Dr. Trattler,

I've had 2 consultations with different opinions. I've searched the internet and haven't come across any information that covers my particular situation. Please give me your opinion.

With Dr. #1 my perscription is: right eye -6.0 -1.75 and axis 10. Left eye: -6.50 -2.25 and axis 180. Corneal thickness was right 495 and left 506 microns using orbscan. Pupil size of 8.5 for both eyes. Says I'm a good candidate for PRK Custom using Bausch and Lomb 5th Generation Technolas 217 Excimer Laser.

With Dr. # 2 my perscription was: right eye -5.87 -1.75 and axis 180. Left eye: -6.75 -2.25 and axis 177. Corneal thickness was right 493 and 499 microns taken manually. Pupil size of 9.0 for both eyes. Says he will only do PRK using VISX Star 4 and that there will more than likely be glaring and halos at night even with custom. Also, says that he doesn't recommend PRK with Customview because it would use more corneal tissue and may prohibit room for enhancements in the future.

I appreciate Dr. #2's honesty but was still left with conflicting info. My questions are...

Does Custom PRK use more corneal tissue than regular PRK?

Are the differences in Dr. #1 and #2's refractions significant enough for a 3rd opinion?

Could the difference in the lasers mentioned be why one surgeon would not do custom? Does one laser use more tissue?

Will Custom PRK significantly lesson the amount of halo and glare?

I would get a third opinion. My prescription ended up being -7.25 with 3.25 astigmatism and -6.5 with 2.25 astigmatism. My corneas were between 524 and 538. I also got two opinions, at first. One doctor told me they were too thin for LASIK. The other said my prescription was way too strong for PRK. I sought another opinion who sided with #2. So, I had Custom LASIK with Intralase 10 days ago with the VISX Star4.

Custom PRK does take more cornea than regular PRK. So, I would get a third opinion just to make sure you really are an okay candidate for PRK and which one he/she would recommend.

Hate to say this, but stick with glasses. Your pupils are 9mm(!) so this will affect your night vision. Your surgeon is telling you that youll get glare, starbursts and halos. You may not be able to drive safely at night or enjoy being out at night and not see well in low light. Your thin corneas disqualify you from lasik. PRK is risky but possible. However you have thin corneas, high myopia, moderate astigmastim and very big pupils. Glasses is going to give you the best vision. Youll be giving up some vision and taking alot of risk to reduce your dependancy on glasses. I know some people are not gonna care if they lose some vision as long as they dont need glasses. How well do you see with glasses? Probably 20/25 or 20/30 due to your high pescription.

My eyes arent as bad as yours(-4 range) and my cornea is thick enough for PRK and lasik but my pupils may be 9mm so its not in my best interest to get it. Id rather see well both day and NIGHT with glasses. I will just wait till something better comes along and I believe it will someday.

Problems with night vision arise mainly in people with large pupils, a strong prescription and a high level of astigmatism. These risk factors should be picked up during assessment.

http://www.tlcbigskylasercenter.com/ZigsPupil.jpg

This is what happened to him and his pupils are only 7mm. Yours at 9mm will give much worse results. If you have any questions, lemmie know

Ace

Thanks for giving me feedback so quickly. Isn't this the result of what can happen when a surgeon uses the wrong type of laser or pupil measurement? This looks like it could have been avoided.

From what I've found so far in my search for answers is that the laser needs to have an optical zone suitable for the patient's pupil size. A 5 mm optical zone was used for a 7mm pupil, a 2mm difference. Each type of laser is different (they even have them for 9mm pupils). See Chart link below. (I'm new to posting so if th link doesn't work, see the site)

http://www.allaboutvision.com/visionsurgery/lasik_laser_3.htm

I understand that my pupil size is larger than his and I'm at an increased risk of night vision problems, but can we really say that mine would be worse than his? I'm not saying that I'd be fine with something slightly better but would like to clarify.

I appreciate your link, I was able to go to the site and actually get a visual of what night vision problems look like.

Ace

Thanks for giving me feedback so quickly. Isn't this the result of what can happen when a surgeon uses the wrong type of laser or pupil measurement? This looks like it could have been avoided.

From what I've found so far in my search for answers is that the laser needs to have an optical zone suitable for the patient's pupil size. A 5 mm optical zone was used for a 7mm pupil, a 2mm difference. Each type of laser is different (they even have them for 9mm pupils). See Chart link below. (I'm new to posting so if th link doesn't work, see the site)

http://www.allaboutvision.com/visionsurgery/lasik_laser_3.htm

I understand that my pupil size is larger than his and I'm at an increased risk of night vision problems, but can we really say that mine would be worse than his? I'm not saying that I'd be fine with something slightly better but would like to clarify.

I appreciate your link, I was able to go to the site and actually get a visual of what night vision problems look like.

Ace

Thanks for giving me feedback so quickly. Isn't this the result of what can happen when a surgeon uses the wrong type of laser or pupil measurement? This looks like it could have been avoided.

From what I've found so far in my search for answers is that the laser needs to have an optical zone suitable for the patient's pupil size. A 5 mm optical zone was used for a 7mm pupil, a 2mm difference. Each type of laser is different (they even have them for 9mm pupils). See Chart link below. (I'm new to posting so if th link doesn't work, see the site)

http://www.allaboutvision.com/visionsurgery/lasik_laser_3.htm

I understand that my pupil size is larger than his and I'm at an increased risk of night vision problems, but can we really say that mine would be worse than his? I'm not saying that I'd be fine with something slightly better but would like to clarify.

I appreciate your link, I was able to go to the site and actually get a visual of what night vision problems look like.

I have never heard of a laser that did more than 8mm optical zone. The largest FDA approved zone is 6.5mm, any larger is considered "off label" Dont forget youll be needing a toric oval zone so even if you got 9mm itll be like 7.5mm on the narrow axis. Youd need alot of cornea removed as well, making your thin cornea very thin. The risks for you is more than 10 times higher than normal. Alot of people with bad results werent good candidates and either didnt know or didnt care and went ahead anyway. My pupils are probably as big as yours and I have myopia and astigmastim just like you do, but not quite as high. I am not gonna take the chance because I am not considered a good candidate. Lasik is a risk for everyone but poor candidates take much, much more risk than others. If you still want to go ahead, its your eyes. Just dont be supprised if you dont see well at night and in reduced light, even your surgeon made it clear to expect glare, halos, starbursts(may also have contrast loss)

Whats your reasons and expectations for lasik anyway? Im guessing theres some good reasons given your strong desire to get it despite high risks. Dont you see well with glasses?

Please do not undergo lasik or PRK with current technology. I had
CustomVue for astigmatism and ended up with disastrous results.
It is possible to reduce your prescription with refractive surgery but
the risks outweigh the potential gain. My pupils were measured at
8mm before surgery. I know you do not like wearing glasses and
contacts but they are a dream come true compared to a bad
refractive surgery outcome.

When you go to any of these Dr's again, ask for other options. I have been following IOL's for more than 3 years, conversing with a DR who took part in the study. My myopia is in the -13 range with more astigmatism than you. I have thin cornias and this is the only option for me. My Dr. indicated that some relief from the astigmatism can be achieved by where and how they cut the incision to insert the lens. The lens may be removed if there is a problem, which to me is a much better option than using a laser to remove tissue that can't be put back. IOL's cost more, but for me, anything else is not worth the risk. Also, Staar optical is working on new IOL's that address astigmatism as well as myopia.

IOLs are made for up to 6.5mm pupils. She will be seeing past the edge of the IOLs and get very bad halos and starbursts. Her vision in the day may be good but she wont be happy at night. I know of no refractive surgury option with todays technology for 8.5mm pupils.

What if she had a pupil size of 6 mm instead of 9 mm. Would that make a difference and would she be a candidate for PRK or Lasik?

Thanks in advance!

Still with her high pescription and thin corneas, its risky. With her huge pupils, shes not a candidate. If she chooses to get PRK anyway, she wont be happy with her poor vision, especially at night.

Did you learn to make that diagnosis at your job at Starbucks?

Hi Tina,

Like you, I have large (8 mm) pupils. I had Lasik done early March. Overall, I have been very happy with my results. I was seeing 20/25 in both eyes at the 2 month mark and I think that has gotten even better recently as my dryness has improved.

The issues I had post lasik were dryness and the starbursting at night around lights. However, the dryness keeps improving as does my vision. I see more crisp now. I also was able to drive at night after a couple of days even with the starbursting. It seems to also be getting a bit better. I did try Alphagan P and it worked for me, eliminating the starbursting completely with no side effects. However, I would be borderline on wanting to use it at all as again, I can drive comfortably at night. I find them more of a mild annoyance versus a large problem.

My doctor said it can take up to 6 months before all of that clears up. I am still very satisfied with my procedure and would do it again. I had similar night vision and dryness issues with contacts so for me this isn't anything new. My advice to you would be to think it through. What type of work do you do? Do you need to be able to see perfectly immediately? If the answer is yes, than I would tend to advise against it. But if you are willing to be patient with your results and you are willing to take the risk of things not being 100% perfect, then you might want to consider it.

Again, I can only speak from my own experience - you need to be the one to make that decision. I would do it again in an instant but that is me. I had very realistic expectations and was told all of the risks very clearly before I did this. Overall, I am pleased with my results.

Good luck to you.

Julie, thanks for sharing your experience. I already see some halo and glare at night with my contacts, I just don't want it to be worse than what I see now. Do you mind sharing whether you had custom lasik and what laser? I know the laser is not the most important thing but I'm curious.

The second surgeon I spoke with says that if I don't do custom upfront the door is open to go back and do an enhancement in the future if the halo and glare is something that I can't tolerate. By then my perscription will be less and won't use as much corneal tissue. I'm still considering and researching.

Your pupils are not 8mm, they are 9mm! They are so big that you even experience slight starbursting with contacts and glasses! If you can tolerate contacts, whats the point of lasik even if you find contacts inconvinencing? Your corneas are thin as well so you might just end back in contacts after lasik as theres not enough for enhancement. Id say your chances of being happy is about 10% do you feel like taking a 1 to 10 against odds?

I am sticking with glasses if you didnt know by now because like you, my pupils are too big and id rather not ruin my night vision.

Ace, what is your prescription? I am just curious to know because I am too borderline for Lasik and PRK. Thanks!

Ace, can you tell me where you got your 1 in 10 ratio from? And where did you find information stating that people with large pupils will POSITIVELY have night vision problems? Can you be that certain that "EVERYONE" with large pupils will have problems? If so then why do some have good results. Even the surgeons that respond on this forum and those I've spoken with don't positively state what a patient's results will be.

I have come across good and bad results from people with large pupils. It seems as if you totally discredit good outcomes and may even be limiting your self. Also, if I were satisfied with wearing contacts and/or glasses I would have never considered lasik nor would I be extensively researching the procedure. I have not made a decision yet and like the feedback, even when people tell of other procedures that they have done that's been sucessful, this give me something else to look into. Even with all that I've come across I know there's increased risk with large pupils but I would be leary to positively say what will be someone's result.

>Ace, what is your prescription?
>I am just curious to know
>because I am too borderline for
>Lasik and PRK. Thanks!

-5 and -4.5 with slight astigmastim but my pupils are about 9mm and im not willing to impair my night vision and still need glasses anyway. I will wait till something better comes along and even if not, my vision is fine with glasses.

Anyway to Tina

>Ace, can you tell me where you
>got your 1 in 10 ratio
>from?

Reading the reports and statics.

>And where did you find
>information stating that people with large
>pupils will POSITIVELY have night vision
>problems? Can you be that certain
>that "EVERYONE" with large pupils will
>have problems?

Everyone who will admit their problems. Its a physical limitation. Make the ablation zone smaller than your pupils and light will come in that uncorrected potion. The only way you can avoid this is by getting something like a 11x9 oval ablation zone and theres no such thing.

>If so then why
>do some have good results. Even
>the surgeons that respond on this
>forum and those I've spoken with
>don't positively state what a patient's
>results will be.

Your surgeon warned you to expect glare, starbursts and halos. Case closed.

>I have come across good and bad
>results from people with large pupils.
>It seems as if you totally
>discredit good outcomes and may even
>be limiting your self.

Their pupils werent 9mm like yours is. Also their pescription may be lower without astigmastim. Not only that, they are still happy despite having night vision problems. Will you be happy not to see well at night?

>Also, if
>I were satisfied with wearing contacts
>and/or glasses I would have never
>considered lasik nor would I be
>extensively researching the procedure.

Thats something id have to agree. I considered lasik but have decided not to persue it due to the risks. I also dont really like glasses but seeing well day and night is very important.

>I have
>not made a decision yet and
>like the feedback, even when people
>tell of other procedures that they
>have done that's been sucessful, this
>give me something else to look
>into.

I also have learned much from this and its very common to experience a decrease in night vision, especially with big pupils. I know people who got lasik and they dont see too well at night but dont care and are still happy they dont need glasses. I will wait for something better.

>Even with all that I've
>come across I know there's increased
>risk with large pupils but I
>would be leary to positively say
>what will be someone's result.

How much of an increased risk are you willing to take? What would you say and do *if* your night vision is so bad you cant drive at night or enjoy being out when it gets dark? You think it wont happen but lets just say it could go either way. Youd either be happy it worked or miserable and wished you could go back to glasses. Let me give you a summary

1. big pupils. I already explained this.
2. thin corneas. You wont have enough for an enhancement and likley will still need glasses for reading and/or distance.
3. high myopia and astigmastim increases the risks.
4. expectations. Are you prepared for the worse or are you expecting the best?

Hi Tina,

I don't see halos at night as much as I see very thin starbursts coming off of lights and I would say they are kind of large but not large enough to impair my driving or functioning at night and they seem to be getting a bit better. I can also see them in low light or articial light environments - although they aren't as prominent as they are in very dark conditions. I had some glare too but that has been improving. I can watch TV at night - no problem. I had the customvue lasik done. I think my overall night vision is better than with contacts - more clear - but the starbursting is a bit worse than with contacts, however, I tolerate it fine.

There is an eye drop called Alphagan P that will constrict the pupil size at night. I tried it twice and it completely eliminated the starbursting with no real side effects. The reason I don't use it regularly is that I can drive at night without and I am unsure of the long term side effects. I also have Raynaud's Disease and I read that if you have that condition, you need to be careful of this drug. If I am still seeing the starbursts at my 6 month appointment, I will talk more to my doctor about this for longer term occasional use. I would only want to use it if I was going to be out at night for a long time but even then it would depend...

As I said before, only you can make the decision. The reason I did it is I was becoming contact lens intolerant. My eyes would get dry and the lenses were uncomfortable. I have experienced very dry eyes with Lasik, however, that is improving quite a bit. My doctor told me that it can take up to 6 months to heal. I just use eye drops and I find that I am needing them less and my eyes feel and see better. I just personally did not want a dependence on glasses so for me it was the right choice.

I would be happy to answer any other questions that you have. Please remember that there are people who post here that do not have a medical background - although they may try to imply they do. I don't either and can only relate my personal experience with this. I certainly can't speak for all people with large pupils who have this done.

Good luck to you in making your decision.

Julie

Julie,

thanks for letting us know about your personal experience with Lasik. I am considering Lasik or PRK but I am still undecided. I am undecided not for the cost, but for the outcome. I am -5 and -5.25 with little astigmatism and pupils of 6.5 mm. My corneas are thin at 498 each. What was your prescription and what outcome did you get? Did you have the traditional Lasik?

Thanks in advance!

Hi Jose,

I had the customvue lasik done. As of my 2 month appt., I was seeing 20/25 in both eyes. When I first had it done I was seeing 20/40 in my left eye and 20/25 in the right after one week, however, the vision wasn't very "crisp" and I still had what you will hear referred to as ghosting. I am starting to near the 3 month mark and that has greatly improved. Minimal to no ghosting, improved dryness and starbursting is slowly getting better - smaller and "thinner" in appearance.

My prescription was -5.75 in both eyes. Your pupils are smaller than mine so you might have better night vision results faster but everyone is different and heals differently too from what I hear.

Good luck to you and let me know if I can answer any more questions.

Julie

Thanks fot the fast response! It helps to get answers from people that had Lasik or PRK. I would like to know if you had thin or tick corneas? Did you have any eye problems before and what did the Doctors tell you at that time?

Thanks in advance

Hi Jose,

I was told that my corneas were "normal" in terms of thickness so that wasn't an issue for me. I did experience some eye dryness before Lasik as I wore contacts most of the time for 20+ years. My doctor tested my tear production before he did the surgery. Other than having larger than average pupils and the dryness with contacts, I didn't really have any other major eye problems. I was afraid that at some point I would become contact lens intolerant and that is why I wanted to have Lasik because I did not want dependency on glasses. I realize that at some point I will need reading glasses - or so I have been told - and I can live with that. I just didn't want to have to wear glasses all of the time.

Please let me know if you have any more questions for me. Good luck to you!

Julie

Your information is very helpfull. I will consider having PRK or Lasik later this year or maybe this year. I am just waiting a little more hoping we get better technology. I am 26 and started to depend on glasses like at 16. Thanks for your help. Did your doctor suggest PRK to you?

Hi Jose,

PRK was not suggested to me because I didn't have issues with thin corneas. I do know someone who just had this done and I can ask her how it is going. I do know it is a harder recovery in terms of eye discomfort but I think the risks and results are similar to regular Lasik from what I hear - although that is a question for the doctors.

Good luck!

Dear Jose,

I have not gone back on the entire thread but I have included some of my opinions on PRK, which I have abstracted from my website.After performing thousands of LASIK and PRK since 1989, I now favor wavefront guided PRK over LASIK for many patients.

Photorefractive keratectomy (PRK) was the first laser vision correction procedure utilizing the excimer laser, approved by the FDA in 1995 and under trials since 1989.

As with other technology, a number of improvements have been made over the last decade. PRK offers excellent visual results and some studies show slightly superior visual results from advanced PRK in comparison to LASIK. The number of PRK procedures performed in the US and elsewhere diminished significantly after the introduction of the LASIK procedure in 1996. In the last several years, due to significant advances in technology and in medications that control healing with mitomycin, surface ablation techniques such as PRK, LASEK and epi-LASEK are gaining in popularity. With over 15 years of experience with this procedure, its long-term safety and stability have been proven. Combined with the use of Wavefront technology, many surgeons refer to PRK as Advanced Surface Ablation (ASA).

In the ASA procedure, the excimer laser is applied on the surface of the cornea, with only a drop of topical anesthetic needed to numb the eye. In surface ablation, the epithelium, or surface layer of corneal cells, has to be removed in order to reach the stromal layer of the cornea. There are a number of methods to remove the cells including a gentle brush like instrument, chemicals such as alcohol, the laser itself or some other instruments. The bottom line is that it does not make much of a difference which epithelial removal technique is used. There are also two related procedures, Epi-LASIK and LASEK, which should not be confused with LASIK but are variants of ASA. To date, I have not seen any advantage from the latter two techniques.

The PRK procedure takes less than fifteen minutes, and is essentially painless. You can see immediately after the surgery, but there is usually a transition period where your vision fluctuates somewhat, and then continues to improve. At the end of the surgery, a soft contact lens, which works as a bandage, is placed on the eye and several different eye drops are administered. The corneal surface cells (the epithelium) regrow to resurface the cornea over the next 3 to 7 days. After these cells are back in place, usually 4-7 days ater the surgery, the soft contact lens is removed and the vision improves very rapidly after that time. There is continued improvement over the next several months.

During the first several days after the procedure, there is some irritation and discomfort in the operative eye, with some patients describing this as a foreign body sensation or contact lens irritation. This varies greatly from patient to patient. Several types of eye drops are given to reduce this discomfort. Most patients return to work the next day. After the epithelium heals, the discomfort disappears.

There is a slower healing time and the need for more postoperative visits and eye drops than with LASIK. Eye drops are commonly used for 1 to 2 months. The vision is blurred after surgery although the uncorrected vision is improved immediately. It does not improve significantly until after the bandage soft contact lens is removed in 4-7 days. There is a wide variation among patients. The maximal vision achieved may take 3-6 months. Currently, there is an interval of 1 or 2 weeks between performing PRK on the first and second eye. Complications with PRK (ASA) include a small chance of inflammation, cornealhaze and infection as well as under/over correction and the inducement of astigmatism.

Sincerely,

Partner, Eye Care Associates
20th Floor Medical Arts Building
Minneapolis, Minnesota 55402

Adjunct Clinical Professor of Ophthalmology
University of Minnesota Medical School
Attending Surgeon, Phillips Eye Institute

Office: , toll free:
Fax
e-mail:
Website: www.drsher.com

Dr. Sher,

Thank you for your detailed explanation on PRK. I am glad to see a doctor reply. I have asked and have posted my information several times but no doctor has replied. Maybe you will. I am in doubt if i am a good candidate. I will post my results and maybe you can advice.

I had a check on my eyes to see if i am a good candidate and these are the results I was given:

O.D. -5.25, -1.50, axis 020,
6.5 mm, cornea 495.

O.S. -5.00, -0.75, axis 165
6.5 mm, cornea 498

Can you please advice on what procedure to do! I was told by the Dr. that my corneas might be thin for Lasik and that I should consider a different option. Are my corneas too thin? Am I in high risk if I decide on Lasik or PRK? I can also mention I have a little bit of pterygium in my right eye and some minor floaters in both eyes.

Thanks in advance!

Dr. Sher,

Thank you for your detailed explanation on PRK. I am glad to see a doctor reply. I have asked and have posted my information several times but no doctor has replied. Maybe you will. I am in doubt if i am a good candidate. I will post my results and maybe you can advice.

I had a check on my eyes to see if i am a good candidate and these are the results I was given:

O.D. -5.25, -1.50, axis 020,
6.5 mm, cornea 495.

O.S. -5.00, -0.75, axis 165
6.5 mm, cornea 498

Can you please advice on what procedure to do! I was told by the Dr. that my corneas might be thin for Lasik and that I should consider a different option. Are my corneas too thin? Am I in high risk if I decide on Lasik or PRK? I can also mention I have a little bit of pterygium in my right eye and some minor floaters in both eyes.

Thanks in advance!

I had wavefront custom lasik in 9/04 and a custom corneal enhancement on 3/05. I am suffering from glare and halos and starbursts still. I have had severe dry eyes from lasik and seen multiple doctors and so on. My dry eyes are starting to be more comfortable to deal with but I can still tell they are dry. I have large pupils. 8mm. I made sure that my ablation zones for both surgerys were adequate for that size. I have 7mm with a blend of 1mm on the first and for the custom enhancement it went out even further so they said thats not the problem. Ive personally seen my wavefront maps with a dilated pupil and every thing was fine. They had explained that all the possible HOA's on the map cannot be seen with the human eye if the numbers on the map were under .40 for the Ladarvision wavefront scan and that would even be hard to see a problem with. My highest number now is the spherical abberation number which is .31 in rt eye and .27 in left which they said is awesome and that was with an artificially dilated pupil which they say could mess up the map to show problems. So having that in mind that I had a good procedure, i decided to go to a corneal specialist I heard of. She had told me that this could take years to heal, that I was very dry and explained how the tear film has to get smooth to stop the light scatter. Months later I went back to her and told her I feel a bit better she looked and said I should be encouraged cause its coming along. I then told her that I dont notice much difference in the glare though. She replied by telling me that what she sees may not be in correlation to the way I see cause there is still the element of dryness involved and just to wait it out cause it will end. I can see 20/15 but things are just not as sharp as I know they should be but I can tell thats from the dryness cause that has improved in these past months. I just hope the glare will go along with it. If possible can any of the doctors here know about the Ladarvision maps and the numbers like I mentioned above about anything under .40 in the HOA's is nearly perfect and cannot be noticed like they told me? Thanks in advance. Phil