Is this REALLY Dry Eye or some other complication

[richbron]

In November 2005 I underwent Laik surgery to correct a severe astigmatism (-5.75 in both eyes). I had an enhancement procedure (Astigmatic Keratotomy) in March 2006 to address the remaining astigmatism. My current prescription is:
L +0.5 – 1.00 x 60
R –0.25 –0.50 x 10

My vision continues to be extremely poor for both distance and close up. Following the AK enhancement to my Dr’s surprise I requested that he prescribed glasses at my new prescription (above). He suggested with the above prescription I should not need glasses (I honestly struggle to read my computer and distance vision uncorrected is not possible to read - eg road signs until I am right on top pf them etc).

The new glasses helped but did not fully correct (distance of 20 foot plus is blurred). My BCVA has certainly noticeably decreased for me. Contact Lenses, although uncomfortable to wear, offered slightly better, but far from perfect, vision. Vision with / without corrective lenses definitely worsens as the day progresses.

11 months since having the AK and my vision has shown NO improvement. My Lasik Dr diagnosed that I am suffering from Roscea in the eyelid. He tested for Dryness and suggested that although I have sufficient tears, the gland in the eye was not performing adequately and hence my eyes dried out very quickly.

For the last 3 weeks I have been on the following routine:
- warm scrubs followed by eye massage (5 – 10 minutes)
- Blephagel (cleanser)
- Tobradex ointment
- Doxycyl anti-biotic pill
- Refresh eye drops as required

I have not noticed ANY improvement in my vision.

Here is the interesting part - I explained to the Dr that ever since my enhancement procedure, my vision is clear and crisp upon waking – ie BEFORE corrective lenses (distance as well as close up). BUT within half an hour the vision begins to blur and worsens as the day progresses to such an extent that it is not corrected by lenses/glasses. Following which I am continually placing my eyes under strain and developing headaches.

Are these symptoms consistent with dry eyes (need to stress how poor the vision becomes during the day AFTER the first half hour after waking up). I have been experiencing this since the enhancement – can Lasik/AK cause such severe dryness that I would be experiencing these symptoms?

Can such dryness be corrected? If so when should I notice an improvement in my vision?

I am going back to my Doctor at the end of this month (February 2007) and he will be performing a Wavelength / topography to identify if there are any higher order aberrations causing my vision problems.

Any feedback will be very helpful as I am finding this situation most debilitating.

Thank you
Richard

[DryEye]

Glenn:

From RichBron's Comments Above:

..."My Lasik Dr diagnosed that I am suffering from Roscea in the eyelid. He tested for Dryness and suggested that although I have sufficient tears, the gland in the eye was not performing adequately and hence my eyes dried out very quickly. "...

How does a doctor know if one has roscea in the eye?

Also, are there tests for one to see if the gland in the eye is performing adequately (for tear production purposes)? My right eye (even when I wore contacts) has been drier than my left eye. Since lasik and a regular artificial tear regimen I do not wake up rubbing that eye, yet during the day it seems to become more dry than my left eye. Any other thoughts on the scenario other than gland/tear production? Thanks!

Thanks

[richbron]

Hi Glenn

What are your thoughts on why I wake up with clear vision and then very quickly (witin the first 30 - 45 minutes after waking) blurs? Surely if I have dry eye, the eye would be dryest first thing in the morning. The blurry vision lasts the whole day and as I am typing this (its 8:30pm in South Africa) I have to be 4 inches from the screen to read what I am typing.

Have you ever come across such radical vision blurry with such a low prescription - can this REALLY be due to dry eye?

My prescription is
L +.25 -1.00 x 60
R -0.25 -.05 x 10

strangely enough I experience the WORSE vision with the R eye which has the smaller astigmatism.

Any thoughts from anyone - I really am struggling and do need some helpful advice as this is seriously debilitating .....

Thank you
Richard

[DryEye]

Richbron
When you insert preservative artificial tears doesn't your vision crispen up even it is just for a little bit?

[richbron]

It clears - not nearly as clear as first thing upon waking up - but only for a matter of seconds.

I so regret having Lasik as I cannot wear contacts from a comfort pooint of view and neither glasses nor contacts correct me.

Richard

[DryEye]

Richbron
Can't remember all about your situation except that I remember reading that your dry eye regimen was working at first.
Try different artificial tears (TheraTears, Systane, Refresh Endura)
Get another good opinion from a corneal specialist
Whats done is done - Try to stay positive - I had lots of moments the first 6 months and wonder at times still myself, but one can only look forward
Glenn should be able to give you better information and look forward to reading it

[richbron]

Thanks DryEye

The reason I thought the regime ws working at first was due to the fact that after removing contact lenses (toric) my vision was good and I thought that this was due to regime/anti biotic I was on. Clearly after removing the contacts (they were new torics that I had only just started wearing) the shape of my eye was temporarily (guessing) changed giving me the temporarily better uncorrected vision immediately after removing the lenses.

I can firmly say that in the 3 weeks I have been doing the dry eye regime that I have not seen ANY improvement at all in my vision. How long do these things take? I am back to my Dr in 10 days time - after whcih I will seek a second opinion.

[Betty39]

Dry eye worsens as the day progresses. My eyes hardly feel dry first thing in the morning too.

[richbron]

Well I had my follow up with my Dr today regarding my dry eye and severe reduced quality of vision.

He performed a wavefront topography on my eyes - my right eye has 90% Higher Order Abberrations and the Left 33%. What does this mean?

R: -0.25 -0.5 x 10
L:+0.5 -1.25 x 50

The right eye (biggest abberrations and smallest prescriptions) has the WORST vision.

The doctor suggested that the HOA should not affect my vision noticeably. He cannot explain why my vision with glasses is not corrected - he even suggested that current vision is BETTER than my corrected vision pre-lasik according to his tests. I told him I wish I could connect my eyes to his computer so that he can experience my vision (corrected or uncorrected) - with glasses 0n, I see road signs just as I am passing them!!

He is still treating me for dry eye (oils not functioning correctly). I reminded him that my current VA has been the same since LAsik and I find the Dry Eye (oil issue) extremely coincedental to the timing of lasik.

Glenn - what do you think?

Thanks
Richard

[LasikExpert]

He performed a wavefront topography on my eyes - my right eye has 90% Higher Order Abberrations and the Left 33%. What does this mean?

I think there is a misunderstanding. What is probably meant is that the Higher Order Aberrations (HOA) are 0.90 Root Mean Squared (RMS) for your right and 0.33 RMS for your left, not 90% and 33%. 0.33 RMS is about the norm for the general population without any sort of disease or surgery. An HOA of 0.90 RMS is quite elevated and would indicate poor vision quality.

R: -0.25 -0.5 x 10
L:+0.5 -1.25 x 50

This is a perfect example of the difference between vision quantity (your prescription above) and vision quality (your HOA). Your prescription is very close to target and your right eye is slightly better than your left. The HOAs indicate poor quality vision for your right eye.

The doctor suggested that the HOA should not affect my vision noticeably.

I respectfully and strongly disagree (keep in mind I'm not a doctor). If my interpretation of your numbers is correct, the HOA in your right eye is significantly elevated from the norm. This is where a second opinion may be helpful.

He cannot explain why my vision with glasses is not corrected - he even suggested that current vision is BETTER than my corrected vision pre-lasik according to his tests.

That is possibly true if you only look at the prescription and ignore the HOAs. Otherwise your symptoms are consistent with the objective analysis.

I told him I wish I could connect my eyes to his computer so that he can experience my vision (corrected or uncorrected) - with glasses 0n, I see road signs just as I am passing them!!

The doctor can see this via the wavefront diagnostic. He can look at your Point Spread Function (PSF) and see how a point of light is blurred. Some systems create a real-world image that includes the HOAs. The information is there.

He is still treating me for dry eye (oils not functioning correctly). I reminded him that my current VA has been the same since LAsik and I find the Dry Eye (oil issue) extremely coincedental to the timing of lasik.

Lasik induced temporary dry eye is a relatively common problem. It apparently relates to inflammation with the healing response and reduction of sensitivity of the corneal nerve cells. What is also important is that dry eye could be the major (if not total) cause of your poor vision quality.

Glenn - what do you think?

I think a second opinion may be valuable. I recommend that you contact the ophthalmology department of a nearby university affiliated teaching hospital. Dry eye is a natural occurring condition. Your doctor visits and care/management may be covered by your major medical insurance.

[DryEye]

I just learned a lot more
Thanks Glenn

[richbron]

Thanks Glenn - extremely helpful.

If my VA is due to Lasik induced Dry Eye (I had Lasik in November 2005) is this still considered "temporary" dry eye or do I need to accept that this could be permanent?

I am still on Doxycyl (I believe it thins the oils) and warm scrubs and lid cleansers. Does this regime combat Lasik induced dry eye or is this regime more focused towards eye infection induced dry eye. The Dr did suggest that I had occular Rocasea which is causing the MGD.

Once again many thanks
Richard

[LasikExpert]

In my opinion nothing so long after Lasik should be considered temporary, however it appears that the difficulties you have encountered may not be directly related to your Lasik at all. Your symptoms may be due entirely to ocular rosacea and related disease.

Ocular rosacea patients commonly have chronically bloodshot eyes, dry eyes, and blepharitis (inflammation and debris of the eyelid margins). In severe ocular rosacea there may be corneal ulceration from infection, which if untreated may even lead to perforation of the eye. Doxycyl is an anti-bacterial medication that your doctor is undoubtedly using to reduce the ocular rosacea symptoms, resolve the problem, and keep you from corneal infection. Doxycyl is not specifically used for dry eye other than to reduce a problem that contributes to dry eyes. The warm scrubs and lid cleansers help for the associated blepharitis.

Ocular rosacea and blepharitis could cause all of the quality of vision symptoms you have been describing. You mentioned Meibomian Gland Dysfunction (MGC). You may have an actual dysfunction of the glands, or the channels that carry the lipid substance may be blocked due to inflammation related to the rosacea and blepharitis. Since all of these problems can affect one eye more than the other, your higher HOA in one eye is consistent with vision quality affected by disease, not surgery.

Another medication that may be helpful in the future is Restasis. Restasis is the anti-inflammatory cyclosporine, however Restasis should not be used in the presence of eye infection. Once the rosacea is under control, Restasis may be able to help.

Ocular rosacea, blepharitis, and MGC are all naturally occurring and treatment for all should be covered under your major medical insurance plan.