Hello Dr. I have posted on this forum for 3 yrs now.All Dr. even my own says to be calm a bout my eye.I have been telling my Dr. Thomson at emory vision with this prob. He says it is dry eyes .I have done every thing that can be done .I can not see well enouth to drive . M y eye gets worse every month I have been telling my dr. this sinse lasik. He checks my eye and tells me every thing is perfict.I was a + 6 I can see good up to about 10 ft. then i start seeing 2 an 3 images 2 stop signs a cluster of red lights an so on. I can see pretty good for about 1 hr. when i wake up in the morning.tHEY scraped my eye 3 times for cells growing under flap Can this cause my prob? thanks ps. My right eye is a lazy eye is it possible to take the cornea from the lazy eye and use it on this eye? I did not have lasik on lazy eye.I have got to do some thing. I need help from some body.

William writes:

"Hello Dr. I have posted on this forum for 3 yrs now.All Dr. even my own says to be calm a bout my eye.I have been telling my Dr. Thomson at emory vision with this prob. He says it is dry eyes .I have done every thing that can be done .I can not see well enouth to drive . M y eye gets worse every month I have been telling my dr. this sinse lasik. He checks my eye and tells me every thing is perfict.I was a + 6 I can see good up to about 10 ft. then i start seeing 2 an 3 images 2 stop signs a cluster of red lights an so on. I can see pretty good for about 1 hr. when i wake up in the morning.tHEY scraped my eye 3 times for cells growing under flap Can this cause my prob? thanks ps. My right eye is a lazy eye is it possible to take the cornea from the lazy eye and use it on this eye? I did not have lasik on lazy eye.I have got to do some thing. I need help from some body."

Hi William. Dry eye can certainly cause blurry vision, but double/triple images... not likely. The fact that you see well in the morning and less well later in the day does suggest dry eye. Do you have plugs in your tear ducts? If your dry eye is severe consider having plugs in all 4 tear ducts if you do not already.

You report that your eyes were scraped 3 times for cells under the flap (this is called epithelial ingrowth). This can certainly cause visual problems. You may still have some residual epithelial ingrowth that interferes with your visual quality.

If you were a +6 they probably NEVER should have done refractive surgery on you. You were farsighted, is this correct? Your distance vision was great, but you couldn't see anything close to you?

Your doctor also never should have performed LASIK on you with a lazy eye. A corneal transplant is a serious matter. Why don't you try seeing another doctor besides the one you saw at Emory for a 2nd opinion on your condition. Ask for color copies of all your scans and your complete chart. Ask for your complete chart and color scans from your original surgeon and also for all your visits at Emory. Take all of this material with you to a new doctor. Keep the copies with you at home.

Likely there are multiple causes to your visual problems... some epithelial ingrowth, an increase in higher order aberrations and dry eye. Perhaps other factors are contributing. You need to talk to a doctor who will give you straight answers and NOT tell you you are OK when you are clearly not seeing well!

Triple vision is not normal! Do not allow a physician to behave in your presence as if this were a perfectly OK way to live.

Each time you have your flap lifted, the healing process that is required to resolve dry eye issues is restarted. While you may have had LASIK three years ago, your healing clock started the last time you had a flap lift. When was this?

A cornea transplant from one eye to the other eye is not going to be necessary. If a corneal transplant is needed (which it does not appear that this is the case), then a donor cornea would be available. There is very little probability of corneal transplant rejection. There is probably a lower probability that you would need a transplant.

Multiple images usually relate to an irregularity in the cornea, often astigmatism. Dry eyes can cause astigmatism and exacerbate existing astigmatism. The fact that you can see well for an hour after waking indicates that dry eyes may be contributing to the problem. Dry eye management will be key to a resolution to your problems. You may want to visit http://www.complicatedeyes.org/dry_eye_treatment.htm or details on dry eye and LASIK.

Multiple images can also be caused by the epithelial ingrowth that you appear to have had multiple times. If you have extra cells growing under the flap, this can cause multiple images.

Your doctor is probably telling you to be calm because he understands that all of these symptoms relate to temporary problems or problems that have a ready resolution.

Dry eyes after LASIK is common and usually resolves within the normal six-month healing process, but your healing process has been interrupted three times by flap lifts.

Epithelial cell ingrowth needs to be resolved with removal of the cells, but sometimes they are determined to remain. The long-term ocular health is not seriously compromised by a flap lift, but may be by the cells being allowed to remain. If the epithelial cells again migrate under the flap, the doctor may lift the flap and apply a very light “dusting” of excimer energy to destroy any remaining cells.

Dry eyes can cause or exacerbate corneal irregularities that can cause multiple images. Ingrowth can cause multiple images too. As the ingrowth is resolved, so will improve the dry eyes, so will be the multiple images.

You are traveling down a rather rough road, but all that you describe has a good history of being able to be resolved with no long-term complications (although I’d call three years of this long-term). You are with a well respected doctor, but I recommend you seek a second opinion. I suspect the second opinion doctor will tell you much the same that you have been told by Dr. Thompson, but the peace of mind that you are on the right road (even if a rough one) would be valuable.

Glenn Hagele
http://www.USAEyes.org

I am not a doctor.

>Each time you have your flap lifted,
>the healing process that is required
>to resolve dry eye issues is
>restarted. While you may have had
>LASIK three years ago, your healing
>clock started the last time you
>had a flap lift. When was
>this?

>A cornea transplant from one eye to
>the other eye is not going
>to be necessary. If a corneal
>transplant is needed (which it does
>not appear that this is the
>case), then a donor cornea would
>be available. There is very little
>probability of corneal transplant rejection. There
>is probably a lower probability that
>you would need a transplant.

>Multiple images usually relate to an irregularity
>in the cornea, often astigmatism. Dry
>eyes can cause astigmatism and exacerbate
>existing astigmatism. The fact that you
>can see well for an hour
>after waking indicates that dry eyes
>may be contributing to the problem.
>Dry eye management will be key
>to a resolution to your problems.
>You may want to visit http://www.complicatedeyes.org/dry_eye_treatment.htm
>or details on dry eye and
>LASIK.

>Multiple images can also be caused by
>the epithelial ingrowth that you appear
>to have had multiple times. If
>you have extra cells growing under
>the flap, this can cause multiple
>images.

>Your doctor is probably telling you to
>be calm because he understands that
>all of these symptoms relate to
>temporary problems or problems that have
>a ready resolution.

>Dry eyes after LASIK is common and
>usually resolves within the normal six-month
>healing process, but your healing process
>has been interrupted three times by
>flap lifts.

>Epithelial cell ingrowth needs to be resolved
>with removal of the cells, but
>sometimes they are determined to remain.
>The long-term ocular health is not
>seriously compromised by a flap lift,
>but may be by the cells
>being allowed to remain. If the
>epithelial cells again migrate under the
>flap, the doctor may lift the
>flap and apply a very light
>“dusting” of excimer energy to destroy
>any remaining cells.

>Dry eyes can cause or exacerbate corneal
>irregularities that can cause multiple images.
>Ingrowth can cause multiple images too.
>As the ingrowth is resolved, so
>will improve the dry eyes, so
>will be the multiple images.

>You are traveling down a rather rough
>road, but all that you describe
>has a good history of being
>able to be resolved with no
>long-term complications (although I’d call three
>years of this long-term). You are
>with a well respected doctor, but
>I recommend you seek a second
>opinion. I suspect the second opinion
>doctor will tell you much the
>same that you have been told
>by Dr. Thompson, but the peace
>of mind that you are on
>the right road (even if a
>rough one) would be valuable.

>Glenn Hagelehttp://www.USAEyes.org

>I am not a doctor.

>

-------------------------------------------
The healing process that is required to resolve dry eye issues after LASIK is nonexistent - every patient who has LASIK gets nerve damage as part of the package. At 3 years post-LASIK, on average, patients have lost more than 40% of their corneal nerve density:
-------------------------------------------------
Corneal Nerve Damage Continues to Increase years 2-3 after LASIK
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retri...=15505047&query_hl=2
Invest Ophthalmol Vis Sci. 2004 Nov;45(11):3991-6.
Corneal reinnervation after LASIK: prospective 3-year longitudinal study.
Calvillo MP, McLaren JW, Hodge DO, Bourne WM.
Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
-----------------------------------------------

It is true that multiple images result from irregularities in the cornea, such as those induced by refractive surgery. You have definitely come by your dry eye honestly, acquiring nerve damage from a first LASIK and then having what nerves did manage to regenerate ripped apart with subsequent flap lifts. It is extremely unlikely, however, that dry eye alone has caused or even contributes much to your double vision symptoms. If it did, eye drops would temporarily alleviate the double vision.

I would bet that epithelial ingrowth (hard to get rid of once it is established) is the root of the double vision problem and is diminishing your visual acuity.

The fact that you cannot drive is not something that you should be calm about. You have been robbed of your mobility and independence. If your problem were temporary or easily remedied, as Glenn Hagele suggests, ANY competent refractive surgeon could and would have remedied it long before the 3 year mark, and would be happy to take your money to do just that.

It was disingenuous for Glenn Hagele to suggest that your problems are temporary and/or easily remedied. He knows better, but somehow getting snowed by a salesman is likely less distasteful for you than being snowed by an Ophthalmologist who is supposed to have your best interests in mind.

You may consider seeing one of the few rehab specialists who handle difficult cases. Salz in the US, Reinstein if you can afford to travel abroad. It may be a good idea to seek a 2nd opinion more locally FIRST. Tell your new doctor that you had discount LASIK surgery in a Canadian shopping mall. If you do this, your 2nd opinion doc will not be tempted to understate (or even conceal) your surgical complications in an attempt to protect Dr. Thomson.

By the way, Glenn is bad at math and has poor reading comprehension. He's bad at math because you were supposed to be all better in 6 months. In the past 36 months you should have had 18 months of poor 'healing vision' and 18 months of that terrific LASIK vision!

Glenn has poor reading comprehension because he failed to grasp what the Mayo Clinic studies have reported in plain language... that LASIK patients have substantial loss of corneal nerve density at the 3 year mark (long after the 6 month mark when he claims that they should be all better).

He also failed to grasp the distinction between irregular astigmatism (the kind of permanent distortions in the cornea that cannot be corrected by glasses) and regular astigmatism which is found in the normal population and doesn't result in multiple images. It was deceptive of Glenn to say that your double vision was caused by astigmatism... makes it sound so innocuous and common. Jeepers, almost as if your vision hasn't been damaged by a refractive surgeon!

After you have determined what is decreasing your visual acuity to the point that you are unable to drive and have documented the problem in your charts (copies of which you have requested and taken home for your records) you can consider your options from a position of knowledge.

If you do have epithelial ingrowth that simply cannot be managed, one possible treatment, although radical, may be a lamellar corneal graft. There is less risk of rejection than with a full graft. Very few surgeons do this technique well, you will want to go to one who does. This surgery will be riskier for you because you have one lazy eye. You'll be risking your only good eye on the surgery.

The refractive surgeon who operated on a patient with a lazy eye in the first place is guilty of malpractice, in my opinion.

I feel like I'm living in the twilight zone here, you can't see well enough to drive as a result of LASIK eye surgery and a refractive surgeon is telling you to be calm about it? If it were his eyes he'd be screaming bloody murder! Go get some real help for this problem and do keep us posted!

All my best to you!

A follow up study by the team at the Mayo Clinic determined that nerve density returns to preop levels at about 5 years for LASIK and 3 years for PRK. Of course density is not the important issue. What is important is that nerve sensitivity returns. This normally occurs within the six month healing process (from each flap lift); however for an unfortunate few this process is delayed.

The suggestion of a lamellar transplant to resolve epithelial ingrowth seems irresponsible. As long as the LASIK flap is healthy, a transplant would be very unwise. Unchecked epithelial ingrowth can cause degradation of the flap, but you are in the care of a doctor who is obviously monitoring your condition and responding with a lift and cleaning before damage occurs.

Other challenges to the accuracy of the information I have provided and the honesty of my response are unfounded and unwarranted.

Glenn Hagele
http://www.USAEyes.org

I am not a doctor.

Glen...the 5 year data that you mentioned...was that from an oral presentation at AAO? Could you please clarify

Thank you

Bill Trattler, MD
Miami, fL

Here is the latest on subnasal nerve density from the 2005 ASCRS meeting.

In a yet unpublished poster presented by Jay Erie, MD of the Mayo Clinic (author of the previous study) we find the five year follow-up on nerve density.

At 1 year postop, PRK patients have 59% of their nerve density return, while LASIK patients have 51%.

At 2 years postop, PRK density is essentially the same as preoperative levels and stays at normal level for the five years of the study.

At 5 years postop, LASIK patients first present nerve density recovery at preoperative levels, however both PRK and LASIK patients have about 20% lower density at five years postop, apparently attributed to norms of patients without surgery.

Glenn Hagele
http://www.USAEyes.org

I am not a doctor.