I had Customvue intralase on August 15th. I have been suffering from severe glare. My doctor was Paul Krawitz Huntington, NY. My pre-op wavescan was OS -0.52 -3.25 X 71, OD +0.32 -3.80 X 98. My pupils were also measured at 8.2mm and 8.3mm average. I have glare both in the day and at night. During the day the glare is like a milky haze around light objects that bleeds over darker objects. At night the glare is much worse and appears more like horizontal starbursts or ghosting. I also notice a ghost image over light objects in my left eye that dissapears when I tilt my head back. I can look at my alarm clock and see a ghost readout pop up as I tilt my head forward. My post-op acuity is 20/25 in both eyes correctable to 20/20- with glasses. Glasses improve my symptoms slightly in my right eye but not the left. I also notice that my glare is very similar in both eyes and appears to take the shape of my pre-op astigmatism (horizontal bow tie). Meaning the starbursts and ghost images seem confined to an area of my vision similar in shape to the symmetrical red area on my pre-op topography. I am also suffering from moderate dry eye and usind drops throughout the day. The dry eye was severe at first but seems like it is getting alot better.

After being shooed out of my first two follow up visits I obtained a copy of my records and got a second and third opinion. Both doctors diagnosed me with micro striae in both eyes with the left eye being a bit worse. One doctor also noted that my flaps were torqued slightly to the left. It was recommended that my flaps be lifted and sutured and that I have an enhancement with the same laser three months after that. While reviewing my records I found that the technician had made a note about my striae at three weeks but Dr. Krawitz crossed it out and did not tell me.

I was not told that my large pupils and high astigmatism put me at a high risk for problems. I was told that the procedure was shown to improve glare and that the minimal glare I had with glasses and contacts would not get worse. I even set up a third consultation with my mother to discuss glare specifically and was assured again. When I signed the consent form I was told it was old so after our previos discussions I assumed that glare was not an issue with the new no blade custom lasik. I never imagined my doctor for more than twelve years would mislead me. My father and a few friends also had Lasik with perfect results so I was prett confident. If I questioned my doctor and did all the research before I would have known better. I am scheduled to have my left flap sutured ond the 15th but I am afraid it will not help. Would an enhancement be dangerous after the suturing? Could my optical zone be enlarged with a different laser than the VISX? I am a 26 year old graphic designer. I do not know what to do. Any advice would be helpful.

Post-op glare is dependent on a number of factors (pupil size, optical zone size, pre-op Rx, oblate v. prolate post-op cornea, Stiles-Crawford effect, etc.), so it is impossible to know for sure beforehand whether or not someone will end up with glare, and, if so, how bad it will be. Nevertheless, you had most of the variables working against you (huge pupils, 6.5 mm optical zone, difficult Rx), so you were definitely at considerable risk for serious issues with post-op glare, wavefront surgery or not. However, although the glare may not resolve completely, it will almost certainly improve significantly over the next several months as your eyes heal. Now, minor ghosting is a common symptom in the early post-op period. It typically resolves on its own within the first few months, and in all likelihood yours will follow this pattern as well. Same thing with post-op dry eye syndrome. Micro-striae, however, are best dealt with very promptly (first few weeks post op). The longer you wait the tougher it is to remove them. At this point, suturing may be required, though there are other techniques that are also effective (which I can describe if you're interested). If your doctors believe that the striae are affecting your vision (which they apparently do) then you should deal with them promptly. You definitely have some significant post-op issues, Aaron, and I understand your concern, but there is a very good chance much of this will resolve with proper follow-up care and a little tincture of time. I also agree with you that due diligence and a questioning posture are important when considering elective lifestyle procedures, such as LASIK.

Bryce Carlson

Another factor that may be at play here is the nature of your flaps. Although they have other advantages, flaps made with the IntraLase laser generally have a measurably rougher bed than those made with a blade because of the differences in the technologies. This relative roughness sometimes results in hazy vision for a few weeks post-op, as well as delayed transient photophobia in some patients. You apparently do not have photophobia, but you do have a problem with hazy or milky vision, and some of this may be due to the IntraLase keratome. If so, it is temporary and should resolve soon.

Bryce Carlson

I was sensitive to light for weeks after the surgery. I also notice that my eyes do not adjust in very low light as well. Two methods have been suggested to resolve the striae. One doctor would like to scrape and iron the flaps and then suture them into place. The other doctor just wants to stretch and suture the flaps and then do an enhancement with the VISX laser.

I tried Aphagan P tonight in conbination with my glasses and the combination almost eliminates my symptoms completely at night. Does this mean that it is probably a pupil size issue or could it still be the striae being more exposed as my pupil enlarges? I am affraid that this is just a case of my pupils being too large and I am going to be stuck with this.

I tried Aphagan P tonight in conbination with my glasses and the combination almost eliminates my symptoms completely at night. Does this mean that it is probably a pupil size issue or could it still be the striae being more exposed as my pupil enlarges? I am affraid that this is just a case of my pupils being too large and I am going to be stuck with this.

I tried Aphagan P tonight in conbination with my glasses and the combination almost eliminates my symptoms completely at night. Does this mean that it is probably a pupil size issue or could it still be the striae being more exposed as my pupil enlarges? I am affraid that this is just a case of my pupils being too large and I am going to be stuck with this.

TC#15

Aaron, the fact that Alphagan, a drug that shrinks your pupil makes your symptoms decrease means that your symptoms are influenced by your pupil size.

When your pupils are smaller you are also likely affected LESS by your microstriae. So it's hard to separate the effects of the two problems. The location of your microstriae could give a hint. Are they central, or more peripheral, or everywhere? Ask to have a diagram of them made for your charts.

Here's an example of how deep the refractive surgery BS you may have to wade in can become...

A large pupil patient with debilitating night vision problems was handed a prescription for alphagan from a LASIK surgeon WHILE he was telling her that many studies indicated pupil size is not a factor in night vision problems after refractive surgery. (Only the flawed studies reach this conclusion).
Same doctor had a pre-stamped prescription pad for Alphagan in his office. He does nothing but refractive surgery in his practice. That pre-stamped pad must be a huge time-saver for him.

I believe there are many small folds across both my flaps. I was told that they did not look like much but they were more obvious when I was fully dilated with drops. Another doctor also mentioned that my left eye "stained" when dye was placed in my eyes while my right eye did not.

That 'staining' indicates dry spots in your cornea. The best dye I'm told for diagnostic purposes is lissamine green. Ask for it when you see your Ophthalmologist. Ask your surgeon if a camera can be attached to the slit lamp to take some pictures of your staining.

I was told the worst kind of striae are those that are not paralell but rather extend in all directions like a spider web. Striae like these, I'm told, impact visual quality the most. They're the kind I have. Yipeee.

Then of course, how central the striae are plays a role. With your huge pupils you will see aberrations in your cornea out past 8mm, so you will really be affected by any incresed distortions that were introduced in your corneas by refractive surgery.

Sometimes the most effective questioning posture is a legal stance.

Aaron, I believe that you have been very well informed about the reasons for your current vision problems. A flap widening procedure at this point would probably induce some farsightedness. A flap stretch with suturing might be a good idea to remove the striae and straighten up the flap, however.

I have had success fitting patients with RGP lenses following this type of ablation. The lenses have oval optical zones to match the ablation pattern on your cornea. They will also neutralize the effects of the striae.

DrG

What is a flap widening procedure? I have not been properly fitted but placing a plano hard contact on my eye does not help. I had trouble making it throught the day with soft toric lenses before Lasik.

I meant "zone" widening procedure, and not flap widening.

I'm not sure what you mean by a "plano" RGP lens. By that do you mean there was no refraction over the contact lens that made you see better? I never suggested a toric soft lens.

DrG

I had a zero prescription hard contact placed on my eye and a prescription held in front of that. I did not notice a dramatic improvement but the lens was not properly fitted to my eye. The hard contact made my vision extremely blurry so I would imagine the prescription held in front of me was fairly high. If I had trouble tolerating a soft contact before lasik I would imagine that I would have difficulty with hard contacts now. I'm not so sure that a hard contact is a good long term solution for me. The reason I had lasik in the first place was because contacts were not working out for me and I did not want to spend every waking moment of my life with glasses on my face. Thank you for your reply. I would appreciate any other advice.

RGP lenses, if properly fitted, do not have to be uncomfortable. I, too, am curious to see what better options there are for you. Also, if you do undergo a successful surgical correction for your problem, I would like to hear about it so that I can recommend it to others.

Best to you.

DrG

Do you believe that I will not benefit from the procedures that have been suggested to me? Any educated opinion or information is of great value to me. I have very little time to decide about the suturing.

I did not say that "any of the procedures recommended" would not benefit you.

What I am saying is that after all of your flap repositioning, stretching, and suturing to get rid of the striae has taken place, you might still be left with visual artifacts for which a good solution may not exist other than contact lenses.

DrG

TC#14 November 6, 2005

Aaron,

You deserved to know that your high astigmatism and VERY large pupils put you at risk for a poor refractive surgery outcome. I'm so sorry that all of this was not clearly explained to you so that your individual risk factors could be taken into consideration when you made your decision about your surgery.

Since no laser exists in the US that can provide a fully treated area the size of your pupil, what you likely have is a 'blend' from the point where your fully treated zone ends and the size of your treatment zone, which may be smaller than your pupil! You can find out what size your treatment zone is by looking at your operative reports. You should have one for each eye in your charts.

Since you had astigmatism, your treated zone will be oval. This means it is narrow on one axis. This may account for the aberrations you see when you tilt your head.

The difference in area between the oval that is fully corrected and the size of your pupil when it is dark-adapted is your undertreated zone.

As the ambient light decreases, more and more unfocused rays of light from the undertreated 'blend' zone will enter your pupil. This may cause your vision to be very poor in dim light, and give you the experience of needing a different 'prescription' at different levels of ambient light.

Yes, the microstriae could be a problem. The fact that microstriae were written in your charts and then crossed out and not explained to you is clearly a breach of medical ethics.

If your microstriae are making a significant contribution to your visual problems, then you should discuss options for smoothing them out with several surgeons.

If you tell your new doctors that you had discount LASIK surgery in a Canadian shopping mall you may get a more honest appraisal of your condition. If a new doctor knows your original surgeon, or worse, is a friend of your original surgeon you will certainly be charged full price for your visit but you may not receive complete and candid avice. Yet again.

I'm very sad that you had to go through all of this... you were a poor candidate for refractive surgery due to your large pupil size and high preoperative astigmatism. Your doctor should have realized that a higher astigmatism correction and the resulting narrow/eliptical fuly treated zone would not be well tolerated in combination with large pupils.

Failure to deal with your microstriae PROMPTLY is another problem.

Here's a hint for you. Take your color topographies, and use a graphics program such as paintshop pro to cut a circle the size of your maximum pupil size. There is a 1mm grid on your topographies that you can use as a guide.

Now have a friend take a digital picure of your pupil while you hold a ruler under your eye. Your friend should use a fast shutter speed and a tripod, and you should be in a closet with only the light from a pen light.

Superimpose the topography circle which is the size of your pupil over your dark-adapted pupil image. This will clearly demonstrate the area of undertreatment.

Just so you know, contact lenses don't really help much with an undersized effective optical zone. Some say that your cornea may be flattened by the lens, and that this may extend your optical zone. Typically with large pupil patients, the area of undercorrection is HUGE, and there's just no remedy for that.

Bryce Carlson will be telling you soon that it's your fault for not knowing all of this. What must he be thinking of the surgeon who actually PERFORMED this surgery?

I'm hoping that many patients may ultimately be helped with lamellar corneal grafts. If the vision is truly intolerable, the graft may represent an improvement as the button could conceivably be cut over a fresh slice that is larger than the dark-adapted pupil. Less risk with a partial transplant than a full.

The new wavefront treatments are ablating more cornea, and ablating cornea farther in the periphery which could spell trouble for ectasia. The button, like the flap, may not contribute to corneal stability. Any LASIK docs care to comment?

I don't really know the incidence of chronic eye pain after corneal transplant... I know so many who have chronic eye pain from LASIK. Aaron, I hope dry eye doesn't end up on your list of refractive surgery complications as well. Use your drops often while you're in the healing phase especially.

I know all of this is a lot to digest, but the sooner you can understand the root cause of the problems you're experiencing, the more prepared you will be to make good decisions as to how to proceed from this point.

I have evidence to support the fact that contact lenses do help pupil-dependent post-LASIK aberrations. To some degree, and in some patients, contact lenses can also enlarge the area of the effective optical zone, similar to the "ortho-K" effect enough to help significantly with pupil-dependent aberrations between contact lens wearing periods. In fact, on Friday last week I dispensed a lens to a patient who had high myopia and very high astigmatism and who had an oval ablation similar to Aaron's. She was very pleased with her vision.

These are documented facts, Eye, not opinion.

DrG

I wish I could say I knew someone who had large pupils and a small effective optical zone and was helped by RGPs but I just don't.

I'm pleased to hear that you found someone with this problem WAS helped by RGPs. All the large pupil victims I've ever met were not. Some improvement perhaps... Most of the damaged post-refractives I know also have dry eye which makes the RGP experience a bit rocky. So some fail to be able to be helped by RGPs due to dryness, as you know.

Eye,

Despite the fact that this "law" or "principle" of optics needs to be proven only once, I have indeed proven it numerous times. You are welcome to the evidence, or just read my paper.

It is quite possible that you are hangin' out with the wrong crowd.

DrG

I don't really know many people who don't have doctoral degrees of some kind - mostly skeptical folks in my crowd, I guess. W need a large N and have to see the data for ourselves.

For example, when a surgeon conducts a LASIK patient satisfaction survey and only includes patients whose effective optical zone is at least 0.5 mm larger than their scotopic pupil in the study, my alarm bells go off.

I don't really know many people who don't have doctoral degrees of some kind - mostly skeptical folks in my crowd, I guess. W need a large N and have to see the data for ourselves.

For example, when a surgeon conducts a LASIK patient satisfaction survey and only includes patients whose effective optical zone is at least 0.5 mm larger than their scotopic pupil in the study, my alarm bells go off.

You say that you need a large "N" to be convinced, yet draw conclusions from your personal acquaintances. I wouldn't call that scepticism. I would call that stubborness.

If, according to you, NVD problems are related to a mismatch between the pupil and the optical zone, why can you not accept that enlarging the optical zone -- either via surgery or via a contact lens -- can eliminate the NVD?

I think that you are full of contradictions. You would deny patients access to rehabilitation through a campaign of misinformation, and you claim that you are a doctor. What a real shame.

DrG

My surgical treatment plan report is:

OS - Optical zone 6.00mm x 6.67mm with an Ablation zone to 8.00mm. My corneal thickness was 566 and my treatment depth was 62.4 microns. My flap thickness is 120 on the cusomvue paperwork but the intralase printout says 110.

My treatment was adjusted to -77 -3.08 x 71

OD - Optical zone 6.00mm with an Ablation zone to 9.00mm My corneal thickness was 565 and my treatment depth was 56 microns. My flap thickness is 120 on the cusomvue paperwork but the intralse printout again says 110.

My treatment was adjusted to +0.07 -3.66 x 98

I think the picture on this report shows the size of my optical and ablation zones relative to my pupil. My pupil seems to be outlined in blue with a green and yellow circle indicating the optical and ablation zones. The green area is eliptical on my left eye and circular for my right. Unfortunately, if I am reading the diagram correctly this would reinforce your theory about the ghosting (head tilting) in my left eye. My pupil is actually dilated beyond the yellow ablation ring on my left eye.

Well, Aaron was certainly NOT well informed by the surgeon who performed his surgery!

It sounds like Aaron did not receive proper informed consent for his initial surgery and that attempts were made to cover up his problems.

He was shooed out of the office at his follow-up visits?

Aaron, consider filing a complaint about your doctor with your state medical board.

Someone needs to start a bulletin board about doctors who perform surgeries on candidates like Aaron, and the experiences patients like Aaron have after the surgery. Excerpts from charts, patient affadavits.... it could be a very helpful resource to other patients out there who need to do their 'due diligence' to find out the facts about surgical procedures and the surgeons who perform them.

I do understand both sides of this argument but I started this thread because I really need honest advice. I belive that lasik can be a good procedure when patients are carefully selected and well informed of the risks. Everyone I know who has had the procedure is thrilled with their result. I also understand that a patient experiencing complications might be angry and blame their surgeon even when they have done no wrong.

I went to my doctor for a check up because my contact prescription was out of date and got the hard sell like you would not believe. In my case my surgeon was also my regular eye doctor for more than twelve years. I met my doctor in the emergency room when I was 14 after being hit in the eye with a hockey puck. I really trusted the information he gave me and did not feel the need to get a second opinion. I asked all the right questions and was carefully led to believe that I was a good candidate when I clearly was not. Even now I remain a fair and rational person. I should have done more research before making such a huge decision but misleading a patient and downplaying the very real risks of a surgery is not ok.

Aaron, Dr. Lee Nordan, a refractive surgeon had this to say about patients who are pleased with their refractive surgery outcomes:
-------------------------------------------------
Lee Nordan on happy refractive surgery patients;

http://www.crstoday.com/PDF%20Articles/0505/crst0505_nordan.html

"He again posed the question that I and many others have been asking for 15 years: Why are we still measuring the results of refractive surgery with a Snellen chart and then resorting to descriptive phrases such as “patients are happy”? Happy usually means that the patient’s visual function is poorer than desired, but he isn’t complaining … today."
------------------------------------------------
Now we know that LASIK does several types of permanent damage to the eye:
- LASIK surgery results in corneal nerve damage
- LASIK weakens the cornea to only 2.4% of the
strength of a normal cornea
- LASIK induces permanent distortions in the cornea
that cannot be fixed by glasses

Sadly, post-refractive surgery patients can develop problems from their surguries years later. About 40% of patients who had RK have a collapse and flattening of the front portion of their eye. This makes them very hyperopic. Not a pleasant prospect when combined with the effects of aging.

Aaron, remember people were very happy smoking until the damage began to take its toll years later. Refractive surgery damages every eye. The industry and surgeons know this but they sell refractive surgery to patients anyway - even the bad candidates sometimes. There is no oversight body governing these practices. The FDA has really dropped the ball.

You're absolutely correct that deceiving patients is wrong. By telling your story to as many people as possible, and spreading the word through the media, your workplace, your church - perpaps with a website... you could educate prospective refractive surgery candidates so that they are less likely to be deceived.

Aaron, my goal was to prevent patients like you, patients with multiple risk factors for a poor outcome, from having refractive surgery. Where would I have needed to place information for you to have seen it before you had surgery? What do you read on the internet? Where did you look before you had your surgery?

TC#16

Aaron said:

"I started this thread because I really need honest advice."
------------------------------------------------
Aaron, I'm a doctor of something but it's not Ophthalmology, so this is not medical advice. I will tell you what I would do if I were you.

First I would seriously look into treatment for the striae, especially if the consensus is that they interfere with vision.

Then I would wait a long long time, at least 6-9 months and wait to see how the flaps heal and how much visual recovery I obtain.

Then I would begin dealing with the symptoms... we're all hoping your dry eye is temporary and that won't be a factor after 6 months. Remember, each time your flap is ripped up you have to start over with nerve recovery. So you will have VERY dry eye right after your flaps are lifted, stretched and sutured if that's the treatment you
elect to have.

After your vision is stable, I'd check to see if it is liveable with glasses. If not, try RGPs. If you had problems with lenses before you're likely to REALLY have them now that you have lost corneal nerve density and your cornea is flattened and irregular in shape.

If regular RGPs don't work there are some new skirted lenses that are hard in the center and soft on the sides. They may help you.

Zone enlargement is a serious decision. It would eat tissue farther out in your periphery. You would need to know how much residual stromal thickness you have under your flap, and how much tissue the surgery would consume. The new 'safe' standard for residual stromal thickness under the flap is 300 microns. I am already below this with a single surgery, with no room for an enhancement. My surgeon knew it was a one-shot deal going in and didn't tell me.

I'm absolutely shocked at how evil some surgeons can be.

Bryce Carlson would say it was my responsibility to understand and learn the Munnerlyn (sp?) formula before I had surgery.

Finally, I would find ways to adapt to reduced visual quality such as buying many many lamps and using high wattage full-spectrum light bulbs.

You can get motion detector lights that come on automatically, and night lights so that you can get to the bathroom safely at night.

If you have too many aberrations to go to a movie theatre, buy a big screen TV and watch movies at home with all of the lights on.

If you are having problems adjusting to your situation, some patients find antidepressants to be helpful for a while. One caution... most antidepressants have a side effect of enlarging the pupil. So they may make your vision even worse.

Some day corneal grafting may help all of us get rid of our laser induced corneal mess. I'm hoping transplant techniques become better and safer really soon because there are many patients out there who will need them, and more future transplant patients are being generated by refractive surgeons every day. Sigh.

I appreciate your advice and I am sorry to hear that you too have had a bad lasik outcome. Please do not overrun this thread with anti lasik propaganda. I have some very difficult decisions to make and I am certain that anger and regret will not make them any easier. If you have any other helpful information I would appreciate it.

Aaron,
I personally am a big fan of flap sutures. They do a very nice job of removing flap striae. As with all procedures - there are risks. But in general - the results with flap suturing - at least in my office - have been excellent.
Obviously - each doctor has their own feelings towards the best methods to eliminate residual striae.
Once the striae are removed - you might notice that your quality of vision and night vision will improve. So it is too early to even consider additional laser treatment. First - the striae need to be fixed (if they are impacting your vision).

I hope this helps

Bill Trattler, MD
Miami, FL

Thank you for the response. I have met with two experienced surgeons. One surgeon would like to simply lift and suture the flaps and then do an enhncement after that. He believes that my striae are contributing to my glare but more laser will be necessary. He also said that most of my symptoms were probably due to residual astigmatism and that glasses would help but they do not. The other surgeon wants to scrape and iron the flaps and then suture them in place. The second surgeon is not so thrilled with the idea of an enhancement considering what happened the first time. He believes that the striae and my large pupils are causing most of my glare. He would rather see me in a pair of glasses if necessary after the suturing. I'm really having trouble deciding which surgeon to go with. The first surgeon has more experience treating striae but the fact that the glasses did not help after he said they would makes me nervous. Which method do you think would be better in my case? What do you expect the healing process to be like after the scraping, ironing, and suturing in one procedure.

Thank you for the response. I have met with two experienced surgeons. One surgeon would like to simply lift and suture the flaps and then do an enhncement after that. He believes that my striae are contributing to my glare but more laser will be necessary. He also said that most of my symptoms were probably due to residual astigmatism and that glasses would help but they do not. The other surgeon wants to scrape and iron the flaps and then suture them in place. The second surgeon is not so thrilled with the idea of an enhancement considering what happened the first time. He believes that the striae and my large pupils are causing most of my glare. He would rather see me in a pair of glasses if necessary after the suturing. I'm really having trouble deciding which surgeon to go with. The first surgeon has more experience treating striae but the fact that the glasses did not help after he said they would makes me nervous. Which method do you think would be better in my case? What do you expect the healing process to be like after the scraping, ironing, and suturing in one procedure.

Aaron,
Sorry to hear about your bad LASIK outcome. I'm dealing with something similar at the moment. I have noticable daytime glare/ghosting and poor night vision as well. The daytime effects are not debilitating but noticable enough to be annoying.

Like you, I noticed that the position of the daytime glare/ghost images seems to be aligned with my astigmatism -- vertical in my case. I had .25/.5D of astigmatism in my last refraction before LASIK, and at least .75/.75D since immediately after it. Still haven't figured out how that happened.

I'll be getting a thorough examination tomorrow from a surgeon who specializes in fixing problems from previous LASIK, so I should soon have more information about the cause of my problem. My fear right now is that flap striae are at least part of the problem, and that I'll be faced with the same choice you're having to make.

Whatever happens, please keep us posted.

My surgical treatment plan report is:
OS - Optical zone 6.00mm x 6.67mm with an Ablation zone to 8.00mm. My corneal thickness was 566 and my treatment depth was 62.4 microns. My flap thickness is 120 on the cusomvue paperwork but the intralase printout says 110.

My treatment was adjusted to -77 -3.08 x 71

OD - Optical zone 6.00mm with an Ablation zone to 9.00mm My corneal thickness was 565 and my treatment depth was 56 microns. My flap thickness is 120 on the cusomvue paperwork but the intralse printout again says 110.

My treatment was adjusted to +0.07 -3.66 x 98

Aaron, these are just estimates. Real numbers would have to come from an artemis:

RST = pre-op corneal thickness - flap thickness - ablation depth.

OS
566 - 110 - 62.4 = 393.6. Let's say 394, we aren't workinking with technology that will give you fractions-of-a-micron resolution.

OD
565 - 110 - 56 = 399.

This is good news, because even if your flaps were 120 you'd stil have over 300 residual stromal thickness under the bed. Don't do anything hasty with this tissue reserve. Wait, heal, do some research and make a carefully considered decision.

I don't think topographies routinely show your pupil size. There may be a 2nd picture above which shows your pupil size, and the technician's attemps at centration (putting the little plus in the center of your eye).

I have noticed that many technicians have been trained to put that little plus anywhere it needs to be to make the ablation seem centered. Sometimes the little plus is barely on the pupil. I have some ridiculous scans of my own eyes taken this way, and some even worse scans sent to me by other patients. The LASIK office personnel were working SO hard to make the decentered ablations seem centered.

Someone needs to creats a special website to post images such as these. If you decide to set one up, let me know. I have some terrific material for you.

Hi there! Sorry to hear about your induced astigmatism. Has your astigmatism changed its orientation... was it horizontal before and is now vertical, or was it vertical before as well and just WORSE now?

What was your pre-op corneal thickness, flap thickness and treatment depth in both eyes? What was your pre-op sphere (nearsightedness or farsightedness)?

You have enough astigmatism to make your vision a bit blurry, and it's on an awkward axis (it's visually easier to tolerate horizontal astigmatism). You have what's called against-the-rule astigmatism.

How could it have gotten worse? Well, LASIK is unpredictable and this point should be emphasized to every patient before they commit to surgery.

One concern is that you may have some inferior or superior thinning. This can result in a shape change in your cornea that gives against-the-rule astigmatism.

An orbscan would be a good test to have. Please report back to us your corneal thickness from the orbscan. You'll want to give the numbers from the image in the lower right corner scan that says 'pachemetry'.

You say you're going to see a doctor who specializes in fixing problems post-LASIK. Do you mind sharing the name of the doctor/clinic so that other damaged patients may consider a 2nd opinion there?

Ask for a copy of every scan that's made while they are printing them, (that's the easiest time to get them) and ask for a photocopy of your entire chart from the days exam before you leave the office. Don't leave the office without it.

Write all the concerns you have on the top of the page on the form you fill out that requests your name and address etc. This will ensure that this information ends up permanently in your charts.

Examples :
Please commment on induced astigmatism. Please comment on scotopic pupil size vs effective optical zone.
Please comment on level of induce higher order aberrations.
Please comment on microstriae.

Ask the doctor if he/she will take wavefront measurements at pupil sizes from 3 mm all the way up to your maximum pupil size, even if it is 7 or 8. This way you will know what your aberrations are at varying light levels.

When you get your wavescans back we'd love to hear some specific numbers from them.

Wish you all the very best! Good luck!

I listed most of the information you mention in my previous posts. My astigmatism was a horizontal bow tie in both eyes pre-op. I now have very little astigmatism in my left eye -0.50 -0.75 x 70. My script for my right eye is +0.75 -1.50 x 95. The orientation of the astigmatism in my right eye has changed and is now vertical. I saw another doctor today who was a bit concerned that I may have keroticonus(spelling?)in my right eye and advised against further laser treatment. She looked at my pre-op orb scan and said that nothing leaped out indicating keroticonus but she was concerned about some of the numbers on one of the two orb scans they made on the day of my surgery. She also said that my refraction was not stable and that I was a poor candidate for treatment. She also did not feel that my striae were significant and that the risk of treatment at this point outweighed the potential gain. My situation gets more confusing with each new doctor I visit.

The numbers on the bottom right image of my post-op orbscan are:

OS-Top,589 Left,581 Bottom,588 Right,614 Middle,468

OD-Top,599 Left,574 Bottom,592 Right,646 Middle,480

Aaron, the propaganda you got was from the guy who sold you this surgery, not from me.

Your pachemetries don't look dangerously thin... you'd be predicted to have OS 348 OD 360 microns under the flap in the thinnest central portion, which is good.

So a 2nd opinion doc doesn't think the flap striae are significant?

Do you have a pre and post- op wavescan? Can you give us the total higher order RMS from the lower right corner of the page for each eye?

Then give us the individual readings for the first three aberrations listed on the graph on the lower right. This could give us a clue as to what's going on with your aberrations. Bet you have TONS of spherical aberration from your untreated periphery. This gives halos and starbursts.

I do not think I have any wavescans post-op. I have pre-op orb scans and another customvue sheet with a picture of my eye. The pre-op RMS Err on that is OS 5.68 OD 5.37. I did have another zywave thing done post-op that lists my RMS at:

OS - RMS 0.94 / - and higher order RMS at 0.29/ - for 5mm/6mm. Higher order RMS w/o Z400 0.27 / -

OD - RMS 1.39 /1.99 and higher order RMS at 0.21/0.44 for 5mm/6mm. Higher order RMS w/o Z400 0.17 / 035

Aaron,

I had my exam yesterday and it looks like the cause of my daytime problems is coma, not flap problems. See my update to:

https://asklasikdocs.com/forum/main/3716.html

If you haven't had a wavescan done recently I'd recommend one before proceeding with your surgery. It may clearly indicate some combination of HOAs that is treatable by a wavefront procedure.

Steven

Eye/Bill you know just enough about refractive surgery to be dangerous. I find it very difficult to believe you have a PhD in anything requiring a shred of critical thinking. Maybe in Sanskrit or butterfly collecting. But in anything requiring an I.Q. above room temperature? No, I don't think so. As even the patient Greg Gemoules pointed out in frustration, "You say that you need a large "N" to be convinced, yet draw conclusions from your personal acquaintances. I wouldn't call that skepticism. I would call that stubbornness... I think that you are full of contradictions. You would deny patients access to rehabilitation through a campaign of misinformation, and you claim that you are a doctor. What a real shame." Yes, what a shame, and what a potential disaster for anyone gullible enough to take your advice seriously.

As just one of many, many ridiculous scaremongering misstatements you have made on these boards, consider your assertion above that "LASIK weakens the cornea to only 2.4% of the strength of a normal cornea." How ridiculous. Although a recent small study of cadaver eyes at Emory University found that central flap adhesion to the stromal bed was only about 2.4% of controls, that is a long, long way from saying that "LASIK weakens the cornea to only 2.4% of the strength of a normal cornea." Obviously, as everyone but apparently you knows, Eye/Bill, most of the strength of the post-LASIK cornea is in the residual stromal bed, and not in the flap, so this (2.4%) result does not in any way support your ridiculous assertion that "LASIK weakens the cornea to only 2.4% of the strength of a normal cornea." In fact, as I demonstrated in a recent thread on this page ( https://asklasikdocs.com/forum/main/3715.html ), there is strong reason to believe that the LASIK flap not only heals very securely, but does, in fact, contribute to some significant degree to the overall strength and structural integrity of the cornea. But I guess that thread is a little beyond your powers of comprehension, Eye/Bill. The above is just one of many, many misstatements and misrepresentations you have made on these pages. Get some help man (woman, whatever); you really need it.

Bryce Carlson

Bryce Carlson said:

"you need alarge "N" to be convinced, yet draw conclusions from your personal acquaintances."

REPLY
If you've asked around and never heard of ANYBODY who had success for a certain problem with a rehab treatment and you had that same experience yourself... it should make you skeptical! Turns out the ex girlfriend of someone I know had an EOZ pupil zone mismatch and claims to be helped by RGPs. She's the only example I've heard of. I wasn't publishing a study, I was openly asking about this matter here and through my contacts.

Bryce Carlson said:
"You would deny patients access to rehabilitation through a campaign of misinformation"

REPLY
I don't deny anyone anything. Howver, anyone who is considering a 2nd surgery to 'fix' problems from a first refractive surgery should think long and hard, because the state of the art of refractive surgery rehab is not terribly advanced. Many patients are made worse.

P.S.
I'm a big advocate of trying RGPs, not everyone can wear them but they probably won't hurt you.

Bryce Carlson said:
'Emory University found that central flap adhesion to the stromal bed was only about 2.4% of controls, that is a long, long way from saying that "LASIK weakens the cornea to only 2.4% of the strength of a normal cornea."

REPLY
Obviously the flap is vunerable to damage, it takes very little force to dislogde it. Not what I wanted for my eyes... or would want for a loved one's eyes. OK, now that I think about it more I wouldn't wish that on an enemy! This is a serious finding made at Emory and people should be giving some serious thought to discontinuing LASIK just on this basis.

Bryce Carlson said:
"Most of the strength of the post-LASIK cornea is in the residual stromal bed"

The thickness of which depends on those unpredictable mikrokeratome cuts, how thick your cornea was to start out with and how much cornea the surgeon vaporized away with the laser. The Emory study was not about RST. I've written enough about the importance of RST that even you know I know it is also important to corneal health and stability.

Look, I'm zooming right along career-wise, and have tons of friends. I have a social conscience and I want to do the right thing by others, so I research refractive surgery and post what I find.

Why don't you debate the science and drop the preschool sandbox tactics. This neener neener neener stuff is tiresome. We'd like to hear you say something that actually gives some credibility to your position. And please support your statements with peer-reviewd publications that you feel are strong scientifically.

Bill and I, separate individuals who live in different states, are ready to pick apart bad publications at any time.

I know it's crowded in there, Eye/Bill, and I know it's hard for a man (woman, whatever) of your unique mental capacity to focus for more than a few seconds at a time, but try really hard, okay? Ready in there? Alright, I repeat, among many other ridiculous assertions you stated "LASIK weakens the cornea to only 2.4% of the strength of a normal cornea." Now, either back up that statement with facts -- not fluff -- or be branded for what you are, namely, a disturbed, scaremongering site-bomber of questionable intellect and unquestionable emotional instability.

Bryce Carlson

Because you're incapable of debating issues. Perhaps you are insecure of your own intellect and emotional stability?

Here is the text you dispute:

Excerpt:
The human corneal stroma typically heals after LASIK in a limited and incomplete fashion; this results in a weak, central and paracentral hypocellular primitive stromal scar that averages 2.4% as strong as normal corneal stroma.

http://www.journalofrefractivesurgery.com/showAbst.asp?thing=11320
Cohesive Tensile Strength of Human LASIK Wounds With Histologic, Ultrastructural, and Clinical Correlations
Journal of Refractive Surgery Vol. 21 No. 5 September/October 2005
Ingo Schmack, MD; Daniel G. Dawson, MD; Bernard E. McCarey, PhD; George O. Waring III, MD, FACS, FRCOphth; Hans E. Grossniklaus, MD; Henry F. Edelhauser, PhD

Why don't we allow patients on the bulletin board follow the link, read the article and decide for themselves if this is something they felt fully informed about and wanted, or want... for their own eyes.

..., or are you just being disingenuous? Either way, your credibility is completely shredded. Again, you stated that, "LASIK weakens the cornea to only 2.4% of the strength of a normal cornea." The study you cited merely states that, "This results in a weak, central and paracentral hypocellular primitive stromal SCAR that averages 2.4% as strong as normal corneal stroma." So, the study says the interface "SCAR," alone, "averages 2.4% as strong as normal corneal stroma," while you say the post-op "CORNEA," itself, "has only 2.4% of the strength of a normal cornea." Unbelievable. I would have thought even someone of your limited capacity would be able to distinguish a difference as drastic as that between interface "scar" and post-op "cornea." But I guess not. Before you lecture others, or challenge me to stay on point, Eye/Bill, I suggest you learn enough about refractive surgery to at least know what the basic points are.

Bryce Carlson

Corneal grafts? You've got to be kidding us, Eye. Many patients with corneal grafts have worse problems than patients with post-LASIK difficulties, and STILL require RGP contact lenses afterwards. Besides, the donor pool for donor corneas is being reduced by the number of patients who are getting LASIK.

The most reliable vision fix for post-surgical problems was, is, and will be RGP contact lenses, and so you might as well quit trying to discourage people from getting the help they need.

By the way, no attorney can restore vision.

DrG

Dr. G said:
"....the donor pool for donor corneas is being reduced by the number of patients who are getting LASIK."

Eye replied:
Can we quote you on this? This is alarming. Should be in all the newspapers.

Dr. G said:
The most reliable vision fix for post-surgical problems was, is, and will be RGP contact lenses, and so you might as well quit trying to discourage people from getting the help they need.

Eye replied.
No, the most reliable fix for post surgical problems is prevention of the medially unnecessary elective surgery. You may consider stopping the spread of the notion that RGPs fix every damaged post-refractive, because for many patients, former visual quality is NOT restored and many patients can't tolerate RGPs at all due to dryness.

Dr. G said:
"By the way, no attorney can restore vision."

Eye replied:
Apparently no refractive surgeon can EITHER.

The former head of the Opthalmic ENT division admits, reluctantly... that litigation is the patient's only recourse:

From the FDA transcripts July 1999 Opthalmic Devices Panel Meeting:

DR. ROSENTHAL: We cannot tell them how to write an informed consent. We can tell them what the labeling issues are with respect to the device, the adverse events, the complications, the potential hazards, and we can embolden it in big bright blue letters, but if a doctor does not want to tell it to the patient, we cannot tell him to do so.
DR. MC CULLEY: The check and balance in the system for that physician who does not is our legal system.
DR. ROSENTHAL: I am afraid.

Aaron said, "Even now I remain a fair and rational person. I should have done more research before making such a huge decision, but misleading a patient and downplaying the very real risks of a surgery is not ok."

Yes, intentionally misleading patients is not okay. Beyond that, it is immoral, unethical and wholly unacceptable. Unfortunately, it does occasionally happen, especially in largely marketing-driven elective lifestyle procedures, such as LASIK. In any case, Aaron, I am glad you've had the strength to keep your emotional balance during this rough time. It's all to the good, as clear thinking and emotional stability are important factors in the healing process.

Bryce Carlson

DrG,

I'm interested in the RGP's. I wonder if I would have a problem wearing them though as my eyes started rejecting the wear of soft contacts after 15 years of use. Does this matter? Have you heard of that before? Do you have any ideas why someone would all of a sudden be unable to wear contacts after such a long time?

Thank you for your time,

Matthew

In more than 20 years of fitting contact lenses, I have never run across a case of an eye "rejecting" a contact lens in the medical sense of the term. On the other hand, I have certainly seen my share of patients who became intolerant of them for one reason or another. The chief reasons are (1) dryness, and (2) allergies.

The dryness that can follow LASIK complicates the wearing of contact lenses, and so we work on treating the dryness. Such patients are typically able to tolerate a larger, comfortable lens like a Macrolens, but not all day. Because of limited wearing time, I try to get a therapeutic effect on cornea, such that the patient gets improved vision upon lens removal, similar to having the lens in, for at least a few hours more.

DrG

It is especially not ok to mislead a 26 year old patient who could potentially have keratoconus. I was told I had "micro changes since my last visit" when my manifest refraction had gone from 3.00 to a 4.25 cylinder over the course of 18 months. During my consultation my refraction was a myopic astigmatism which would be to high for treatment with customvue. I guess by chance my right eye came up on the wavescan as a mixed astigmatism so I was approved. My orbscans prior to surgery indicate that I am in a sort of grey area for keratoconus. None of this was discussed with me. I did not even understand what keratoconus was until last week. I urge all patients considering refractive surgery in the NY area to avoid the name Paul Krawitz.

Yes, the buck stops at the guy with "M.D." after his name. This is something Glenn Hagele has stated many times, and I agree with it completely.

Also, in addition to abnormal topography (generally, high eccentric astigmatism), the posterior float is a key marker for keratoconus (including iatrogenic keratoconus, or ectasia). Therefore, if you will take a look at your pre- and post-op Orbscans and estimate your max OS and OD posterior floats from the color bar (upper right-hand corner), I may be able to give you some idea of whether or not you likely had overt keratoconus pre-op or incipient iatrogenic keratoconus (ectasia), now.

Bryce Carlson

Aaron,

Contraindications for LASIK include indications of keratokonus, which you had and also an unstable prescription, which you had.

Performing customvue LASIK on someone higher than the approved limit for myopia is called an 'off-label procedure' and you would have had to sign an extra consent form for that to be kosher. Did you?

Are you aware that LASIK surgeon Dr. Mark Speaker lost a 7 million dollar judgement to a patient who had signs of preoperative keratokonus and developed problems afer surgery?

Your doctor made several other 'misteps'.

Refractive surgery complications are a lot to go through at age 26, and none of this should have happened to you. You deserved to be better protected by the FDA and the medical community.

I am so deeply sorry. How to move forward from here? Try rehabilitation with contact lenses before you consider additional surgery, give your eyes a looooong time to heal and check the statute of limitations for lawsuits in your state.

The expert witness on the Speaker case may still be available!