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  #1  
Old 07-29-2007, 09:37 PM
alanlcit alanlcit is offline
 
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Location: san diego
Posts: 6
Persistent double vision, floaters

I noticed that there was already a thread addressing double vision, but I was hoping to have some more questions answered.

I had IntraLase with custom wavefront LASIK performed in mid-April of this year. Myopic, with 5-6 diopters of correction in each eye.

My vision in my right eye was within a day almost perfect, except for a very faint ghost image below it.
The vision in the left eye was very bad, with significant undercorrection (more than a diopter), and a very prominent double image above and to the right (and a fainter third image above and to the left). I'm left eye dominant, so understandably this became an immediate nightmare.

After 6 weeks, I had retreatment done on the left eye, and was told that it would correct both the residual undercorrection and the double vision. I can now read 20/20 on the eye chart, but they're right when they say all 20/20 is not the same; the double vision is better (less displacement of the image), but still there. In bright light conditions, it's particularly bad, and causes me some difficulty reading and mild headaches/dizziness. There is a distinct lack of clarity when reading that was not there prior to surgery.

I also seem to have persistent, annoying floaters...as far as I know, I did not have permanent floaters prior to surgery.

At night, I observe a 6-pointed rainbow effect, accompanied by starbursts and halos. The visual artifacts are annoying, but probably something I could live with if the other issues weren't there.

Overall, even though my vision is technically 20/20, the result overall is unacceptable and I am concerned about my ability to continue to do my job effectively, which requires a lot of fine detail work on a computer screen. Right now it is difficult for me to be productive.

I will be going back to the doctor at the end of August, and I want to be prepared with reliable information. Double vision is my worst problem, followed by the floaters, followed by the night vision issues.

1) What are some of the causes of double vision from LASIK? I have read about decentered ablations and raised islands, but I was led to believe that these issues no longer exist with modern LASIK techniques. What other causes are there?

2) Is a wavefront analysis all that's necessary to diagnose double vision, or should I request another specific type of analysis to diagnose the problem?

3) I am very leery to do a third procedure/second procedure on my eyes. What non-surgical methods are there to correct this problem, assuming it does not resolve on its own (which seems unlikely, since there seems to be very little difference now, two months after surgery, vs. a few days after surgery).

4) What are some of the causes of floaters? I know they are from bits of coagulated stuff floating around the fluid in the eyeball, but what is it about the LASIK procedure that causes them to appear in greater numbers?

5) What is the cause of the six pointed rainbow effect (what you might expect to see from a diffraction grating)? And the halos and starbursts? I thought these issues were all minimal with the custom wavefront lasik now in use?



Thank you.
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  #2  
Old 08-02-2007, 08:27 PM
Damien Goldberg MD's Avatar
Damien Goldberg MD Damien Goldberg MD is offline
 
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After any type of refractive surgery, even with the IntraLase and wavefront LASIK, the new changes in your vision can be exciting but may take time to adjust and recover from. Even though your vision now is 20/20 in both eyes, sometimes a small amount of swelling induced by the laser may cause the side effects of double vision and glare or halos. The great news is after a few weeks, as your eyes continue to heal these symptoms usually improve.

Another common cause of your symptoms is post-LASIK dry eyes. This typically starts 1-3 months after the initial procedure. Although the Lasik flaps heal within a week, the nerves that remind the eyes to blink on a regular basis can take 3-6 months to regain their full potential. How can you overcome these changes? Talk it over with your surgeon and consider some quality artifical tears like Optive, Systane, Refresh, or Thera tears etc. You may need prescription eye drops like Restasis or perhaps you may consider punctal plugs. (Tiny temporary plugs that help your own natural tears cover your eye surface for a bit longer by reduce the speed at which their drained.)

So to answer your first, third and fifth question, even though your procedure results have not met your expectations yet, give yourself time to continue to adjust and heal. Rushing into a second or third procedure may not be the right answer at this time. I would consider waiting at least 3 to 6 months before doing another procedure.

As far as the second question, again after giving yourself time to recover if symptoms still persist consider repeating the topography, orbscan and wave scan. By reviewing this information most refractive surgeons can pinpoint any residual error. There is also another diagnostic device called the Pentacam that your surgeon may have access to. This may be an alternative diagnostic device to explore if things are not improving.

And finally for your forth question, floaters are usually an aging process. However, they have been reported after LASIK when the flap is generated by a microkeratome. Take a look at this listing:

http://www.ncbi.nlm.nih.gov/sites/en...ubmed_RVDocSum

As of date there has not yet been a reported case of a vitreous floater after the Intralase. Again give this new change time. We find when patients first notice new floaters they do adjust and get use to them within a few weeks.

Hope this all helps!
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Wolstan Eye Associates
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(310) 543-2611
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  #3  
Old 08-17-2007, 05:38 PM
alanlcit alanlcit is offline
 
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Dr. Goldberg,
Thanks very much for your helpful reply. I really appreciate it. I have a followup appointment on August 30th, so hopefully I'll be able to get a more detailed analysis with Pentacam or similar instrument at that time, which will reveal more than the wavefront/orbscan measurement (which shows no problems).

Since my last email of a few weeks ago, nothing has changed, still difficult to do my work, and the double vision in the left eye (worse in high light conditions, and when using a computer (the brightness is the issue here)) and minor resultant dizziness is still there. I haven't gone to to doctor because otherwise my eyes feel comfortable, and I found that there doesn't seem to be much of a response to my complaints other than "be patient". Which I'm trying to be!

Quote:
Originally Posted by Damien Goldberg MD View Post
After any type of refractive surgery, even with the IntraLase and wavefront LASIK, the new changes in your vision can be exciting but may take time to adjust and recover from. Even though your vision now is 20/20 in both eyes, sometimes a small amount of swelling induced by the laser may cause the side effects of double vision and glare or halos. The great news is after a few weeks, as your eyes continue to heal these symptoms usually improve.
So it has been 4 months for my right eye, and a little under 3 months for my right at this time. Should I expect that all of the swelling should be gone by now?

Quote:
Another common cause of your symptoms is post-LASIK dry eyes. This typically starts 1-3 months after the initial procedure. Although the Lasik flaps heal within a week, the nerves that remind the eyes to blink on a regular basis can take 3-6 months to regain their full potential. How can you overcome these changes? Talk it over with your surgeon and consider some quality artifical tears like Optive, Systane, Refresh, or Thera tears etc. You may need prescription eye drops like Restasis or perhaps you may consider punctal plugs. (Tiny temporary plugs that help your own natural tears cover your eye surface for a bit longer by reduce the speed at which their drained.)
I have been using Systane regularly, although my eyes typically do not feel dry, except late in the evening. I use Genteal at night. I actually find that using the Systane eyedrops typically makes my vision blurrier for a while after using them.
Why do dry eyes cause double vision? My double vision was present from day 1 after surgery, and has changed very little since then. Does that mean dry eyes are less likely to be the cause in my case? I would assume chronic dryness would take a while to manifest symptoms, which is why it takes 1-3 months to show up.

Quote:
So to answer your first, third and fifth question, even though your procedure results have not met your expectations yet, give yourself time to continue to adjust and heal. Rushing into a second or third procedure may not be the right answer at this time. I would consider waiting at least 3 to 6 months before doing another procedure.
At this point, I do not have plans to do another procedure; seems very risky to me. However, what are the other options? Having waited three months, I really do need some other option now to restore my vision to my pre-surgery state. Working is highly unpleasant now...very hard to focus on things (I'm 30, so presbyopia is probably not the issue here...it's more the double vision...plus, I've tried reading glasses...they make it worse and give me a headache). I've heard that gas-permeable contacts (which I wore before surgery) have really good optical quality, and I'm hoping that maybe I could get those to help alleviate the double vision. Is there any such treatment for this problem? Maybe even soft contacts (which I've also worn) would be enough to smooth the surface if the problem is some sort of topographical one? I basically want to avoid any sort procedure involving corneal ablation in fixing this problem. So what are my options in this regard? I just want to restore the visual clarity in my left eye.

Obviously I'll be asking my doctor these questions as well, but I'm looking for alternate opinions too.


Quote:
As of date there has not yet been a reported case of a vitreous floater after the Intralase. Again give this new change time. We find when patients first notice new floaters they do adjust and get use to them within a few weeks.
Hope this all helps!
It's hard to say, but I kind of sense that with improved clarity in my left eye, the presence of floaters might be easier to ignore....

Thanks so much for any advice you or the other doctors on this site can provide!
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  #4  
Old 08-24-2007, 05:22 PM
Damien Goldberg MD's Avatar
Damien Goldberg MD Damien Goldberg MD is offline
 
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The edema that can occur in the flap after Intralase usually dissipates within a month. If it has been 3-4 months the more likely issue is dry eye, de-centered ablation or other issue with your cornea. After refractive surgery even though your eye will not feel dry, your blink reflex will be decreased. And this goes back to what I mentioned about the nerves taking 3-6 months to regrow. Sometimes patients complain of these symptoms from the beginning sometimes they donít manifest the symptoms for several months and sometimes their symptoms are present the whole course. If your surgeon sees even the slight evidence of dry eye be sure to also consider restasis or punctual plugs.

If this does not fix the problem right away then maybe reconsider gas permeable contact lens or glasses as a temporary solution.

Another option to consider, that is an off label use of medication, is to use glaucoma eye drops that lowers the pressure of the eye (ie. Cosopt, Alphagan, timolol etc.) Occasionally, we see that Alphagan can reduce oneís pupil from dilating at night which may reduce glare from the computer or bright lights at night. Its also been recognized that sometimes reducing the pressure in the eye reconfigures the shape of the cornea to a more natural curve alleviating symptoms of double vision. These are however off label uses of these medications and do not work for everyone. You need to really discuss these alternatives in further detail with your doctor.

Good luck,
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Wolstan Eye Associates
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(310) 543-2611
www.wolstaneye.com
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  #5  
Old 10-02-2007, 11:21 AM
alanlcit alanlcit is offline
 
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Quote:
Originally Posted by Damien Goldberg MD View Post
If your surgeon sees even the slight evidence of dry eye be sure to also consider restasis or punctual plugs.
I just wanted to follow up and let you and others know how this situation is going. If you recall, my main problem is double vision. In my follow-up appointment, the doctor did several different tests using two types of wavefront measurements (also looked at something called the point spread function). In addition, as you suggested, the Pentacam was used to see whether there were any other corneal irregularities. None of these measurements, according to the doctor, showed ANY evidence of the double vision symptoms I am experiencing. In fact, my left eye, which has the more serious double vision, has less spherical aberration than the right, and generally looks "better". He suggested trying reading glasses to alleviate the issues at work, which I tried. It doesn't help.

In discussing the dramatically worse night vision with the doctor (I see halos and starbursts around lights, which make it difficult to see when there is oncoming traffic), it seems that the issue there is my enormous scotopic pupil size. I asked about this issue prior to surgery, and I specifically asked whether my night vision would be better than it was before surgery, and I was assured that it most likely would be. So I'm a little disappointed about that. I would not have proceeded with surgery if I had not been reassured that my large pupil size could be properly addressed.

Quote:
Another option to consider, that is an off label use of medication, is to use glaucoma eye drops that lowers the pressure of the eye (ie. Cosopt, Alphagan, timolol etc.) Occasionally, we see that Alphagan can reduce oneís pupil from dilating at night which may reduce glare from the computer or bright lights at night. Its also been recognized that sometimes reducing the pressure in the eye reconfigures the shape of the cornea to a more natural curve alleviating symptoms of double vision. These are however off label uses of these medications and do not work for everyone. You need to really discuss these alternatives in further detail with your doctor.
I didn't feel comfortable bringing up these alternatives with my doctor, but I have set up a second opinion appointment, and I will discuss these options with this doctor. Thanks again for all your help in providing these suggestions.
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  #6  
Old 08-10-2008, 09:15 PM
alanlcit alanlcit is offline
 
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My double vision continues...

I just thought I'd speak up again about my experience with Lasik. Just to summarize the above thread, I initially had LASIK (custom wavefront, at a reputable and expensive San Diego surgery center) on April 13th 2007. In the first 24 hours after the surgery, I noticed the double vision (particularly in the left eye), night-time starbursts, and rainbow colored halos around lights at night, and noticeable floaters.

About a month later, I had the left eye redone to correct residual undercorrection (and hopefully get rid of the double vision).

The double vision improved somewhat with this second procedure, but there was still some of that (and all of the other issues remained).

About six months after the procedure, I did get a second opinion. That doctor, too, could not find any measurable cause of the double vision problem (I test at around 20/20 both eyes, but as the charts in all the custom Lasik offices say "not all 20/20 is the same!!!").

I've also been regularly going back to my original surgeon (probably 6 or 7 appointments over the past year). My eyes have been extensively scanned with whatever equipment they have, and none of that equipment has the ability to measure whatever is causing the double vision.

It's now been over a year since the procedure. If I had to do it all over again, I definitely wouldn't get LASIK! As far as I can tell from reading the various horror stories, I'm actually lucky, though. Although my eyes are a little drier than before the procedure, I don't have to deal with constant discomfort. However, that's not to say the issues I mention above don't affect me.

Here's how they affect me today, more than a year after surgery:

Double vision: This problem is noticeable at all times of the day. In the daytime, traffic lights look "doubled" (particularly green traffic lights, for whatever reason). I mention traffic lights because that's the most obvious example, but everything is actually doubled. Although I read 20/20 on an eye chart, the effective clarity of the vision in my left eye is SUBSTANTIALLY less than that in daylight conditions; with just my left eye, it can be quite difficult to read street signs and other brightly lit text. The degree of overlap of the two images depends on distance from the object. When working on a computer, I have a much more difficult time than prior to surgery. I notice fatigue comes a lot more easily, and there is eyestrain. (Reading glasses don't help.) The only thing I've found that helps is contact lenses! On most days, I wear a -0.5 lens in my left eye only, and that helps reduce the fatigue. It also takes care of the double image, for the most part, and restores my ability to read street signs with my left eye. Note that I do NOT have a residual undercorrection, according to the tests done in the doctor's office. The contact lens apparently acts to smooth out whatever is causing the double image [speculation]. Fortunately, I can wear soft contact lenses with adequate comfort...
At night, the double vision problem is also noticeable. The most striking thing is light sources and traffic lights. At night, I also notice double images from my right eye, although they are somewhat fainter than the ones from my left eye. It really makes for quite a show! The days when a traffic light in the distance looked like a single traffic light are gone! It would be very cool, if it weren't my eyes!

Floaters: This one is really hard to judge, but if I had to put money on it, I would say that I have more floaters, and they're more annoying than they were prior to surgery. Prior to surgery, I recalled occasionally noticing floaters in the eye. Now, it happens all the time. This is really only an issue when I'm working at a computer, during the day, and not at any other time. On the list of all my problems, this one probably ranks pretty low.

Starbursts and halos, poor night vision: Both the starbursts and halos are really only noticeable at night, when my pupils open up. The starbursts are probably the more annoying visual artifact of the two, since they make it more difficult for me to drive safely at night. The long rays emanating in all directions from headlights (it sort of looks like a "ruffled frill" of rays extending from a light source) tends to make it hard to see objects near those light sources. In a way, the overall contrast of the image has been effectively reduced. This is not really a recipe for success/safety when driving at night! Turning on the dome light in the car helps reduce the starbursts (because it tends to shut down my pupil), but tends to make things appear darker, too. So usually, I leave the dome light off, and just try to drive a little slower to give myself more time to react.

The rainbow colored halos only really show up when a bright light shines directly into my eyes, so practically, this isn't much of an issue. However, for the curious, here's a description: around a bright light source, at some distance from the source, I see a circular rainbow encircling the light source. Inside this rainbow extending all the way to the actual light source, there is a diffuse disk of "glare" or "halo", reducing contrast in that region. For very bright lights, I'll also see six distinct points of light equally distributed in distance around the rainbow. This "points of light" phenomenon has definitely dissipated somewhat as time has passed (I've been told this has to do with the hexagonal matrix of bubbles formed during the "bladeless" LASIK procedure), but the rainbow and glare really hasn't substantially changed. I'd prefer to not have this visual artifact, but for the most part it's not a big deal.

The following is my opinion only:
As far as I can tell, NOTHING went wrong with my procedure. The above is a "normal" result from LASIK, as far as I can tell from talking to my doctors. My doctor's surgical technique was excellent, in my opinion. As far as I can tell, this a major limitation to the modern full-custom LASIK procedure, which will presumably continue to improve with time. First, measurement: as far as I can tell, the instruments used to measure the eye prior to surgery are surprisingly crude and of low resolution! They can basically measure spherical aberration and some higher order aberrations (thus it can be called custom wavefront LASIK...this is just a marketing term), but the number of points they use to derive these aberrations is quite small...something like 250? I don't know the exact numbers (I do know that only 250 pulses of laser energy were used to reshape my cornea - a surprisingly small number!!!). What I believe this means is that tiny imperfections can't really be measured (or corrected). It is kind of like comparing standard TV to high definition TV; standard TV is ok for most things, but high definition is required if you want to see every last imperfection in the image.

I don't see any other explanation which would answer why I see double vision (particularly in HIGH light conditions), but the instruments are unable to measure it.

One of these days, my hope is that LASIK will get so good that it can correct my problem. It's possible that even today some people wouldn't be bothered with my result; they might be happy that they can see "well enough" without glasses/contacts. For me personally, since I work all day on a computer, it's somewhat debilitating (in the form of increased fatigue), unless I wear my contact.

When LASIK does improve, I'm going to be faced with a difficult decision: have my left eye redone, or leave it as is?

My number one regret (other than having the procedure done in the first place): I should have had only ONE eye done at a time. That would have given me the opportunity to compare a post-LASIK eye with an eye corrected by a contact lens, and given me the chance to decide on whether I wanted the other eye done. If I had done that, I'm pretty sure I'd be walking around today with only one eye with the LASIK procedure, and one with a contact lens. Which would have been slightly better than my current position: both eyes with LASIK, and one with a contact lens.

I wish all readers the best of luck with their LASIK decision.
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Old 08-11-2008, 01:24 PM
Damien Goldberg MD's Avatar
Damien Goldberg MD Damien Goldberg MD is offline
 
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Alanlcit,

Sorry to hear about your frustration and it sounds like you were very methodical about exploring all your options. I may have missed it in your responses, did your ever try the eye medication like alphagan or cosopt? This is off label use but alphagan can significantly help with night driving in patients who have large pupils. Secondly, I do not doubt you went to well respected surgeons to perform your lasik. But it’s difficult in this type of forum to get the whole picture of your case. What were your pupil sizes in mesopic (Dim light) or scotopic lighting conditions?
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Wolstan Eye Associates
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(310) 543-2611
www.wolstaneye.com
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  #8  
Old 01-21-2009, 02:55 PM
alanlcit alanlcit is offline
 
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Location: san diego
Posts: 6
Thanks

Dr. Goldberg,

Thank you very much for your helpful suggestions over the past year, and the explanations regarding the LASIK procedure and side effects. I have scheduled an appointment for early February at your office, and hopefully you can get a better idea of the issues that I have mentioned in this thread at that time.
Just to update, my situation is essentially unchanged from what I describe above. And to answer your last question , I did NOT try any of these glaucoma medications/ other medications as possible solutions to my double vision.

Best regards,
Alan
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Old 01-21-2009, 06:28 PM
Damien Goldberg MD's Avatar
Damien Goldberg MD Damien Goldberg MD is offline
 
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Alan,

I look forward to our meeting. It will be great for us to review the old records of your LASIK treatment. It will be important to bring your old and most current orbscans and wavescans in color as well. Any corneal topography information in color will be helpful too. If you can get a copy of those tests and bring them on your appointment Iíll better be able to help you at our appointment. Do plan on having a dilated exam. I will provide you with sunglasses but I wanted to give you heads up to bring a friend if you would feel more comfortable having someone drive you back home. See you in February!

Best regards,
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www.wolstaneye.com
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  #10  
Old 06-17-2009, 09:16 PM
alanlcit alanlcit is offline
 
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An update to my issues...

Quote:
Originally Posted by Damien Goldberg MD View Post
Alan,

I look forward to our meeting.

Best regards,
Dr. Goldberg,
Thanks very much for your help and advice at our meeting.

The Alphagan P was definitely extremely helpful for my night vision problems. However, I didn't find that it really improved my double vision issues (which I guess I would say is the most debilitating feature of my Lasik treatment). So I haven't been using it regularly...I still keep some Alphagan P around, just in case I have to do a long car drive at night - I feel it enhances my safety in that case, since I can generally see better without the halos and starbursts!
In the months since our meeting, I've basically taken to regularly wearing the soft contact lens (in my left eye only) that my regular eye doctor (not the surgeon) prescribed for me. However, the soft contact lens only made the double vision a bit better - it didn't make it go away completely. Also, when I changed the contact lens for a new one (once a month - they're 30 day lenses), the new one would sometimes be inconsistent - my vision would not be as good. Also, the night vision is still a problem with the soft lens.
So I needed a new solution. I'm happy to report that I've found one!

I went back to my regular eye doctor and explained my issues with the soft contact lens. He prescribed extra large hard contact lenses (they cover the entire cornea). (I actually only ordered one for my left eye...they are quite expensive.) Today was my first day wearing the contact in my left eye. My vision is FINALLY excellent! There is NO more evidence of double vision, regardless of the light conditions, in my left eye. I haven't yet gone driving at night, but I suspect based on the excellent quality of my vision that my halos and starbursts will at least be somewhat better. Certainly, I do not think I will see double/triple images of traffic lights - previously these were visible even during the day, but not anymore!
The best part is, these extra large hard contact lenses are actually quite comfortable - more comfortable than traditional RGP lenses.
Overall, I'm a happy user of hard contact lenses. I would definitely recommend that other people experiencing my issues who can still wear lenses look at this as an option.

If you told me two years ago that after LASIK I would have to wear a contact lens to achieve acceptable, working vision, I would have been unhappy. But after dealing with the unpleasantness and unworkable vision (my vision was not acceptable for my job without contact lens correction) for two years, I am thrilled to finally be free of those problems.

Regarding my LASIK surgeon, he has continued to be supportive of me and has continued to see me regularly. He has settled on the theory that my cornea is somewhat flattened in the center of the optical zone, which probably causes the double vision. Some of this irregularity is visible on the topography measurements. However, he has recommended that I wait on any sort of treatment until clinical trials for "topography-guided" LASIK are complete. As I understand it, LASIK which corrects ONLY topography issues (rather than treating the entire optical system) is not currently approved in the US. My surgeon feels this is the treatment that would give me the best chance of excellent vision without contact lenses. So he wants me to wait for a while....
For my part, I'm not sure that I will even do surgery, since this new hard contact lens is such a marvelous improvement over my previous state. I think I can live with this....

Thanks again for your support over the months. If anything else comes up, I'll be sure to keep this thread updated.

Alan
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