Hyperopia, RK, LASIK and IOL/To Dr. Flavius Pernoud

[starman6600]

To: Dr. Flavius Pernoud
Dear Dr. Pernoud,

I have read some of your postings and appreciate the good information that you share with others.  I do not have cataracts as yet but am interested in improving my vision.  Please allow me to elaborate.

I am a 67 y/o male who has had RK (15 years ago) for myopia correction in my left eye, my dominant eye for distance, and Lasik (8 years ago) also in my left eye.   I also had RK (15 years ago) in my right eye, for a monovision outcome.  I was very satisfied with the outcomes of these procecures.   In the past eight years since my Lasik, I have become farsighted (+1.50) in my left eye.  At this time, I am interested in determining the best procedure for improving the distance vision in my left eye.  I have communicated with Dr. Hagen somewhat and he has been very helpful in sharing his thoughts.  I would like your thoughts as well if I may.  Here are my questions:

1.  What is the best first step ( Lasik, IOL, etc.) to take so that I can possibly keep my options open in the event that the first step is not successful?  

2.  If you recommend an IOL as my first step, I understand that prior RK patients are not good candidates for a multifocal lens.  Do you agree?  Do you have any suggestions as to how I can determine which monofocal lens would be appropriate for me.  Dr. Hagan is positive about the Tecnis.  

3.  Would there be any point in waiting for a year or so in order to see if a lens with better technology becomes available?

4.  Since it has been 15 years since my RK and 8 years since my Lasik,  do you know if any research shows how long it might be before my cornea stops flattening? Is there a solution available that can stop the flattening?

Thank you in advance for any thoughts or suggestions that you may be able to share with me.  

Frank

[malog]

You might do a Google search on "collagen cross linking rk". It is something that is under trial. I had RK 15 years ago. I was -7. That is a lot to correct with RK but for the most part it worked out very well. However when I am tired I become a little nearsighted and when I travel to high altitude areas I become farsighted. It would be nice if it were completly stable.

[Michael J Kutryb, MD]

Some thoughts.  There no way to stop the cornea from flattening but fortunately at this stage it has probably just about done all it can do.  I would recommend you consider cataract surgery and have careful Pentacam readings with simulated Holladay keratomety readings before surgery, as well as IOLMaster readings in order to determine the optimum IOL power.  I would try to have wavefront testing as well in order to find out the spherical aberration of the cornea.  If you have negative spherical aberration present, then a Tecnis or Acrysof IQ lens would add even more negative spherical aberration to the system which is a bad thing.  Remember these type of lenses are made to try to cancel out some of the positive cornea spherical aberration present in most normal corneas.  A truly aspheric like the Sofport AO or Acryos or might be a better choice in some of these situations.  I don't expect any  major new lens technology in the next few  years that will make a major difference for you.  I would avoid multifocal in you case.  In the end, regardless of how great the measurmements and surgery, I  still advise my patients in your situatuion (prior RK and Lasik) that there is about a 10-20% chance of being so far off with the result that a second surgery to exchange or add a piggyback lens might be needed.  Unfortunately that is the reality of the situation.  In the end, most patients do quite well though.

MJK MD

[starman6600]

I  will appreciate ongoing dialogue with you as I value your excellent comments.  

1.  Having kept all of my visual exam records, can I tell from the data on my recent Wavefront charts whether I have a negative or positive spherical aberration?  (Given the advantage of the Tecnis lens with it's low-light feature, it would be super if I might be a candidate for this lens).

2. In a recent post in this thread, "Malog" thoughtfully posted an informative post  on "collagen cross linking" and, after researching it some,  it seems that this could be a safe solution to stabilize my cornea flattening. Do you believe this is safe and  would it be something I should consider before I have a lens implant ? If you are positive about this linking, do you know if I can get it done here in the US via a clinical trial as it has not been approved in the US as yet?

Frank

[starman6600]

Thanks for the information.  I appreciate your writing.  I will check this out.  
Frank

[starman6600]

Thank you very much for all of you excellent ideas.  Your comments were extremely helpful and I appreciate them very much.  Best wishes.
Frank