Vertcle downward Light streaking and ghosting from light sources whilst blinking

[PaulF123]

I had lasik surgery about 9 years ago now. I remember having dry eye symptoms and light sensitivity immediately after. My vision was pretty good at this point. After about 3 months along with dry eyes still, i noticed a verticle downward streaking of light from car headlights at night as i blinked. Over the next few months this became more noticeable off all light sources both day and night along with the usual glare and starbursts off light sources. The streak can be from the top to the bottom of my vision. I was treated for dry eyes quite aggressively and although this improved comfort, it made no difference to the other issues. Over the years i have seen a number of doctors, had dilated eye exams, topography, wavefront analysis all which come back normal. Irregular astigmatism came back within normal range with small amount of verticle coma. I can cope with most the issues but the light streaking when blinking is something i cant get used too and nothing any doctor can understand or advise on. I have exhaused most avenues but know a few people on here have had similar issues but seems to be without any success of treating.
I really feel like it is being caused by my eyelid or eyelid muscles causing it. I feel a tightness whilst blinking, alot of my blinks are only partial. I think it could  possibly be tension of the upper eyelid causing a prismatic effect of the cornea when blinking. I notice my eyes blur alot especially when i use any eyedrops too as if they are not being spread properly over my cornea maybe due to this. Any help or input would be appreciated. Would you recommend seeing an ocuplastic surgeon or neuro ophthalmologist to suggest my ideas too as everything is coming back normal in regards to what the corneal doctors are seeing. Thanks. Paul

[John C Hagan III, MD, FACS, FAAO]

Given your history and work up and the fact it only occurs with blinking, the most likely cause is that your eyelids create bending of the cornea due to eyelids pushing on the cornea. If it was dry eyes putting in tears would eliminate it for a few minutes.  This problem is more common in younger people with stronger eyelid muscles and good lid tone.   Since you have dry eyes and only symptomatic when blinking I doubt an ocuplastic surgeon would be willing to do eye lid surgery and at this point with all the tests, the amount of time a neuro-opthalmologist a wast of time and money.  I would suggest you see either optometrist that is highly skilled in fitting contact lens.  He/She can try both soft CTL but the one most likely to help you would be a gas permeable CTL.  If that cures the problem you know the cause and the cure and can decide whether to live with it or wear the gas perm. CTL.

[PaulF123]

Many thanks for your reply Dr Hagan.
I dont reccall having my eyelids everted after having the dye put in. Is this worth me asking for at my next appointment? To access the lid wiper and contact area from the eyelid?

It happens when i blink or if there is any movement on my upper  eyelid for example if im out at night and its a bit windy then my eyes might take a partial squinting position where i seem to notice it so much more. If im concentrating on something, again i sometimes take this position with my eyes and notice the downward streaking from my phone or computer screen more.
I have quite prominent eyes. Although my upper eyelid seems to sit ok most of the time my lower eyelid does sit lower with a small amount of scleral show above my lower lid, increasing the distance the upper eyelid must travel during a blink. I dont know if this adds to the issue. Possibly the dryness and incomplete blinking? )
I have mentioned this to an ophthalmologist but been told they dont see any problem, i just have quite big eyes. I mentioned if it was possible protosis but again told not likely as no scleral show below my upper eyelid. The upper eyelid does have more tension in it and will flex off the surface of the eye with more force if i pinch it together like its held there under pressure if that makes sense. This is unlike the lower lid that seems a lot softer and doesnt do that. Is that normal?
Many thanks
Paul

[John C Hagan III, MD, FACS, FAAO]

At some point you eyelid should be everted but it not likely a problem.  Some people have prominent eyes, some people develop prominent eyes due to over-active thyroid and you should have a blood test for over=active thyroid. Have big eyes also increases risk of eyelid surgery. My recommendation remains same trying contact gas permeable lens.

[PaulF123]

I am awaiting for an appointment for fitting of lenses. Would scleral lenses be a good option if i suffer dry eyes still?

I have been told off one specialist that the likely cause of it is the tear meniscus and that lenses didnt help one patient who had the same issue. Is this possible and would there be a fix if it was caused by the tear meniscus?

Thanks

Paul

[John C Hagan III, MD, FACS, FAAO]

1. I have not fit contact lens for over 30 years deferring that to the excellent optometrists in our practice. Thus I cannot give advice on scleral lens, gas-perm CTL or soft CTL.
2. I am reasonably sure that the tear menisucs (TM) is not a problem.  First do a quick read and see what it looks like with a internet search. The TM is small and reduced in dry eyes. The TM can be a problem with UPPER lids that ride LOW which is not your problem. TM has been implicated in problems like yours in patients with low upper lids who have had a laser hold put in the iris at the 12 oclock position for angle closure glaucoma.

[PaulF123]

Thanks for your reply.
The reason i was also thinking tear meniscus is if i tip my head far enough back whilst looking at a light source it changes to an upward streak which appears to be through my lower tear meniscus and dissappears if i move the lower lid off the surface.
I have read the artcle of it happening after laser iridotomy, could it theoretically happen after lasik? Im guessing theres no way to diagnose and fix  if this is the problem?

[John C Hagan III, MD, FACS, FAAO]

Yes in the artificial, non-pysiologic experiment you conduct on your self with that type of extreme position the lower TM could do that.  If could also be due to the extreme downward gaze and the ocualr muscles being stretched to their max,  in any case what is important is problems you have in everyday life (some people see double if they look up/down/left/right as far as they can)   The problem with LPI superiorly is much different than LASIK.   Most surgeons now put LIP at 3 of 9 oclock rather than 12    Your problem may be caused by irregular astigmatism that doesn't show up on cornea topography.

[PaulF123]

Hi. When i was mentioning earlier about prominent eyes. I measured my palpebral fissue height which is 16mm in a straight gaze and even more when im looking upwards. From what i understand 8-11mm is normal. Could this be causing issues with incomplete blinking and adding to irritation through exposure of the ocular surface? Could it be also causing the visual issues when blinking or gazing in certain directions do you think? Many thanks paul

[John C Hagan III, MD, FACS, FAAO]

If it has changed over the years, yes it could be a problem.  Eyes that start to 'bug out' are called exophthalmos. Most common is over=active thyroid (Graves Disease) and that should be excluded. Another cause is swelling of the tissue behind the eye due to disease like lymphoma. Orbit MRI should be done.

[PaulF123]

I dont have measurements from years ago but it does seem that way.
Does an orbit MRI allow them to access the eye muscles for abnormalities too?

[John C Hagan III, MD, FACS, FAAO]

When you go in to see the Eye MD take some good quality facial photos on your phone of you taken 10-15 years ago. Comparing then to now can often determine if the eye is moving forward.  Eye muscle abnormalities are not generally checked adequately by just orbital MRI, needs testing by Eye MD.

[PaulF123]

Hi Dr Hagan

So i had an appointment today and addressed my concerns and the doctor did notice a level of proptosis and lower eyelid retaction. He has referred me to an ocuplastic surgeon for a full assessment.
Is it possible that this could be the reason im experiencing the verticle  light streaking/ghosting  only when blinking as there is an increased pressure of the eyelid on the cornea?
A light can go from looking normal with my eyes open to extending from the top to bottom of my vision during a blink  surely there has to be something  going on to cause this as significant as it is and if it was just corneal related my topograpghy and wavefront scans wouldnt be coming back as normal? Both eyes are effected exactly the same should i add.
My upper eyelids are also travelling a further distant with my lower lids sitting lower, could this be extending the blink duration and reason i am noticing it more? If i blink quicker it is definitely less intense
Many thanks
Paul

[John C Hagan III, MD, FACS, FAAO]

In an eye with forward movement during a blink the tight ocular muscles can temproarly bend the cornea causing irregular astigmatism. So if the ghosting only occurs on blinking that could be the cause. Discuss with the oculoplastic surgeon.