Patient: 52-yr. old male

Preop level of myopia and astigmatism:
Humphrey autorefactor results
OD: -5.25, -1.25 x 173
OS: -4.75, -1.25 x 170
Subjective refraction results
OD: -5.25, -1.25 x 173
OS: -5.00, -1.50 x 10

Preop pupil size:
undilated: 3.63mm and 3.60mm
Colvard Pupillometer: 4mm each
Wavefront scan: 5.25mm and 5mm (Note: pupils were dilated for scan)

Laser used:
VISX S4 Star Excimer

Did you have custom laser? Yes, VISX CustomView

Date of surgery: 8/1/06

I am a 52 yr-old male who had bilateral LASIK on 8/1/06 (IntraLASIK with VISX S4 Star wavefront-guided ablation) and have experienced profound halos, starbursts, and dry eye pain ever since with no improvement. Halos and starbursts are much worse at night, but I also see starbursts when the sun reflects off of shiny surfaces in the day.

My undilated pupil size is 3.63mm (approximate – both eyes). Pupils measure 4mm with a Colvard pupillometer. Pupils needed to be dilated to obtain an “accurate” wavefront scan measurement. Records show that they were dilated to 5.25mm and 5mm. Optical zone was 6 x 6.5mm with transition out to 8mm.

My surgeon claims that my aberrations are definitely not pupil-related, but he can’t explain why I have them. He claims that the laser tracking was enabled and accurate. I have since read that it is difficult to obtain accurate wavefront scans with small pupils like mine and that dilating the pupils can potentially affect accuracy of the measurement. Furthermore, the VISX literature that I’ve read claims that the safety of LASIK on pupils smaller than 6mm has not been evaluated, implying that it is not advised. My post-op topography map shows the flattest area of my cornea (blue) skewed superiorly and I’m wondering if I’ve had a decentered ablation, which is contributing to the halos and starbursts.

Before surgery, I was aberration-free and had crystal clear night vision with prescription glasses. Street lights, headlights, LEDs, etc. all appeared as precise, clear, beautiful points of light.

I have tried prescription glasses due to some residual astigmatism not corrected by the LASIK procedure, but aberrations were not diminished. I have even experimented with Alphagan, even though my pupils are small, but it, predictably, had no effect on aberrations.

In addition, I’ve learned by obtaining copies of my records after surgery that my Schirmer test resulted in a reading of 4mm, which is very low. My surgeon’s response, when confronted with this information, was that males rarely suffer dry eye beyond the healing period (6 months) so, apparently, he was not concerned.

Should not my Schirmer test result and small pupil size have been considered contraindicators to surgery by the physician, which he should have discussed with me? Any ideas on what could be causing my aberrations? Thanks

You are about six weeks postop. That is a long way from the normal six month healing period. It is way too early to make a decision about your outcome.

The wavefront aberrometer is able to accurately read aberrations at any pupil size, however those readings will not be the same at a different pupil size. What is important is that the reading be with the pupils at least as large as they are in a low light environment. Dilation of the pupils is not only common, but is required on some systems. In the FDA clinical trials the average pupil size was may have been about 6.0mm or larger, however that does not mean that the laser cannot be used on smaller pupils.

It is difficult to say from your description of your colored scan if a decentration occurred, however a shift in color can indicate simple astigmatism, which you state you have.

There is nothing in the preop information you have provided that would exclude you from being a candidate for Lasik. A low Shirmer test can indicate mild dry eye, but if the tear breakup time is good the low Shirmer may not accurately reflect the condition of your tearing function. I assume that you did not have dry eye problems before Lasik and this was reported to your doctor. We recommend that any dry eye problem be fully managed before Lasik, but if you had no dry eye symptoms other than a low Shirmer number it would appear that whatever dry eye you may have had preop was already managed. We have a detailed article about Lasik and Dry Eye at http://www.usaeyes.org/lasik/faq/lasik-dry-eyes.htm that you may find helpful. The starbursting you describe (day and night) can be caused by dry eye.

The daytime starbursting can also be caused by the interface of the laser created flap not yet fully adhering. If your vision clears with the application of preservative-free artificial tears, then it would appear that your starbursting is a dry eye issue. If your vision clears, but not fully, with artificial tears, the starbursting may be due to a combination of the dry eyes and the IntraLasik flap not fully healed. If artificial tears do not change the starbursting, then a rough interface that has not healed and smoothed yet may be the problem.

I recommend that you seek a second opinion from a corneal specialist at a university affiliated teaching hospital. A second opinion can respond to your concerns much better than anything anyone can do on the Internet.

Glenn Hagele
http://USAEyes.org
Lasik Patient Advocacy & Surgeon Certification

I am not a doctor.