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Corneal Central Island

Causes and treatment of a central island after Lasik, Bladeless Lasik, PRK, LASEK, or Epi-Lasik.

Image of a clock in ghosted vision.  
Image of a clock in normal vision.  

Temporary doubled vision or ghosting images during the normal six-month healing period after conventional or wavefront custom Lasik tend to be caused by an irregularity in the cornea

Monocular or Binocular Diplopia

If the ghosting occurs with only one eye open it is called monocular diplopia and is usually related to edema, astigmatism, epithelial defect, or incision wound healing. If the ghosting occurs only when both eyes are open, the problem may be binocular diplopia, an aberration in the alignment of the two eyes.

Surgery Induced

On more rare occasions, ghosting can be due to an irregularity in the application of the excimer laser energy used for conventional or custom wavefront Lasik, Bladeless Lasik, PRK, LASEK, and Epi-Lasik. Examples of complications due to irregularity in the application of excimer energy would be decentered ablation or central islands.

If the patient had RLE or P-IOL, the ghosting can be caused by a misaligned lens or incision wound healing.

Edema, Epithelial Defect, Astigmatism, Dry Eyes

Dry eyes will almost always exacerbate ghosting, and can be the sole cause of the ghosting.

Probably the most common cause of temporary surgery-induced ghosting is edema. All types of refractive surgery are an insult to the eye and swelling of the cornea is a common response. As the eye heals, edema is reduced and the corneal irregularity is resolved. With the resolution of the edema, the ghosting disappears. Edema seems to be most pronounced with PRK and Bladeless Lasik, although all eye surgery can cause edema.

Epithelial defect causes ghosting primarily with PRK, LASEK, and Epi-Lasik, but the process of creating a corneal flap for Lasik and Bladeless Lasik can damage the epithelium too. Fortunately the epithelial cells are the fastest reproducing cells in the human body and within a few days to weeks can cover the cornea, thicken, and smooth to preoperative levels.

Longer-term ghosting may be caused by astigmatism, which can cause multiple focal points. Astigmatism after surgery may be preoperative astigmatism that was not fully eliminated. With Lasik, Bladeless Lasik, PRK, LASEK, and Epi-Lasik, it is possible that astigmatism was induced during surgery by an inaccurate laser ablation. P-IOL and RLE require an incision at the edge of the cornea to insert the lens. This incision and subsequent stitching may induce astigmatism.

An easy test for astigmatism is to put a small hole through an index card then look through that hole with one eye while covering the other eye. Be sure to do this in a dimly lit room. As you move the hole around you will probably notice that the ghosting is gone.

Worse in Low Light

Ghosting is often worse in low light environments and can disappear completely in well lit environments. When you are in a well-lit environment, the pupil is smaller and is not letting the light that is passing through the irregular component of your cornea reach the retina. The multiple focal points are still there; they are just not reaching the retina and being "seen".

Central Islands

Central islands are formed when an area of the Lasik, Bladeless Lasik, PRK, LASEK, or Epi-Lasik treatment zone does not receive the full amount of laser energy. Wrinkles in the flap (striae) may provide multiple ghost images. Central islands are much more rare than astigmatism, edema, or epithelial defect.

Check with your doctor to determine the exact nature of your problem. If the ghosting is caused by your remaining astigmatism, ask your doctor about the possibility of an enhancement to eliminate your residual astigmatism. Or just see if a good pair of glasses or contacts do the trick. If ghosting is caused by swelling, you need to wait for healing. Since dry eyes can cause and exacerbate ghosting, you may want to visit an article on dry eye treatment. Depending upon the nature of the striae, a flap lift may be necessary. We have an article on striae resolution too.

Looking For Best Lasik Surgeon?

If you are ready to choose a doctor to be evaluated for conventional or custom wavefront Lasik, Bladeless Lasik, PRK, or any refractive surgery procedure, we recommend you consider a doctor who has been evaluated and certified by the USAEyes nonprofit organization. Locate a USAEyes Evaluated & Certified Lasik Doctor.

Personalized Answers

If this article did not fully answer your questions, use our free Ask Lasik Expert patient forum.

Recent Lasik Ghosting Journal Articles...

Related Articles

Impact of laser refractive surgery on ocular alignment in myopic patients.

Eye (Lond). 2014 Nov;28(11):1321-7

Authors: Chung SA, Kim WK, Moon JW, Yang H, Kim JK, Lee SB, Lee JB

PURPOSE: To evaluate the impact of myopic keratorefractive surgery on ocular alignment.
METHODS: This prospective study included 194 eyes of 97 myopic patients undergoing laser refractive surgery. All patients received a complete ophthalmic examination with particular attention to ocular alignment before and 3 months after surgery.
RESULTS: Patients with a mean age of 26.6 years and a mean refractive error of -4.83 diopters (D) myopia were treated. Asymptomatic ocular misalignment was present preoperatively in 46 (47%) patients: a small-angle heterophoria (1-8 prism diopters, PD) in 36%; and a large-angle heterophoria (>8 PD)/heterotropia in 11%. Postoperatively, the change in angles of 10 PD or greater occurred in 3% for distance and 6% for near fixation: in 7% of the patients with orthophoria, in 3% of those with a small-angle heterophoria, and in 18% of those with a large-angle heterophoria/heterotropia. No patient developed diplopia. The preoperative magnitude of myopia or postoperative refractive status was not related to the change in ocular alignment. The higher anisometropia was associated with a decrease in deviation (P=0.041 for distance and P=0.002 for near fixation), whereas the further near point of convergence tended to be related with an increase in near deviation (P=0.055).
CONCLUSIONS: Myopic refractive surgery may cause a change in ocular alignment, especially in cases with a large-angle heterophoria/heterotropia. There is also a chance of improvement of misalignment in patients with anisometropia.

PMID: 25190533 [PubMed - indexed for MEDLINE]


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