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  #1  
Old 02-14-2009, 05:29 AM
vickim vickim is offline
 
Join Date: Feb 2009
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Is PRK advisable after LASIK followed by cataract surgery?

Hello

I had LASIK in 1998 to correct -6.50 myopia in each eye. This was successful and stable until my vision started deteriorating in 2004. The increasing myopia resulting in my wearing contact lenses and necessitating several changes in my contact lens prescriptions each year was diagnosed as nuclear cataracts in July 2008. I had the cataracts removed and monovision IOLs implanted in November and December 2008. My distance eye had the unexpected outcome of a significant degree of post-operative astigmatism at 135 degrees across the right eye. I now wear a -0.25 -1.75 Acuvue Advance contact lens for astigmatism which corrects my blurred vision very well. However, I am disappointed with the result as I was hoping to be contact lens-free. My ophthalmologist has suggested doing PRK/LASEK to correct the residual astigmatism. Is this advisable 4 months after the cataract removal or might the astigmatism resolve to some degree of its own accord? I am also concerned about having an enhancement on top of the original LASIK treatment in case there are complications with the flap.
I would appreciate your opinion.
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  #2  
Old 02-16-2009, 05:05 PM
Steven Safran MD's Avatar
Steven Safran MD Steven Safran MD is offline
 
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It has become quite a common practice these days to enhance Lasik patients by doing PRK on the flap. I personally prefer this to relifting old flaps because I believe it is safer. You don't risk epithelial ingrowth and you don't further thin the corneal bed. I'd say this is a better way to go than lifting the flap.
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  #3  
Old 02-16-2009, 07:15 PM
vickim vickim is offline
 
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Thank you, Dr. Safran.

Given that the astigmatism has been caused by the cataract surgery, do you think it advisable to wait for a period of time before doing the PRK/LASEK? I am now 3 months post IOL implant and am concerned that the astigmatism might resolve or improve over time. in which case PRK/LASEK would then overcorrect my vision. There has been no change in the past 3 months, however. Is there a recommended time frame within which one should not do an enhancement?

Thank you.
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  #4  
Old 02-18-2009, 09:35 PM
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Steven Safran MD Steven Safran MD is offline
 
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Without examining you I can't really respond to your question completely. When you say the astigmatism was caused by the cataract surgery this is unclear. Was the astigmatism due to the possiblity that you had lenticular astigmatism which had been corrected on the cornea by Lasik and now with the removal of the cataract you are now corrected for something that isn't there or was the astigmatism created by the cataract incision?

My feeling is that if you have been stable for a few months it's probably fine to go ahead and fix what's there but your surgeon has examined you and I haven't so I would certainly defer to his judgement here.
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Phone: 609-896-3931
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  #5  
Old 02-18-2009, 11:19 PM
vickim vickim is offline
 
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Thank you for your reply, Dr Safran. I do realise it is difficult to make an informed judgement without an examination.

My ophthalmic surgeon who performed both my LASIK surgery in 1998 and my cataract removal 3 months ago was surprised by the degree of astigmatism post-cataract surgery and said it was an “unexpected result”. This led me to believe that the astigmatism was surgery-induced as I would have expected that lenticular astigmatism would have been factored into the calculations for the IOL replacement before surgery was performed. I might be completely wrong here and am obviously not qualified to make a judgement. I have found some pre-LASIK measurements which mean little to me but which might enable you to give an opinion on whether there was pre-existing lenticular astigmatism in my right eye:

I quote: “Her unaided visual acuity measured 4/120 on the right and 2/120 on the left, improving to 6/4.5-1 right and 6/6+1 left with spectacle correction.

The subjective phoropter refraction preoperatively measured:

R -4.25 -1.00 x160
L -6.25 -0.75 x10

The preop K’s were:

R 43.50 x165
44.50 x75
L 43.25 x14
44.25 x104

She underwent bilateral LASIK refractive surgery in 1998.

73 months post-operatively she now sees 6/30-2 unaided right and 6/7.5-2 unaided left. The subjective refraction now shows minimal residual distance refractive error.

The subjective phoropter refraction after LASIK refractive surgery measured:

R -0.75 –0.50 x135
L -0.25 -0.50 x110”

My optometrist who prescribed contact lenses when my vision started to deteriorate in 2004 (due to what we now know was cataract formation) has said that pre-cataract surgery my astigmatism in my right (distance) eye was -0.25. It is now -1.75 at 135 degrees, as I said in my first post, and is corrected with a contact lens for astigmatism.

I suppose that, regardless of whether the astigmatism was lenticular or caused by the incision during cataract surgery, my decision now is whether to go ahead with the enhancement by PRK/LASEK and hope that the further surgery does not cause my vision to be worse than it is now corrected with the contact lens. I appreciate your thoughts that 3 months’ stability is sufficient to enable me to proceed with confidence. I have read a good deal on PRK/LASEK on the internet and am concerned about the vision fluctuations that seem to take place for several months post-op. Is it as accurate as LASIK, and why does the vision fluctuate so much?

Thank you for taking your time to respond. It is greatly appreciated. I am rather nervous about having further surgery and my ophthalmologist has a tendency to be rather dismissive of my concerns and doesn’t explain things very clearly.
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  #6  
Old 02-19-2009, 06:33 AM
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Steven Safran MD Steven Safran MD is offline
 
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I can answer the last questions easily. The quality of vision and accuracy of PRK is just as good as Lasik if not better. Vision fluctuates as the epithelium heals and remodels and this is variable depending on the patient and how quickly and completely the ocular surface heals.

Looking at the numbers you have provided does not reveal to me why you have this astigmatism. It could be due to many different possibilities and it would be reasonble for you to ask your surgeon where he thinks it is coming from prior to fixing it.
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Phone: 609-896-3931
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  #7  
Old 02-19-2009, 09:05 AM
vickim vickim is offline
 
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Thank you for your reply, Dr Safran. I appreciate the time you have taken to consider my questions and reply. I feel more confident now in regard to proceeding with the PRK enhancement.
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  #8  
Old 07-16-2009, 10:28 PM
vickim vickim is offline
 
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Use of FML drops?

I had the enhancement done on 11 June (6.5 months post- cataract operation). My surgeon said he would aim for LASEK instead of PRK and everything seemed to go smoothly. I had no post-op pain and very little discomfort. According to my optometrist, my eyeball has now completely changed shape. I have been left with .75 astigmatism but in a different place and at a different angle to the previous 1.75 astigmatism at 135 degrees. My vision is very good, though, and I don't need corrective lenses to drive. I do, however, have some corneal haze, which my ophthalmic surgeon noted when I had my second post-op appointment a week ago. He has put me onto FML (fluoromtholone) 0.1% drops 3x per day for 2 months, saying "they can't do any harm" and told me to come back in two months' time. However, I understand from my reading on the internet to the contrary. I am really concerned about the length of time he wants me to be using the FML as I have read that they can increase IOP and that the patient needs to be monitored closely. When I rang his practice to query this and voice my misgivings, I was told that there was no reason to come back to see him prior to my 2-month appointment. What is your opinion, Dr Safran? In addition, I understand that these drops should be used with caution in post-cataract patients (of which I am one) and that they need to be tapered off.
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  #9  
Old 07-21-2009, 10:29 PM
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Steven Safran MD Steven Safran MD is offline
 
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I think it would be a good idea to have your pressure checked after 3-4 weeks of taking the FML. Some people can have a pressure response to the drops.
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Phone: 609-896-3931
http://www.safranlasik.com/
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