My pupils measure 7mm.
Contact lens prescription is -4.50. -4.75

I see minor haloes, glare and starbursts today with both my contacts and glasses.

I've had three lasik consultations.
One physician recmmended the ladarvision laser.
One recommended the B&L laser.
... and the doctor I chose to perform lasik next week swears that the VISX Star S3 laser can do the job utilizing the blend zone.(he has access to the ladarvision as well)
and is planning th use the VISX.
Your thoughts are appreciated.

Thanks

For a treatment like yours, any of the lasers should do fine. I have used the ladarvision and the Visx with blend zone on patients with prescriptions like yours and pupils like yours and found that both work effectively with minimal glare and haloes. There has even been some recent research that has shown that haloes are not necessarily always related to pupil size. I think you should go with what your surgeon feels comfortable with since he knows what gives him the best results.

Good Luck

Patrick Chin, MD
Westwood, NJ

I guess you could get halos even with small pupils. That would be a case where halos aren't related to pupil size. But, otherwise, there is a strong correlation between large pupils/undersized treatment zones and halos. It is no accident that the latest generation lasers have larger treatment zones. Getting the right treatment zone is imperative for large pupils.

Dr. Chin, I'm dismayed that you would downplay this necessity.

Ralph, I'm not a doctor but let me give you my rule of thumb for laser treatment zones for mild/moderate prescriptions such as yours. You want AT LEAST 50% correction all the way out to the edge of your pupils. Note that a blend zone transitions from 100% correction to 0% correction. As an example, a 6 mm to 9 mm blend zone would have 50% correction at 7.5 mm. Such a blend would be more than adequate for you. Find out from your doctor(s) what size treatment zone they would provide for you. This would include a 100% corrected Central Ablation Zone (CAZ) and possibly a blend zone also known as a Transition Zone (TZ).

One other important note, if there is any astigmatism in your prescription, the Visx laser will reduce the size of one axis to achieve the necessary ablation. That is, the ablation area will look like an oval. For example, it could be 5.5 mm x 7.5 mm. It is important to ensure that you get the necessary treatment all the way around. Make sure you have this base covered before you submit to LASIK.

The three lasers that you cite are all POTENTIALLY capable. That is, if they have updated to the point that they allow the larger treatment zones and (in the case of the Visx) you have little or no astigmatism, you should be fine. Make it your job to know that the laser that you choose can handle your eyes.

I know clinically there is a correlation between pupil size, ablation zones, and night time vision problems. However, the medical literature has a few papers that have shown there is no correlation between pupil size and ablation zone (atleast in their test subjects).
I am dissapointed that there are not studies to back up what I have seen clinically - which is that people with large pupils treated with smal optical zones can develop severe night time problems.
As for the VISX - for a patient with moderate sphetical correction can typically be treated with the VISX laser with large zones (6.5mm optical zone) and transition zone (out to 8.2mm). Please understand that I can not say whether one is a good candidate with a particular laser since I have not had the chance to examine the patient personally.

I hope this helps

Bill Trattler, MD
Miami, FL

I am now 12 days post lasik. I'm seeing 20/20 in my left eye and 20/30 in my right. My right eye has "lasik induced astigmatism", which may require an enhancement.
Yesterday, I drove in a dark rural area. The starbursts from oncoming headlights, house lights and street lights were blinding.
When I stared at a light, or turned on my car dome lights and allowed my pupils to open up, the starbursts went away... then returned when my pupils dialated again.
Do you think my starbursts are temporary or permanent? How can I know for sure?

Thanks...

Did you go with the VISX laser? What size treatment zone did you get?

It's too early to tell if these effects are temporary or permanent. Give it time. But my guess from personal experience is that it will improve to a certain extent over the next few months but not completely. Only time will tell how much improvement you will get.

We used the VISX Star S3, nasal flap.

I'm now 4 months post lasik and am still experiencing halos and starbursts at night.
Alphagan P has been my only salvation.
Perhaps the VISX Star S3 was not the correct choice.

Please let me know the following, so I can answer your question

1. What is your current refractive error?
2. Do you have any astigmatism or irregular astigmatism
3. Is your vision 20/15 or 20/20 without glasses right now?
4. Can glasses sharpen or crisp up your vision in anyway?
5. When was the last time your surgeon performed a topography to look at the shape of your cornea?

I am happy to help - please let me know

Bill Trattler, MD
Miami, FL

>Please let me know the following, so
>I can answer your question

>1. What is your current refractive error?

Left eye is plano.
I wear a contact lens in my right eye -0.00 -0.75 100. It corrects the astigmatism, increases contrast and virtually eliminates the halos and starbursts.

>2. Do you have any astigmatism or
>irregular astigmatism

Yes, astigmatism in the right eye.
The astigmatism in my right eye was induced by the lasik procedure. My doctor attributes it to an irregular shaped cornea going into the procedure.

3. Is your vision
>20/15 or 20/20 without glasses right
>now?

Left eye is 20/20. Right eye is 20/30 but corrects to 20/20 with the soft toric lens

4. Can glasses sharpen or crisp
>up your vision in any way?

Yes. The soft toric lens in my right eye sharpens my vision to 20/20, increases contrast and significantly helps the halos and starbursts

5. When
>was the last time your surgeon
>performed a topography to look at
>the shape of your cornea?

At the 2 week post-op visit.

I have an enhancement scheduled for 9/25 to correct the astigmatism in my right eye.

Dr. Trattler - Thank you so much for your continued dedication...

>I am happy to help - please
>let me know

>Bill Trattler, MDMiami, FL

Ralph,
I am happy to help. But I am confused. Why do you say Alphagan P is your only salvation - yet a soft toric lens also corrects your vision and eliminates the night time vision problems. Can you please clarify.
Thank you

Bill Trattler, MD
Miami, FL

I only wear a contact lens in my right eye. My left eye is plano. I need to use Alphagan P in order to eliminate the starbursts in both eyes.

Not to confuse the issue though... My question is "Can I reasonably expect the starbursting to subside over time considering I am already 4 months post lasik?... and more to the point... Was the selection of the Visx Star S3 (6.5mm treatment zone with blend to 8.2) the correct choice?"
Please review my initial (April 10th) posting and the responses.

Thank you.

First - you may want to have your pupil size remeasured.

Second - your surgeon had access to both the VISX and Autonomous. Was there a reason he chose the VISX?

Third: Do your corneal topographies show any irregularities suggestive of
A. Irrgular astigmatism
B. Central islands
C. Decentered ablations

Fourth: Do you have dry eyes? Does lubcrication affect your night time symptoms

Fifth: If you shine a small penlight into one of your eyes - do the night time symptoms reduce/resolve?

Sixth: You should request a wavefront measurement exam - which is a new technology that can examine your eyes and see what types of aberrations you may have in your vision that are causing the night time vision problems.

For patients without astigmatism - the experts have reported that the VISX laser with transition zone provides excellent results for patients with mild to moderate myopia (up to 6-7 diopters) and helps significantly reduce the risk of night time vision problems.

I think the key issue is for you to have more testing to determine the exact source of your vision problems.

I hope this helps

Bill Trattler, MD
Miami, FL

>First - you may want to have
>your pupil size remeasured.

OK. Thanks

>Second - your surgeon had access to
>both the VISX and Autonomous.
>Was there a reason he chose
>the VISX?

The Visx preserved more corneal tissue

>Third: Do your corneal topographies show
>any irregularities suggestive of
>A. Irrgular astigmatism
No
B. >Central islands
No
C. Decentered
>ablations
No

>Fourth: Do you have dry eyes?
> Does lubcrication affect your night
>time symptoms
No, No

>Fifth: If you shine a small
>penlight into one of your eyes
>- do the night time symptoms
>reduce/resolve?

Yes. Also turning on the dome lights while driving resolves the starbursting

>Sixth: You should request a wavefront
>measurement exam - which is a
>new technology that can examine your
>eyes and see what types of
>aberrations you may have in your
>vision that are causing the night
>time vision problems.

OK. Thanks

>For patients without astigmatism - the experts
>have reported that the VISX laser
>with transition zone provides excellent results
>for patients with mild to moderate
>myopia (up to 6-7 diopters) and
>helps significantly reduce the risk of
>night time vision problems.

>I think the key issue is for
>you to have more testing to
>determine the exact source of your
>vision problems.

>I hope this helps

>Bill Trattler, MDMiami, FL

Thank you...

Wednesday, 9/25, I'm scheduled for an enhancement to correct the astigmatism in my right eye so I decided to get a second opinion prior to the surgery.
The second doctor agrees with the planned treatment however... he determined that my pupils measure more like 8mm in total darkness, a probable cause for the starbursts!
Looks like I'll be on Alphagan-P for the forseeable future.

So I was on the money with my comments to remeasure your pupil size.

I hope everything went well.

Bill

Following a flap relift (one week later) to smooth out wrinkles left behind by some corneal swelling, the enhancement was a success; the astigmatism in my right eye was eliminated.
We also did a wavescan to help determine if any high order abberations were responsible for the starbursts. The results were inconclusive.

Is there any hope for curing the halos and starbursts besides Alphagan-P?
Is it save to use Alphagan-P every night for "life"?

Thanks!

Alphagan-p is a commonly used drug for glaucoma with minimal side effects. As for long term safety, the FDA studies have not found any problems to date. The drug has really been on the market for about 6 or 7 years (initially as Alphagan).

Are the starbursts and haloes any less than they were before the retreatment? If so, they may continue to improve as your eye heals. In addition, future wavefront readings may give more conclusive readings.

Good luck and let me know if there are other questions.

Patrick Chin, MD
Westwood, NJ

I've been using Alphagan P occasionally for about a year. It is remarkable. The side effects are negligible.

I don't find a need to use it every day. I just use it when I know I'll be in prolonged low-light situations like night driving.

I find this discussion very interesting. I was about to have Lasik but found out the day of surgery I had 9mm pupils. I could have had a 7.5mm treatment zone with a 1mm blend zone, for a total of 8.5mm (Autonomous laser with Ladarvision). It sounded like too much of a risk of nighttime vision problem without doing further research, so I cancelled. But I would still like to get Lasik if I could better predict the outcome. How much does Alphagan P reduce pupil size? To me it doesn't sound like a big inconvenience (probably less than glasses) unless it is painful or expensive. And if it takes pupils down by a consistent 2 or more millimeters, it might be an option for me. Anyone have opinions on this????

My Alphagan P is covered by my company's drug prescription program so I only pay a $15 copayment. However, the full price is around $60-$80 per bottle.

If your pupuls are truly 9mm, you were smart to cancel. Even with the possibility of using Alphagan, I don't think you want to put yourself in a situation where you KNOW you will depend on them.

Although Alphagan P can be effective to reduce pupil size, I would never ever perform surgery knowing that a patient would require Alphagan P on a daily basis - since some patients can develop allergies or have side effects to the ALphagan - so that it could not be used any more.
The goal should be either to feel confident that the ablation will not leave you with significant night time vision problems - or wait untul technology is available.

I hope this helps

Bill Trattler, MD
Miami, FL

did u have to ask about your pupils on the day of surgery? or did they just tell u..?
i think my pupils look big but i have'nt been told ANYTHING .. i could'nt even remember wheather they did it or not ... becoz she wasn't telling me what she was doing as she went along...
i even rang up pretending to ask about something esle and added oh by the way did u measure my pupils and she got all catty with me ...but still never told me how big they were..
Dr Bill ..Whats the consquences of having lasik on big pupils/-7 myopia .. i don't know about my corneal bed.....? like i mentioned a few times my big concern is double vision..i don't mind starbursts/halos so much....i am using the Visx Star 3 with tracker

I was told that my pupils "were not humongous" and that the Visx Star S3 would not leave me with starbursts or halos.
I was told that not one of my physician's patients ever had a lasting problem with starbusts or halos.
Eight months post lasik, and I am still forced to use Alphagan-P drops every evening in order to walk in NYC and then drive home.
Without the drops, I can't sense whether a car in the distance is moving forward or backwards (the headlights appear to pulsate as my pupils dilate and constrict to adjust for the light).
Visit Surgical eyes and look at the photograph of a person with starbursts and halos at night; Get your pupils measured accurately before you proceed with surgery!!

Hi Ralph:
You had mentioned that you had a resultant astigmatism after LASIK. Could this be the cause of your night vision problems? Alphagan P would reduce the symptoms of such a problem. Perhaps an enhancement would help. What has your doctor said?

And don't interpret this as adding insult to injury but I've long strongly advocated that patients know their pupil size and know the proprosed treatment zone prior to LASIK to ensure that it will be adequate. Hopefully, more will heed this advice. You'd be surprised how many people I tell this to and they still undergo LASIK without knowing the answers to these important basic questions.

On a more positive note, let me say that last winter at 6-8 months post-LASIK, I was using Alphagan P about twice a week for night driving. This winter (now 18 months post-LASIK), I feel less of a need to use it. Either my night vision has improved over that period or my brain has adjusted to it (I think its a little of both, actually).

Good luck in the future. Let us know how you make out.

George,

I never took the pupil size debate lightly. I guess my issue is that pupil size measurement is not an exacting science. Not one of 4 well established surgeons I visited pre-op used a tool to measure my pupils; they all measured manually with the card. In fact my doc argued that the infrared devices are not worth the investment.

As for the astigmatism, I had an enhancement 2 months ago to correct it and I now have 20/15 vision in both eyes during the day.

My doc assures me that in about 10 years, my pupils will decrease in size as a natural result of the aging process... something to look forward to!!

Ralph

I haven't checked the board lately since I've given up on refractive surgery, at least for now, due to pupil size.

I would agree with others who have posted that my main gripe would be the inexact science of measuring pupil size. I was told I had 7mm pupils by my cooperating eye doc, then told by my surgeon's staff I had 7mm pupils (this was 1 week prior to my scheduled surgery.) Then, on the day of surgery, I insisted on another measurement, whereby I was measured repeatedly at 9mm! All this after driving 3 hours a week earlier for the same test. Every time I was just measured with the card. I was also told that the infrared machines are not necessarily more accurate. I think you need to be very careful, watch how they estimate the size if using a card, who is doing it, how dark do they make the room, etc. There is so much guess work! Which is fine if you're a 5mm pupil, but not when you're at the upper end of the range.

I was also surprised at how cavalier the surgeon could be about potential problems. "You will have an increased chance of problems with your pupil size, but we can still do it". Well great, as long as ALL of the risk is mine. I'm glad I backed out, and am more appreciative now of my crystal-clear nighttime vision with my glasses.