Hyperopic Lasik - seek info / help

[lex]

I had hyperopic lasik.
Here is my script pre-lasik (+3.25 / -1.25 astig and +3.75 / -1.5 astig) and had lasik about 11 weeks ago. I was already presbyopic, that is why i had lasik.
I have read with much interest how hyperopic lasik has recovered and i have some issues i would like some of you who had hyperopic lasik to comment about.
croanster,Mack,gkrogers .. are you still around? would you comment it? Expert lasik, please comment...
After the surgery i felt i had a macro zoom, i could read my watch model name and read road signs far away, but everything was double and blurry. It made me think that the surgeon had adjusted to some +3.50 and 4.00 diopter target, and expect to regress? This would mean i would be -0.25 in both eyes? I dont know how a myopic world is, so, being presbyopic with hyperopia is not really nice.
When i looked to a keyboard "single quote" i would see a "double quote", that started to worries me a lot.
I returned to the surgeon on the same day and asked him to look again to see if the flap was ok, and he did not see anything wrong.
The next day, same thing, and asked doc what went wrong, i got this answer and i quote "I dont know why you are seeing double, we have the best tool and everything was made according to planning, you are with irregular cornea", by best tools he meant Allegretto Wavefront, i dont know if it is 200 hz or 400 hz.
Next appt would be in 30 days, but i was back in 10 days complaining about my vision and the feeling of burning corneas i was having. He told me "This is normal, dont worry, just come back in 3 months, just wait, and use the drops every hour".
The burning feeling kept and i was really in panic, started googling and also started to worries me more.
Where is the normal feeling, no pain,1 to 2 weeks recovery to normal life that lasik gives?
Some days later, the burning feeling got me really hard, and an examination from the surgeon said this was normall!!!!!!
I went to a second opinion, and got some info from this doc, "your surgery is called what we say: technically a success, so nothing wrong apparently, to make sure it is ok we will do an OCT exam", the results were normal stroma, and normal flap.
I was worried that the flap was made too small, believe or not, i could see the edges against an indirect light, seeing on the mirror.
apart from what the docs said that i was seeing "more" and was an anxious person, i had to be certain that there was no flap related problem.
So the OCT revealed nothing wrong.

He stated that there was a start of blepharitis and that is what i was feeling and not the corneas, why the surgeon did not notice it i dont know.
In fact i had never felt a normal eyes.
I have never had blepharitis in my life, he said it was due to too many drops in and it had altered the flora and that i had to clean the eyelids more frequently.
Got some medication during the nights for 20 days, baby shampoo to clean and eventually i got better (coincidence or not?) on day 20 - today.
Fortunately, double vision has diminished for near vision.

So the issues i am having and would like those who had hyperopic lasik to comment please (also lasik expert):

a) Dry eyes - burning sensation, but not in the eyelids (plepharitis), i would think is in the periphery of the cornea. It does not sting as the normal dry eyes complaint. I am putting in drops every 2 hrs, some times every hour.
What is/was the feeling of a dry eyes you were having and how long it last?

b) Every time a Blink (open the eye) first time i get a blurry vision, and have to blink right after to get a good vision, did any one have it? Could be Dry Eyes?
This is the unstable vision i am experiencing now, some times i have to blink twice to get a good vision, would it be regression symptoms or dry eyes or the tears is unstable enough to not have a smooth epithelium?

c) I think regression took place, i have noticed that the zoom factor is diminished, near is getting worse, far is getting better, i have to wear glasses to read +2.0, no astigmatism
question: If i have +2.0 to read and this causes to blurry far, that means i become Myopic looking far away?

d) I have noticed that i see near (5 feet < ) without astigmatism and beyond i notice some ghost on blue and green light, specially blue, right above, 90 (12 oclock) that i think is astigmatism.
question: Is this irregular astigmastism? Thats why refrator sees -1.0 and cycoplegic dont get this value? Green lights get a bit Oval far away, not near.

e) I have a very hard time focusing, is this accommodation or an indication that the astigmatism is getting worse or i have regressed. Everything is out of focus until a force to focus, so i get tired at the end of the day, i have not get a prescription after 30 days of the surgery.

f) I have borrowed a glasses from my brother that is myopic, he is not sure what diopter, but he says is less than -1.0, and i think i get o bit sharper image far away, but i am not sure, but at least is more comfortable, would it be an indication that i am nearsighted seeing far away and longsighted seeing near? Is it possible?
Have i expressed it correctly? The 2nd opinion says he would not take this aproach to let me nearsighted and than expect it to regression to plano.
I was thinking that the target would be +3.5 (so more tissues removed than the +3.25) and then expect it to regress to +3.25 to get plano?, if you know what i mean? or it is just the couple effect that every 1.0 astigmatism is about -0.25, it will never get to 0.00 (plano)? thats why hyperopic astigmatic is so unpredictable? If i had know it!!!!!!!

g) The weird feeling of focuses is worse indoor where neon exists and when i try to read printed charts, say: red with white letters, green with white letters, is this astigmatism or just accommodation?

Please, croanster, Mack, Lasik expert or any other who had hyperopic lasik could comment on this?

Thanks
Lex

[lex]

Just for the record..
Most of the complications have been resolved.
What is left is a bit of upper eyelid swollen. Dry Eye, perhaps? I dont feel dry eyes, only a bit of swollen at the edges.
For the first time i woke-up in the morning without needing to put in any drop. Reducing to 3x the use of drops. Will do a warm compress and get some fish oil and see if it can help.

[Mack]

Lex,
It appears you are now only 11 weeks out from your primary lasik and were about +3.5 with -1.5 astig and presbyopic, compounded by significant dry-eye. It's still VERY early in your healing and regression process. I know my vision at this stage was not stable and I recall some discomfort and stinging. That will slowly dissipate and as you've already experienced and noted, you've gotten less near-sighted and distance vision is sharpening. The double vision you describe that is apparently also dissipating is not that uncommon. My experience with that seemed rather variable. I would have periods every few days of a half hour to an hour in either eye where it would get noticeably worse and then resolve. The OD said this could be an "occular migraine".

After almost 13 years from my orignal primary treatment with a Visx-2 and double carding, I still experience those double-vision and ghosting episodes on occasion, but only in one eye at a time. My original +5.25 dominant eye seems to get them more often than the +3.75 eye. And it also has less contrast sensitivity than the +3.75 pre-lasik. In outdoor sunshine when the pupils are constricted, my vision is always the best, easily 20/20 in both eyes. But in lower light and indoors when the pupils open further, visual accuity decreases as the periphery of my ablation zone reveals increased hyperopic refractive error that was not properly treated. I attribute that to the original -1.5 astigmatism and the double-carding not providing accurate ablation across my entire OZ. And unfortunately, my one year enhancements did not fully fix that. In recent years I've resorted to +1.0 readers when watching TV in the evening from about 10 feet away to get a sharp focus. I also use +1.75 readers for close work and +2.75 for really close.

I would be patient Lex and let the regression process continue for at least another 6 months before you even consider an enhancement or doing anything other than continuing to treat your dry eye and possible blepheritis condition. I only had minor dry eye issues and did not take drops after the first few months. The corneal nerves and tissue that provide signals and conduits for tears for normal tearing need to grow back and should return in 3 to 6 months. And remember you need a film of tears always on the cornea, not only for lubrication but also to contribute a small amount of refraction. Thats why many folks see best immediately after blinking or applying drops and as the surface of the cornea dries, some refractive error creeps in and makes vision less clear.

Good luck.

Mack

[lex]

Mack,
Thank you for answering, i am glad you did and you are doing good after this years.
My dry eye issue is someway bothering me all day. 2 days ago i had my best vision all day and could see near, mid range and far very sharp (+.175 for close-up) and i was really happy, but it was not crystal clear. Since then i am back to 8x drop in, and in the morning i could notice a bit of MG swollen on the RE, some times i think the preserv tears is causing this, so i am trying to put in drops less if i can. Will try refresh tears to see if it improves.
My RE (3.75) is crystal clear near and mid-range, far is a bit blurry, but unfortunately my LE is dominant.

I cannot define in words my eye dry feeling, is more like i am wearing a hard (gp) contact lenses (somewhat dry) and with a lot of pressure (from inside to outside) on its edges (outer ring), the eyelids never get stuck on the eyeballs,never. Some times this feeling vanish and i get a good vision (or i think i get) and i feel my eyes really calm down. I think +3.25 d removes o lot of tissues and the results are this dry eyes we (hyperopes) experiment, my doc said it is not from the corneas that i am feeling this sensation, but my mind disagree.

Could you notice you had a regression? i mean, did you notice it when you wake-up or it was noticed only when refracted? (in your 6 months post op)
From day one, i had a macro zoom feeling and expressed it to surgeon that i think the diopter he removed was more than the +3.25 (that is what i was thinking, had no knowledge i would regress) , say removed tissue for +3.5 or +3.75, and now this macro zoom is gone, and for some distance (near) is without zoom now (letters are smaller).

If he removed tissues for a +3.5 diopter, that means i would be -0.25 (myopic), right? It then regressed to plano. I think it was the world i was seeing after the surgery, then i got paranoid because the day after surgery i talked to a person who had the surgery right before me and she was smiling and saying she could see far as never seen before! Those lucky myopic people!

I am really afraid of enhancement, due to flap related problems or microstriae and the epithelium ingrowth possibility.
I had double vision, got a second opinion, did an OCT exam just to make sure any of this was not causing my double vision, finally i got paranoid, my LE i expected a better result than the RE.

Is it possible that this ghost on the blue, green and yellow led lights mean i still have irregular cornea or an edema and it can be resolved during the 6 month healing time? Decenter ablation can be resolved with an enhancement?

I am really glad you came all this way and being so brave to do your enhancements and tell your experience so far.
Good luck to you all and good luck to me

lex

[lex]

Mack,

I wonder if you would answer this rather technical question:

"[b]But in lower light and indoors when the pupils open further, visual accuity decreases as the periphery of my ablation zone reveals increased hyperopic refractive error that was not properly treated[/b]":

Further enhancement would not treat this area? Was this a limitation of the Visx-2? Would it be dangerous to try to treat this area, even with new technology?

I had mine done on Allegretto Wave (dont know if 200 or 400) will ask in the next appt if i get this answered.

Seeing my 2d corneal pachymetry at 60 days i could see the outer ring is lower then the center, would it be this most outer ring that will regress due to epithelium filling the space once belonging to corneal tissue? If there would be any edema on this outer ring, the cornea would be thicker and than causing some regression?

Edema can be seeing on silt-lamp?

As a presbiopic since 40 i wonder if the area we are seeing through the corneas when in close up would be this outer ring, or it is just the crystaline that does not bend much? This will help me to get an ideia how further my presbiopia would progress and how it would reflect it if regression keep going on the next months.(I really, really dont wnat this to happen).

Sorry to bother you with silly questions, but i want to learn and understand everything before i attempt to do anything further.

Any comments? (lasik expert, would you comment also?)

Thank you anyways
lex

[Mack]

Lex,
Regarding regression in high hyperopes after lasik: I know my doc allowed for +1.25 D of spherical regression with the Visx-S2 for both my eyes, OS +5.25/-1.50cyl and OD +3.75/-1.75cyl back in 1999. I recall being -1.25 right after the procedure and he prepared me for that saying, "Enjoy your close-up vision without glasses, but realize it will slowly regress to plano over about 3 or 4 months and your distance vision will sharpen. It did exactly that. For the first time in my entire life, I could read small print without any specs. I even borrowed a pair of old -1.25 specs from my brother for driving for the first 2 months. Then I got my own prescription for about half that amount of myopia, with some astig correction too. But after another few months, those didnt help.

The Visx-S2 double-carding didnt clean up my astig in either eye. So at 3 months, he re-treated just the right, OD. It helped improve accuity in good light, but my low light accuity always has suffered from about a diopter of hyperopic astig. We waited 6 months before enhancing the left eye OS which is my dominant eye and was correctable to a very sharp 20/15 prelasik. Because so much tissue was ablated around the periphery of that cornea, I see more astigmatic abberations in that eye in low light, including small wings or flares coming off light sources to the left and right. While I have 20/20 uncorrected in good light, I cannot achieve 20/15 with any sort of correction since the error changes with the amount of light and pupil opening. But I've gotten used to that.

I recall my vision kept changing and fluctuating slightly for another year or more. But after maybe 2 years out, I felt that my normal tearing had become completely restored and other than the occasional 30 minute periods of occular migraines with degraded double vision, my vision is reasonably stable. But not as good as corrected pre-lasik. In hindsight, I'm convinced I should have waited a full year before the enhancements. Technology and improved technique for treating hyperopes with lasik were rapidly improving back then as more of us were opting for lasik. I recall a number of hyperopes on these boards complaining they were not properly over-corrected initially to allow for regression and were very happy during the "magic period" of the first few months with good vision and then regressed back into hyperopia and were very disappointed. Most all high hyperopes I know or have read about have needed enhancements to get close to plano without astig.

The lasers have gotten better over the years and the doc's hyperopia treatment technique has improved as well, as many more patients and their responses have been tracked. They don't do double carding anymore. With computer-aided tracking during the ablation and better software to simultaneously treat both sphere and cylinder error, very good results for hyperopes up to +4 are now common. However most lasik docs will not treat over +4 or +5 and advise the IOL instead. The interocular lens is like a cataract operation where the human lens is removed and a plastic one with the necessary amount of refraction to offset the natural error of the corneal surface will result in fully corrected vision. Younger patients lose their accomodation doing that and will need readers post-op. That was being tested in 1999 but seemed just too experimental and invasive for me at the time. Since then, several docs have assured me my final result would have been more stable in all lighting conditions, had I waited to do the IOL instead of the early H-lasik like I did. IOL's are also much more expensive, about $10k per eye. Too late now to worry about that or doing more enhancements. They dont lift 13 year old flaps. They can't even see the edges of mine anymore, so they would have to cut new ones. Not worth the risk at my age and anyway I dont mind wearing readers when needed.

For you Lex, I think enhancements at one year will likely be warranted and desireable, BUT ONLY if they are done by a hyperopic lasik enhancement specialist that has done many such procedures and lifted old flaps with great success already. I dont know where you live, but it might pay you to get a 2nd or 3rd opinion if your present doc is not a hyperopic lasik expert. You may not need to wait the entire one year, if you refract to the same numbers 3 months in a row.

I also think that after another 3 to 6 months of healing, your normal tearing should return and as the edema subsides, your eyes will become more comfortable and your vision should stabilize more. You mentioned the possibility of a decentered ablation. Those are very rare nowadays and your doc would have easily seen that with the Orbscan on your subsequent checkups.

I'm not exactly sure how to answer your last question about how regression proceeds in the area under the flap of the lost tissue that was ablated. The epithelium is the outer layer of the cornea that stays on the flap. Collagen cells (not epithelial cells) will fill in along the edges of the ablated area where the flap sits back down as well as on the underside of the flap in the healing process. They do not want stripped off epithelial cells getting caught under the flap by mistake and will sometimes have to relift the flap to scrape them out. That is a common complication of LASIK. As you probably know, LASEK is a similar procedure that does not cut a flap but removes the epithelial layer and then the laser ablates the cornea. The epithelium grows back on its own over time. Ablated corneal cells dont grow back, but when a lot of them are ablated, the shape of the cornea becomes quite different than before, so the natural biological response of the eye is to try and revert back to that original shape as it heals, and that I think is what regression is mostly about. Since there is so much more tissue ablated for hyperopes than myopes for the same diopter level of correction, hyperopes experience a lot more regression. I am not a doctor and one of them would probably have a better explanation on the mechanics of regression.

All the best to you Lex, in whatever you decide.

[lex]

Mack,
Thank you for such a nice explanation, really.
Techonlogy has improved since you had your surgery for sure, but not for hyperopes, and i hope i will be completely wrong with this statement when i have my final outcome.
I am suffering a lot with this sort of dry eye, sort of blepharitis or sort of MGD that i dont want to even think about retreatment, that can get worse after a flap lift.
I can see the folks out there with dry eye takes restasis, punctual plugs, gel nite or some other sources to alleviate this symptoms, and my dry eye does not have really the "dry" feeling , it is some kind of eye sore that is killing me. I have tried refresh (no preserv), systane ul, but it all seems to get it worse, so back to my refresh tears.

You told us you did not have dry eye, did you have any sort of mild sore or burning sensation during your healing time? I mean, some discomfort that would keep you out of concentration in your normal activities during this 3 months healing process?

One last question... Did you know all this process you got through before you had your initial lasik surgery or it is an hyperopes nature to learn the hard way this every bit of information after h-lasik procedure?

best wishes to you and good luck to me.

lex

[Mack]

H-Lasik technology has improved over the past 13 years to the extent that double-carding is no longer used, flaps are rarely sliced with microkeratomes anymore and auto-tracking insures more accurately centered and consistent ablations. But perhaps more importantly, doctor technique and being able to more accurately guage the proper amount of regression has improved as the overall hyperopic patient database has grown.

I did experience some dry eye symptoms during the first 3 months and after enhancements, but mine was not debilitating as it seems to be for you Lex. I recall feeling a dull pain and slight burning sensation then and did not feel ample tearing returned until perhaps a full year afterwards. Did you have punctal plugs put in yet to help relieve that? Good tearing is absolutely essential for regaining personal comfort and consistent clarity of vision after lasik. Getting your normal tearing function back will probably just take more time for you, unless you had dry eye pre-lasik. Severe dry eye usually disqualifies candidates in the hands of most docs.

The dry eye problem hits myopes and hyperopes alike as an equal opportunity attacker. But the higher the script and the more tissue ablated, the risk for more problems and slower recovery does seem to increase. I really think you'll be able to overcome that Lex, and hopefully after another 6 to 9 months you'll be able to justify an enhancement should that be necessary to get you to 20/20 plano. If you are still a little far sighted with + astig, CK may be an option for you as it was for me to get a better final result. No recutting is required.

Hang in there.

[lex]

Mack,
Thanks for the encouragement words.

I was not diagnosed with dry eyes in any of the appt i had so far, no punctual plugs or restasis were prescribed, only increased the drops.
I think i poisoned my eyes with too many drops along with lasik, and this fired the whole dry eye sort of, for now i will try optive soon.

I am sure i will come up with good news.
I will take your advice and will not take any action until it is resolved.

Thank you for taking your time to answer this and for the reassurance words.
Wish you all the best and good luck to me.

lex

[lex]

Mack,

While wearing sunglasses i realize i can get a tidy bit sharper image and is much easier to focus on the objects that are far and close distance.
I have had a hard time focusing objects to get a sharp image from them, with sunglasses on i find it much more relaxing (no focusing issue, the way it should be).
This sunglasses is UV and no prescription. I wear it on sunny days and overcast days.

I wish to report this to the doc on next appt.

What can we infer from this finding?

lex

[Mack]

Lex,
UV sunglasses, and especially polarized lens sunglasses reduce the amount of light entering the cornea. So the resulting amount of glare the eye sees from light sources is also reduced and visual accuity appears sharper. I notice this effect myself and wear dark polarized sunglasses during the day, except when it's overcast while driving or working outside to sharpen up focus a little better. They especially help with driving. Polarized lenses only pass light in one plane, and even less light reaches the eye so that focal aberrations casued by glare are reduced even further.

[lex]

Mack,

Would you think a allegreto wavefront guided would be able to correct +1.0 (-0.75 astig)?
I just found that my focusing issues are related to astig left. Today I tried my son glasses and one of the lenses is about < 1.0 and some astig and i got my eyes much more relaxed to focus far and mid distances and a bit sharper. I managed to rotate the lens to match my supposed astig angle and that helped.

Would i have good chances for a success?

Please, any input would be really appreciated

lex

[Mack]

Lex,
You should really have your doc do both a manifest and cyclopegic refraction now to see what your residual corneal errors actually are in each eye. Aren't you coming up on your 3 month checkup where they should be doing that anyway? +1.0 sph with -0.75 cyl is mostly a hyperopic astigmatism error in one plane. That script can also be written +0.25 sph and +0.75 cyl 90 degrees shifted. It sounds to me like you were either a bit undercorrected or have regressed back to these numbers. I recall my numbers were close to these several years beyond my final lasik enhancement procedures. I then opted for CK to clean up most of the residual hyperopic astig. It worked quite well. But you need to wait at least another 3 months before considering that kind of procedure. Your numbers may keep shifting a little more towards more hyperopia. Only regular monthly refractions will tell the tale.

Mack

[lex]

Mack,
Please, share your thoughts.

Can astigmatism regress back to prior Lasik values and in the same axis, or would it be a surgeon fault?
3rd opinion said there would be a possibility due to a laser head "turning movement", but still a possibility only.

Can CK get rid of -0.50 astig and -1.0 astig? How precise would it be?
I have read there is a type of incision in CK, very thin penetration, would you think this technology have improved during these years?

Cyclopegic refraction will be done at 6 months only.

I am now taking restasis. Treating the Dry Eye, still an issue.

Lex

[lex]

Here is an update in case someone is interested in.
Please Mack, if you are still around, give any input.

Cyclopegic:
LE - +1.0 -0.5 (changed axis from the last measure in manifest refraction)
RE - +1.0 -1.0 (same axis as before)

Manifest Refraction:
LE - +0.5 - 0.5
RE - +1.0 - 1.0

Doctor says it is a good result which i disagree.

Anyone had an enhancement with this script that worth the risks?