retard the goal?

3. Is there anything one can do to aid the healing process? Seems inflammation isn't really the culprit here. Vitamin E? Using versus not using the eye (ignoring image vs not; focusing lens vs not, etc)? "Eye yoga", oxygen bars, humidity levels, anything? I'm okay with experimental, unproven theories.

For grins, here's my situation: I am also experiencing double vision in my right eye, I'm only a few days out, no reason to sound alarms -- but it's significant enough (far more than what's in the left), that intuition would tell me this is not going to go away anytime soon. I see from the above post, this is probably confirmed.

My dad, of unrelated medical degree, suggested that "pinhole" test would measure my vision of purely parallel light and thus measure what my script is void of other effects. He suggests this would give an indication of the inflammation that's present, and help me comprehend that there is healing still occurring. No doubt. But my problem with this is that inflammation itself does not seem to be necessary and sufficient for the double, and it seems a secondary factor. The OP's situation lends evidence to this because, assuming inflammation 3 weeks out is gone, then only scarring/healing and shape are remaining factors. Clearly this is a process, not an event, so interfering in the meantime would be a no-no, but staring off into space for 8 weeks seems a waste of all this frustration. Actions?

Best,
Ed

[LasikExpert]

1. Is there definitive reason to believe the eye heals properly; or, is it rather the brain that "fixes" the double image? I tend to assume the latter, which really isn't a happy-maker.

For most people, after 3-6 months the cornea has recovered from the surgery. Additional improvement will be from the brain's ability to ignore bad information and a small amount may be from continued healing refinement.

The brain is amazing at analysis of visual information to create the best vision possible. You have a huge blind spot in your field of vision caused by the entry of the optic nerve to the retina, yet you never see it. That is the brain at work.

To get a bit more esoteric, the eyes do not see in three dimensions. Each eye is able to see only in two dimensions. The brain takes the two dimension images from the two eyes and calculates the third dimension by analysis of the differences between the images from the two eyes.

Draw a square block on a piece of paper. It looks three dimensional, but you know that it is not because it is drawn on a two dimensional surface. That is pretty much how three dimensional vision works. The brain fools you into believing you are seeing three dimensions while using only two dimensional images. In a very real sense, only the mind’s eye sees three dimensions.

2. Since it's somewhat annoying and distracting from work, is there anything that can be done in the mean time that mitigate the poor vision caused by double image? E.g., temporary lens, patch, "pinhole glasses"/partial-blinders? Does it retard the goal?

Temporary glasses or disposable contact lenses are an excellent way to deal with refractive errors as the eye heals or until the patient decides to have additional surgery. Double images in one eye is almost always astigmatism and this is relatively easy to resolve with lenses. Your vision at work can be about as good as your vision in the doctor's office looking through the phoropter (funny lens machine against your face).

3. Is there anything one can do to aid the healing process?

The eye likes moisture. Preservative-free eye drops are often very good. Adjusting the room's humidity is often helpful because air conditioning in summer and heating in winter tend to dry out the air. Close your eyes for a full 30 seconds about twice an hour. This helps lubricate and clean. A healthy eye gets enough oxygen without hitting the bars and hyperbaric exposure may dry/shrink the cornea. Eye exercises may have a great placebo effect, but you are not going to learn to "focus around" astigmatism.

What is probably the best, and most simple, workaround for astigmatism is a lot of light. That makes the pupil small and often improves vision by reducing the amount of light passing through the irregular part of the cornea. You also get some advantage of the pinhole effect.

For grins, here's my situation: I am also experiencing double vision in my right eye, I'm only a few days out, no reason to sound alarms -- but it's significant enough (far more than what's in the left), that intuition would tell me this is not going to go away anytime soon. I see from the above post, this is probably confirmed.

An actual measurement of the amount of astigmatism would indicate how much you can expect to resolve. Just look at a current eyeglass prescription. If you are a few days out after PRK, you should be delighted that you can see with any clarity. Normally PRK provides only "functional fuzzy" vision for the first several days. Your epithelium has covered the treatment area, but would not have thickened and has certainly not smoothed.

My dad, of unrelated medical degree, suggested that "pinhole" test would measure my vision of purely parallel light and thus measure what my script is void of other effects. He suggests this would give an indication of the inflammation that's present, and help me comprehend that there is healing still occurring.

Smart dad. Boggle him with the third dimension.

But my problem with this is that inflammation itself does not seem to be necessary and sufficient for the double, and it seems a secondary factor.

Astigmatism occurs naturally and is commonly corrected with glasses or contacts. Inflammation is not necessary for astigmatism to be present, but inflammation will present astigmatism almost every time.

The OP's situation lends evidence to this because, assuming inflammation 3 weeks out is gone, then only scarring/healing and shape are remaining factors.

Inflammation and other surface issues can be gone in three weeks with Lasik, but don't expect that kind of recovery speed with PRK. It is an entirely different process.

[ArlingtonNewEyes]

Very settling response, thank you Glenn.

[LasikExpert]

Do keep us up to date on your progress.

[ArlingtonNewEyes]

1 week out. The optometrist indicated the suture line is directly over fovea. Bummer! I believe this risk of healing in the center of vision is a known problem for PRK but I do not regret my decision over LASIK. As Glenn has suggested above, the discrete edge causing the double vision should smooth eventually. Experientially, it is more annoying than the asigmatism, which I perceive as a "comet's tail" on a point source of light. Too early to tell anything else. In the mean time, the only thing else I can report -- it was painful 2 days after surgery, but feels fine now, and any dryness I experience now isn't painful, and I think I have definitely retained my ability to tear. I am (tentatively) happy with my decision for surgery.

[LasikExpert]

1 week out. The optometrist indicated the suture line is directly over fovea. Bummer! I believe this risk of healing in the center of vision is a known problem for PRK but I do not regret my decision over LASIK.

The epithelium heals from the outer edges of the cornea toward the center, coming in from three directions at once. The three initial panels of cells meet in the center forming a what looks like a Mercedes hood ornament three sided star. There is no suture line, but this is a seam. This is absolutely normal and nothing about which you need to be concerned unless the doctor is concerned for some reason.

Too early to tell anything else. In the mean time, the only thing else I can report -- it was painful 2 days after surgery, but feels fine now, and any dryness I experience now isn't painful, and I think I have definitely retained my ability to tear. I am (tentatively) happy with my decision for surgery.

This all sounds like good news and your PRK is healing as should be expected. Let me also put some things in perspective.

Commonly astigmatism is 0.25 to 1.00 diopters (D). To make a full 1.00 D of change, the laser used for PRK removes about 12 microns of corneal tissue. A human hair is about 60 microns thick. So 1.00 D off the mark is about 1/5th of the width of a human hair. To put this further into perspective, the largest epithelial cell is about 5 microns across. If the surgeon misses by two cells, you would have about 1.00 D of refractive error. When the surgeon and laser is within 1/5th the width of a human hair or within 1-2 cells of target, wating a few weeks for everything to thicken and smooth may not seem so bad.

[ArlingtonNewEyes]

This is a follow-up post. I am now one year and one week out and I am not pleased. My displeasure steadily increased as the normal course of improvement gave way to the reality that this vision is likely what is considered "functionally usable" (but-"practically worthless".) My displeasure sharply increased as I realized the surgeon is not very keen on performing the "free enhancement" promised (rightfully, if she's not so confident), and when I experienced the difference a cheap-o pair of glasses from China makes. My current agenda is to seek an additional enhancement (if it can be fruitful) and I will be reading and posting elsewhere on this forum.