I was THRILLED to read that the VISX laser can treat hyperopia up to 6.0. I was told the past few years that Lasik could only treat hyperopia up to 4.0, and I'm at 6.0.
Is it difficult to find doctors using this laser or correcting hyperopia at 6.0? (Since it was just last year that I was told that only up to 4.0 could be treated.) Do I need to worry that there will be problems since I am at the high end of treatable hyperopia?

There is a huge difference between what can be done and what should be done. There are many very legitimate arguments why refractive surgery should not be performed on a 6.00 diopter hyperope. Hyperopic (farsighted/longsighted) correction is much more difficult to predict than myopic (nearsighted/shortsighted) correction.

For a shift in refractive error to reduce myopia, the center of the cornea needs to be flattened. For a shift in refractive power to reduce hyperopia, the center of the cornea needs to be steepened with a "bulge" outward.

Think of the old saying, "If you can't raise the bridge, lower the water." Myopic correction raises the bridge. Hyperopic correction lowers the water. As with lowering the water, steepening the cornea is much more difficult.

First, I'll describe current techniques in myopic correction: A laser removes tissue in the center of the cornea to make it flatter. That's about it.

Now, hyperopic correction: Remember, the intent is to create a "bulge" outward in the center of the cornea. This is attempted with two primary methods:

LTK and CK apply laser and radio wave energy, respectively, to a ring of dots on the outside edges of the cornea. This causes the corneal tissue to shrink. Like the string around your laundry bag, when pulled tight by the shrinking, the center of the cornea bulges outward. Both CK and LTK are not approved or effective on such a high refractive error.

With excimer laser assisted hyperopic correction such as PRK, LASEK, and LASIK, the cornea is reshaped by removing a ring of tissue around the outer edge of the cornea. By leaving the center of the cornea thick and thinning the outer ring, the cornea changes shape to give the effect of a bulge outward in the center.

All hyperopic correction techniques are very difficult to perform well. The bulging may not be centered or spherical, causing regular or irregular astigmatism. Knowing just how much energy to apply and where, is an art as much as it is science. The cornea tends to naturally go back toward its original shape (regression). LTK tends to regress rather quickly. CK regresses slower than LTK, but is still considered a temporary fix. PRK, LASEK, and LASIK hyperopic correction also tend to regress, but at a relatively slow rate.

For all its technical foibles, hyperopic correction is often considered very successful by the patient. The reason is that hyperopes really cannot see very well at any distance. The greatest advantage of hyperopic correction is for someone who is also presbyopic.

Presbyopia is when the natural lens of the eye is no longer able to change focus. This is when we need reading glasses and/or bifocals. Before presbyopia, the natural lens can somewhat "focus around" the hyperopia. When you are presbyopic, you get hit with the full effect of the hyperopia. That is why a presbyopic hyperope is often the most satisfied patient even if the surgery is a marginal success. Any amount of improvement is significant in its ability to help a presbyopic hyperope function day-to-day and is greatly appreciated.

Your thrill at learning that a laser has is approved to correct high hyperopia should be tempered with the knowledge that the probability of a successful result is significantly different than for low hyperopic or myopic correction.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAeyes.org
http://www.ComplicatedEyes.org

I am not a doctor.

Glenn, thank you for all of your information...even though I almost cried when I read it. I am presbyopic and have "coke bottle" bifocals which I am unable to find when taken off...other than by feeling around for them. I would give anything to be able to see because even the combination of contac lenses and reading glasses is not very effective.
Is it possible to have multiple surgeries for someone with extreme hyperopia, as myself, to correct the problem? If not, do you know if the outlook is good for this to be treated in the future?

>Glenn, thank you for all of your
>information...even though I almost cried when
>I read it. I am
>presbyopic and have "coke bottle" bifocals
>which I am unable to find
>when taken off...other than by feeling
>around for them. I would
>give anything to be able to
>see because even the combination of
>contac lenses and reading glasses is
>not very effective. Is it
>possible to have multiple surgeries for
>someone with extreme hyperopia, as myself,
>to correct the problem? If
>not, do you know if the
>outlook is good for this to
>be treated in the future?

Peggy,

Sorry to rain on your parade, but I would much rather disappoint you now, than say nothing and see surgery disappoint you later.

With high hyperopic correction, it is not so much whether or not correction can be made. It is about the quality of vision after the correction. The probability of excellent vision quality with one hyperopic LASIK surgery is low enough that it is not appropriate for most people. Some are motivated enough to accept the risk. That is an individual’s decision and I am not one to tell someone if he or she should have surgery. I will, however, warn about potential problems when the probability of difficulties is greater than normal.

One alternative that may be appropriate for you is Clear Lens Exchange (CLE). This is also called refractive lens exchange, refractive lens replacement, clear lens replacement, but no matter what it is called it is essentially cataract surgery for refractive purposes.

In CLE the natural lens of your eye would be removed and replaced with a plastic or silicon intraocular lens (IOL). This new IOL would be of a power to correct your hyperopia. A downside of CLE is that you would lose the ability to change focus from distance vision to near, however if you are already fully presbyopic then this is not really an issue.

You may want to consider monovision correction to “work around” the presbyopia. More on that is at http://www.usaeyes.org/faq/subjects/monovision.htm.

CLE is invasive surgery and not for everyone, but there have been millions of cataract surgeries performed and it is a well understood modality. I suggest you investigate this type of surgery as an alternative to LASIK, but keep in mind it has its own set of limitations and advantages.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAeyes.org
http://www.ComplicatedEyes.org

I am not a doctor.

I was off the charts and wore coke bottle glasses for many years too. I am 47 years old and have had cataract surgery covered by insurance in both eyes. Afterwards, I could see 20/50 in my right eye and only 20/70 uncorrected in my left. I had lasik surgery not long ago in only my left eye and could see 20/30 uncorrected the next day. This is great however, because the best I could see corrected in my left eye before surgery was 20/30. I think most people can see much better following just cataract surgery though?

Take it from somone who has had complications from Hyperopic Astig.

I was +6 almost +7 in both eyes before surgery.
+2.50 +4.25
+2.25 +3.75

I am now. These are estimates since my vision changes all the damn time.
-.25 +3.00
-.50 +3.25

At this point I am waiting until the new wavefront s4 procedure is approved before I get an enhancement to attempt to correct my eyes once again. Does anyone know if this is in process of approval? I have bad night vision, and my BCVA is not as good as it was priot to surgery.

If I had to do it all over again????? Hell no.... The only reason I am considering going under he laser again is to fix my night vision.

My advice to current Hyper Astigs out there is to wait until better technology arrives.

Feel free to email

Kevin,

I'm sorry to hear of your difficulties.

Don't hold your breath for the S4's approval to treat high astigmatic correction with wavefront-guided excimer energy. It appears that their current priority is to get a new version of the existing myopic correction approved first. I'm sure the S4 will eventually be approved for high astigmatic correction, but I doubt it will be very soon.

You may want to consider other lasers beyond the S4. Other platforms may receive approval for wavefront-guided high astigmatic correction before that S4, and/or be better able to correct your situation.

It appears from the prescription you post that the majority of your refractive problem is due to your very high astigmatism. This would become more problematic at night as your pupils become large and more light passing through the astigmatic portion of your cornea reaches the retina and is "seen". Since it appears that the refractive correction you need is astigmatism, not hyperopia, you may want to explore the possibility of conventional refrative surgery techniques, but only if a wavefront diagnostic shows that your High Order Aberrations (HOA) are normal or low. If your HOA is elevated, wavefront-guided ablation may be a requirement – if you decide to have surgery.

An alternative to surgery would be contact lenses. Many patients have reported success with rigid gas permeable (RGP) lenses. You may even want to explore the cornea warping techniques like Ortho-K.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAeyes.org
http://www.ComplicatedEyes.org

I am not a doctor.

Peggy,

Listen to Kevin. He is one of over 100,000 Americans who have had bad results from refractive surgery.

Be wary of anything that Glenn Hagele posts (although his posts in this thread are fairly accurate, which is unusual). Hagele (who posts a lot here to promote CRSQA marketing services) sells refractive surgery for a living and is physically a perfect candidate but won't have the surgery because he knows that he will never be happy with the results. Follow Hagele's example and don't have RS.

Terri

-

Kevin,

I am sorry that your surgeon destroyed your vision. I hope that someday they are able to restore your correctable vision. Three years ago they were telling us that technology would fix us in “about six months”. Now they are saying 3-5 years.

Best of luck,

Terri

Terri is one of those anti-refractive surgery/surgeon/industry zealots who posts negative statements in this forum quite often. The following is a standard reply to Terri’s most common accusations:

The Council for Refractive Surgery Quality Assurance (CRSQA, www.USAeyes.org) provides objective and factually substantiated information for patients, promotes complete and accurate communication between doctor and patient, and provides suggestions on how a potential patient may find the best available doctor through our 50 Tough Questions For Your Doctor (http://www.usaeyes.org/faq/tough_questions.htm) and by certification of doctors who meet or exceed our patient outcomes requirements. Details of what is required for CRSQA certification are available at http://www.usaeyes.org/faq/subjects/certified.html. A list of certified doctors is available at http://www.usaeyes.org/surgeons/locate.htm.

I am the Executive Director and founder of CRSQA. CRSQA is a nonprofit, tax-exempt, public benefit corporation that is lead by a 13-member Board of Trustees, which includes ophthalmologists, optometrists, patient advocates, consumer advocates, and other representatives of elements of the refractive surgery industry. There are no shareholders or owners, as a nonprofit’s ownership is held, by law, for the public good.

CRSQA also operates a sister website at www.ComplicatedEyes.org that is devoted to providing information and resources to those unfortunate few who have poor refractive surgery outcomes.

There is no doubt that doctors tout the fact that they have earned our certification in their own marketing – we encourage this – but we do not market refractive surgeons, market for refractive surgeons, or market refractive surgery beyond providing objective information. CRSQA does not provide marketing services to physicians.

Similar to the American Board of Ophthalmology, American Board of Eye Surgeons, and every other certification organization, CRSQA charges fees to doctors for their certification. This is the sole source of our funding. No fee is charged to patients who seek our assistance. We believe that those who financially benefit from refractive surgery are the most appropriate source for financial support of an organization that benefits refractive surgery patients.

I have personally never ever, publicly or privately, told anyone they should have refractive surgery. I have never in the past or present, sold refractive surgery.

I have not personally had refractive surgery because I am a poor candidate. The probability is not very high that I would achieve the excellent 20/10 to 20/15 vision I enjoy with spectacles. It is unreasonable to expect anything better than "normal" 20/20 vision from refractive surgery (even though superior vision does occur) and I know from my experience with contacts that 20/20 would make me 20/UnHappy. Also, at my age I am presbyopic enough that the mechanical advantage for near vision I achieve with glasses reduces my need for bifocals or reading glasses. I am a poor candidate for refractive surgery at this time, and I would hope that anyone in my situation who reads our website would come to the same conclusion and refrain from refractive surgery. Refractive surgery is not appropriate for everybody.

Although detractors may decry our message of cautious optimism regarding refractive surgery, a reasonable person will find that the detractors do not provide evidence that information provided on our website or in my posts is inaccurate.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAeyes.org
http://www.ComplicatedEyes.org

I am not a doctor.