I had lasik in Feb. 2005. For about 2 weeks my vision was very blurry and then it cleared up except for a smudge on my right eye. It eventually got better but it never completely went away. The doctor thinks it's a prescription problem but I really don't think that's what it is. I think something has been scratched -- the flap or the lens or something else. I want to get an enhancement but I'm worried the smudge might get worse. Do you know what this could be? It's noticeable in different kinds of lighting and not very much so in other kinds.

Ask your current doctor for a referral to a corneal specialist, preferably one in a teaching hospital. Only with a direct examination by an expert could you possible get a reliable answer to your question.

Glenn Hagele
http://www.USAEyes.org

I am not a doctor.

Thanks for your reply Glenn. I have an appt. on Oct. 4.

Be sure to let us know what the doctor finds.

Had the appointment with the cornea specialist. He found nothing wrong with my cornea. He wants to do an optic nerve fiber analysis in his other office. I've had that done before and there's something that shows up in one of the quadrants -- I really don't know what it means. I guess I could have had the smudge before the lasik but never noticed it because my vision was so bad. It's hardly noticeable with glasses on. Don't know yet when I'll be able to get to his other office for the test -- probably November some time. At least it's not too terrible. I might just have to live with it.

I didn't see my response. I wanted to add something further. To repeat my response, the cornea specialist didn't find anything wrong. He wants to do a nerve fiber analysis in his other office. I won't be able to get there until November probably. I've had that done before and they say there's something wrong with one quadrant. I don't know what it means. I have controlled glaucoma so it might be something to do with that. At least it's not too terrible. It's hardly noticeable especially with glasses on. I don't know if I'll be able to get an enhancement as he said no more surgeries. I've got to find out what he meant by that still. I've been reading about people with halo problems. My pupils are very small and I still have halos although they aren't as bad as they were at first. After reading about other peoples' problems, I feel pretty lucky.

Based on what you've stated, Lynda, what is going on is that the corneal specialist is suspicious that the "smudge" in your vision is caused by an optic nerve defect. Your admission of an Hx of glaucoma is a likely confirmation of that suspicion, as optic nerve damage is one of the common (and potentially serious) consequences of uncontrolled glaucoma. You say your glaucoma is now under control, however, it obviously wasn't before it was diagnosed and during that time some optic nerve damage may have occurred. Also, the statement by your refractive surgeon that you should have "no more surgeries" likely indicates that your residual stromal beds (the amount of cornea remaining under your LASIK flaps) is getting down close to the 250 um minimum (or whatever minimum your doc believes is necessary to avert ectasia). Some docs believe that pre-existing optic nerve damage is a contraindication to (initial) LASIK surgery because of the potential for further nerve damage from the spike in IOP caused by the microkeratome's suction, but this is not an issue with enhancements (as the old flap is just lifted up).

So, all in all, Lynda, although you've had some problems early on, it sounds like you are going to end up with a good, 20/happy result.

Bryce Carlson

Thanks for the reply Bryce. The cornea specialist also said something about maybe having a cataract. I'd be happier if I could see distance better. I've gotten glasses I use when I drive during the day and at night. At night I'm really blind without the glasses. The halos are still disturbing. I think I'm glad I got the surgery though. At first I wasn't when I lost my near vision but I've pretty much adjusted to having to wear the reading glasses. I think I'd only recommend the surgery for people with perfectly healthy eyes and with a good surgeon of course. I went to one of those cheapo places so I was really taking my chances. I was about 20/500 before the surgery so being able to see around the house without glasses is neat. I can even see some numbers in the phone book without glasses in the right light. I hear they might be coming out with this multifocal lasik, which I would like to get IF they have good results with it. Or I might just get the enhancement on my good eye. Haven't decided yet. I think my corneas are thick enough. I asked the cornea specialist what he meant by no more surgeries and he said we have to find out what's going on with my right eye first.

Lynda,

I'm curious to know what kinds of tests were done by the cornea specialist. The standard tests I would perform would be a refraction to see if eyeglasses would correct the problem, a topography to see is there was any defect on the surface of the cornea to explain the problem, and finally a wavefront aberrometry to see if a higher order aberration was causing the problem.

Unfortunately, it is not uncommon not to be able to pinpoint the problem even after all of these tests are performed. For me, the most useful device for diagnosing an aberration following LASIK is to place a rigid contact lens on the eye. The result would be that anything caused by the surgery on the surface of the cornea would be corrected by the lens, and the aberration would disappear. It is the only sure way to know. In fact, I would do this before I tried anything else. If the defect remained, then there would be more certainty about it not being on the corneal surface, and therefore not an artifact of surgery.

I am not sure that an OCT will tell you anything you don't know already, unless of course you had that same test performed just prior to surgery, in which case some additional loss would be found.

Best,

DrG

Greg Gemoules, O.D.
Coppell, Texas

Thanks for the follow-up Lynda. It's good that you have enough corneal RSB for an enhancement, if one is otherwise indicated. But, as your doc says, job one is to first find out why your vision is not as sharp as it should be, and what is causing the "smudge" in your vision. If it were a cataract mature enough to cause noticeable aberrations in your vision, it should be readily visible upon slit-lamp examination. So, since no cataract is apparently clearly visible at slit-lamp exam, I find it hard to believe that that is your problem. Another likely cause is an optic-nerve defect, and this can be readily diagnosed with a visual-field exam combined with an evoked-potential response test. Another, though less likely, cause would be an isolated corneal irregularity causing aberrations in only one quadrant of your visual field. However, if this were the cause, it would likely show on topography, which apparently is not the case. The tests Greg Gemoules suggests would also isolate the problem if it is surface based, and should also disclose any other remaining refractive errors, as well. So, you still need to proceed with some aggressive detective work to pin things down, Lynda.

Also, the fact that you have somewhat compromised vision both at distance and close-up is interesting. You say that reading glasses (+ sphere lenses) clear up your close vision, and you use different glasses (presumably, - sphere lenses) for driving. This implies that you are slightly undercorrected, but still suffer from some presbyopia. Unless you are well over 50 years of age, this is unusual. So, your case seems to have some unusual aspects to it. Please keep us informed as to your final diagnosis, treatment(s), and outcome.

Bryce

Well, I do agree with much of what Bryce has said. Perhaps this is an exercise in semantics, and the definition of "smudge." If I rub my thumb over my eyeglasses, I perceive a "smudge" or a "smear." However, if I have visual loss from glaucoma, I experience a "scotoma," or loss of retinal sensitivity. Very few, if any glaucoma patients report their scotomas, or blind spots, as a "smudge."

DrG

Dr. G,
The only tests he did was to dialate my eyes and look through I guess it's called the slit lamp? It was just a visual test with his eyes and his equipment. He might have the topography equipment in his other office. When I can get there, I'll let you know what happens.
Bryce,
I'm 54 and have been wearing progressive lenses since my early 40's. I used to be able to see tiny print if I lifted my glasses. Now I have to wear the reading glasses. Yes, my distance is slightly undercorrected and that is why I wanted the enhancement. But then I would probably not be able to read as well as I can without the reading glasses. It's a tradeoff I'm not sure I want to do. I'm in the process of getting another pair of progressive lenses. At least I can see things around the house without my glasses. I go outside when it's sunny without glasses but I still drive with the glasses on. It was very disappointing at first to have to wear the distance glasses but if I have to compromise my reading ability, I'm not sure I want to do that. I may just get the left eye, my dominant and good eye, done at a later time. How long do I have for them to lift the flip easily -- a year, two years?

Thanks for all your responses. I'll let you know what tests the cornea doctor does when I get there.

Virtually every normal healthy flap can be lifted for at least one year post op, and most flaps can be safely lifted for at least two years post op. After that it tends to be an individual thing. Some people heal more aggressively than others in the central and mid-periphery flap interface and this makes it very difficult and somewhat risky (due to the potential for a flap tear) to try to lift such flaps after two or more years. For other people the pari-central interface healing is more nominal and once the scar line around the periphery is broken open the flap can be lifted virtually indefinitely. The problem is it is impossible to know for sure if an individual flap will lift easily (or not) without trying, so it is prudent to have any enhancements done within two years of the original surgery, and, if possible, within the first year.

Bryce Carlson

I have an appointment with the cornea specialist in his other office tomorrow, Oct. 27th. Some days and moments, I don't see the 'smudge' at all. Other times, it's very clearly there. I'll mention the topography and wavefront abberometry to him. Will let you know what I find out in the PM.

Lynda

I had the appt. with the cornea specialist in his other office today. All he did was a nerve fiber analysis and said I had more damage in my right eye than my left. He said my glaucoma and cataracts is why I couldn't see clearly and there was nothing he could do for me. He said my eyes aren't bad enough for cataract surgery and that I probably shouldn't have had lasik in the first place. He said there was nothing wrong with my cornea. He is not a very pleasant doctor to deal with. I may go to someone else for a second opinion.

Lynda

Sometimes doctors forget that chairside manner is equally important to technical skill.

The analysis has shown that due to greater damage you are going to have a longer and more difficult healing process. At least that is something that can resolve on its own.

The doctor mentioned glaucoma, but you did not say if you are using any medication to resolve this issue. Long-term glaucoma can be very damaging to the eyes, but can normally be managed with meds or laser surgery – laser surgery different that LASIK. You will want to discuss this with your regular eye doctor.

Glenn Hagele
http://www.USAEyes.org

I am not a doctor.

My take-away from what you say the corneal specialist told you is that the evoked-potential test indicated that you do, indeed, have some clinically significant glaucoma-induced optic nerve damage, especially in your OD eye. This type of damage does not resolve. In addition, you apparently also have immature cataracts that may be affecting your vision to some degree. This also does not resolve. So, what the specialist is telling you is that while a LASIK enhancement may improve your uncorrected distance vision somewhat (at the expense of your near vision), it will not improve the "smudge" and other visual disturbances you are experiencing, and as the cataracts mature your vision will continue to degrade. So, bottom line, based on all these factors, you need to really evaluate whether or not there is enough potential gain in an enhancement to justify the risk.

Also, while some docs have a pleasant chairside manner, some docs, unfortunately, don't; nevertheless, in the end, the important thing is the quality of their work, and this guy sounds like he knows what he's talking about. Still, a second opinion is never a bad idea.

Bryce Carlson

Glenn,
I've been taking 2 kinds of drops in both eyes for around 10 years now. I was told that the pressure in my eyes needed to be stablized before having lasik and because they were, I went ahead and had it done. This cornea specialist seemed to think it was a mistake. I don't think it was unless there's something I'm missing. I was about 20/500 before lasik and am about 20/40 now. I think that's a big improvement.
Bryce,
I was going to say something to you but I forgot what it was... I'm losing my mind. I'll have to go back and reread your post.
Lynda

It may be that the cornea specialist though LASIK was a mistake because during the surgery a microkeratome is attached to the eye with suction. While this suction is applied, pressure inside the eye is dramatically increased - this is when your eye went dark during surgery. The increase in intraocular pressure is not normally a problem for a healthy eye, but your eye may not be healthy due to long-term glaucoma.

If this was the reason the cornea specialist thought LASIK was a mistake (and remember that I'm only speculating), then it would seem to be a judgment call, rather than an absolute contraindication.

Glenn Hagele
http://www.USAEyes.org

I am not a doctor.