I realize from having read the numerous posts on the subject that my question has been asked before. However, my situation compels me to ask it again.
I underwent bilateral PRK in June of 1998. While my daytime vision is quite good, I, like many others, experience a fairly significant degree of nighttime starbursts and halos. My left eye is "plano"(20/15-20/20), and my right is only slightly overcorrected(20/20). My doctor has determined that this problem is solely related to pupil dilation in low light. (and I have confirmed this by shining lights in my eyes, etc. and watching the starbursts and halos recede).
I had originally contemplated a career in the military, or even the police, but my nighttime vision is now unfortunately inadequate to the task; and for obvious reasons, neither organization will accept people who require eye drops, however infrequently. Since I can still function (in my miserable day to day existence, ha ha), I would rather avoid pilocarpine drops, however safe they may be.
My question is this: At 27, I still technically have 6 or 7 years before I would be too old for the military. Is it reasonable to believe that new custom enhancements, wavefront technology, TOSCA, etc. could be viable as an effective treatment option within such a timeframe? Alternatively, will it take longer, or will it likely never be possible to ever fix this condition. To be quite honest, at the current rate of technological advancement, I fail to see why future hope isn't warranted. (but I've certainly been wrong before). I also understand the conservative approach of Doctors regarding further surgery, and their reliance on eyedrops, but if one cannot currently pursue any of one's career choices, it seems reasonable for one to seek out a permanent solution. I have read every post on the bulletin board in re this subject but I have found only incomplete or equivocal answers (no offense intended). In short, I am willing to be patient, but I would be even more depressed if I thought I would have to live with this side effect forever, or until such time as my pupil dilates less due to aging.(my night vision will evidently begin to improve just as my arthritis sets in - great.) Thank you very much for your help, I'm really desperate for an answer.

it sounds like you do not understand pupils and how they change over the course of time. With age, the pupil size gradually reduces in diameter. So if a person has large pupils when they are younger, over time their pupil size at night will naturally decrease.
However, if this takes 5- 10 years or more, then the night time problems will significantly affect your life for a long time. So for that reason, you might want to consider one of the eye drops that reduce or eliminate the night time symptoms.
One drop that you did not mention is Alphagan - which a lot of patient report helps with their night time symptoms. Alphagan is completely different than pilocarpine, but can be effective in patients with the symptoms that you are describing. Alphagan is a safe medication - although you should certainly talk with your doctor about this and any other medication that you might use.
As for pilocarpines - if you do use pilocarpine, all that is generally needed is 1/2% or less. 1/2% is commercially availabe - and 1/4 % can be made up by some pharmacies. One of the nice things about pilocarpine is that using it for a few weeks to months can result in a mild but permanent reduction in the pupil size. Since having a large pupil size is the cause of your problem, this "effect" of pilocarpine to permanently reduce your pupil size should be very helpful. So in effect - the use of pilocarpine may be a temporary treatment which over time will pemanently reduce or eliminate your night time problems
When talking about risks - there are significantly more risks about trying experimental laser ablation to widen the treatment zone without altering the refactive error. These risks include infection, inflammation, epithelial ingrowth, flap folds,alteration in refractive effect, etc. So any type of "custom" surgery will have far more risks compared to the use of eye drops for reducing the pupil size.
I hope my thoughts on the treatment of night time problems are helpful. Please of course talk with your doctor prior to using any medications

Best of luck

Bill Trattler, MD
Miami, FL

Thanks for the response Dr. Trattler. Three followup questions:

1) Generally, how much less will the pupil dilate as one ages? If I'm 27 now, will I likely see an improvement by the time I'm 35, 40, etc?

2) I am intrigued by your description of pilocarpine's possibly permanent effect on pupil size. Does the beneficial effect of using pilocarpine as you suggested come with any trade-offs? I.e.: would a slight permanent reduction in pupil size cause any other problems with vision (nightime or otherwise). My doctor for some reason did not mention that the effect of the drops could be permanent in the long-term, though, as you pointed out, this would appear to be a permanent fix to the problem.

3) While the surgical solutions I mentioned are now experimental and seemingly too risky, do you believe the state of the art is improving to the point where they would be worth considering in the future? (in the timeframe I mentioned in my earlier post). (also, I would choose PRK again to avoid flap complications, etc.). Thank you again for your assistance.

Ask your doctor about the use of pilocarpine. Patients who use Pilocarpine 4% for many years end up with small 2mm pupils. However, your goal is to reduce your pupil size from 7-8mm to about 5-6mm at night time. Low dose pilocarpine may do this with time (but I can not give you the exact extent of time).
As for trade offs- I can not think of any negative trade-offs with the use of low dose pilocarpine. You of course need to talk with your doctor and understand the use of pilocarpine.
As for the natural time it takes for the pupil to reduce in diameter over time - I can not guess if it will take 5 or 20 years. It is a slow process, but if you look at people over the age of 50, very few have very large pupils.
Again - my point is that why take a risk of further corneal surgery, which comes with the risks of infection, scarring, haze, induction of astigmatism, etc. I do not have any patients of my own in your exact situation, but it would seem that the risks of using medications to constrict the pupil would be far less than the risks of further corneal surgery. This is my opinion, and you should certainly discuss these issues with your own doctor

Best of luck

Bill Trattler, MD
Miami, FL

can cause retinal detachment. There are many very unpleasant side effects which can make it an unacceptable option for some.

Pupil size does decrease with age, but this happens over DECADES.

Pilocarpine at high doses has been shown to increase the risk of developing retinal detachments. However, taking one drop a day of dilute pilocarpine (1/4%) would have a significantly lower chance of being associated with a retinal detachment. People who are myopia (that includes - any patient who has had LASIK for myopia) naturally have an increased risk of a retinal detachment, and thus require dilated pupil exams to look at the retina. The chance that dilute pilocarpine would be responsible for a retinal detachment would be extremely rare.
The other side effects of pilocarpine such as headache occur when used at high concentrations, and generally do not occur when used in low doses.
Again - the purpose of the pilocarpine or Alphagan is to treat a signficiant problem - difficulty with night time vision. As with everything, one has to compare the "risks" versus benefits. But if taking one drop at dusk of an eye drop allows a person to resume their normal life in the "nighttime environment" - then the benefits of these medications will outweigh the risks.
These are individual decisions - but it is importnat that people be aware of their options

Best of luck

Bill Trattler, MD
Miami, FL