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Ask Dr. A.S. Desai Your Own Question

Dr. A.S. Desai
Dr. A.S. Desai, Ophthalmologist
Category: Eye
Satisfied Customers: 2113
Experience:  MS Ophthalmology with 11 years of surgical expereince
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I had RK surgery 12 years ago to correct myopia -4.25 and -3.75.

Resolved Question:

I had RK surgery 12 years ago to correct myopia -4.25 and -3.75. Slight diurnal shift to + 1.75 and +2.50 in morning which corrected to +1.25 and +0.75 by 1pm. All perfect until Jan 2013 when I had double bleph. Now +2.75 in both eyes with slight correction but lots of ghosting. Have seen a number of opthalmologists and refractive surgeons but no answers really apart from have an IOL or get contacts which is not helpful. D'you think this might correct spontaneously?
Submitted: 1 year ago.
Category: Eye
Expert:  Dr. A.S. Desai replied 1 year ago.

Dr. A.S. Desai : Hello,Welcome to Pearl.com
Dr. A.S. Desai : Are you available for chat now?
Customer: yes I am
Dr. A.S. Desai : Are you experiencing double vision since january 2013?
Customer: No I am not. Just very hyperopic and things are blurry at distance
Dr. A.S. Desai : Have you been examined by your ophthalmologist recently for any signs suggestive of early cataracts? Do you have any history of diabetes ?
Customer: I have had full glaucoma tests 17 and 19 last week. Orbscan showed irregularities in cornea. Right eye astigmatic -1 Axis 105. No history of diabetes and have recently been tested. Very early cataracts at periphery. The hyperopic shift presented immediately after blepharoplasty. Could surgery have aggravated RK scars?
Dr. A.S. Desai : After the blepharoplasty, have you noticed any change in the position of the lids? Blepharoplasty surgery would not cause any change in the RK scars.
Dr. A.S. Desai : Though I cannot very sure but it appears that the +1.0 dioptre hyperopic shift is more likely to be due to early cataracts. The natural crystalline lens has a refractive index which changes depending on the type of cataract which developes.
Customer: Lids are well positioned and there is no dryness or lagophththalmos. 2 Opthalmologists who examined me said that cataracts are very early and have no effect on vision yet and warned me about complications with IOL and RK issues. Could the Bleph have exerted pressure on RK scars to cause refractive error?
Dr. A.S. Desai : Hyperopic shift can occur with a reduction in the axial length of the eyeball ( certainly not changed in your case as it is the same since birth), due to change in the shape of the cornea as can occur when it becomes more convex ( again unlikely for the cornea to have become more convex in your case). Diabetes is another cause for a hyperopic shift which is associated with a drastic fall in the blood glucose level- since you are not a diabetic even this possibility is ruled out). That leaves us with a change in the refractive index of the lens as the most likely cause of the hyperopic shift.
Dr. A.S. Desai : Even if the lids were to have exerted a pressure on the cornea , it would result in astigmatism and not hypermetropia.
Customer: I have read that it can sometimes take a while for cornea to settle down post surgery? If nothing has changed after 4 months do you think that is it?
Dr. A.S. Desai : Moreover the blepharoplasty is very unlikely to have caused such a drastic narrowing of the palpebral aperture that it should actually induce hyperopia by kind of squeesing the cornea and opening up the RK scars.
Dr. A.S. Desai : It looks like the change in the refractive index of the crystalline lens has caused the hyperopic shift . Since it is very early cataract, it has not caused any reduction in vision. Peripheral cataract is usually of the cortical type which is again associated with hyperopic shift ( unlike nuclear cataract which induces a myopic shift).
Customer: Strangely I did have slight astigmatism increase in one eye but that has resolved. I am left with fluctuating vision which sometimes gets worse and sometimes better. If I come out of the sunlight and go into house focus is hard. However there is no question of doubt that my vision was absolutely fine until I had the bleph. I did have to wear glasses for reading but was 20/20 for distance vision.
Dr. A.S. Desai : Yes, it does seem very strange that post-blepharoplasty the vision has changed and it can get a bit difficult to analyse the cause in the given circumstances. You are the best judge of your vision and I am sure there has to be some valid explanation for your symptoms.
Customer: How can the crystalline lens be affected by blepharoplasty? All was well on Jan 1st 2013 and then deteriorated after 2nd when I had my bleph? Could I be experiencing some sort of stromal edema?
Dr. A.S. Desai : However fluctuation in the vision can be explained due to tear film issues. Since the eyelid plays a very important role in the formation of one of the layers of the tearfilm ( the lipid layer), there could have been some kind of disturbance in the tear film post-surgery.
Dr. A.S. Desai : You are right that the crystalline lens cannot be affected by blepharoplasty. Moreover cataract cannot be the cause of change in vision within one day. As you have mentioned that on Jan 1st the vision was fine but changed on Jan 2nd.
Customer: I did have dry eye for a while but again when examined by ophthalmologist he said that while my tear film was a little oily it would not affect my vision that dramatically.
Dr. A.S. Desai : Tear film issues can only explain the fluctuation in the vision. It cannot explain the hyperopic shift.
Customer: I guess you are as mystified as all the other specialists that I have seen. The lead Prof at Moorfields is convinced that this will resolve spontaneously once the scars have fully matured at 9 months. Others say that edema and swelling will have unsettled the cornea and this will resolve...others say that I am lumbered with this and it might get worse. I am worried about getting contact lenses as there is risk of infection with RK scars and IOL implants look even more risky. What would you suggest?
Dr. A.S. Desai : Bingo ! The other specialists got to examine the eyes too ! Not complaining but a closer look can speak more than symptoms sometimes.Corneal edema would cause blurring of vision for sure but it is not a permanent thing and should get resolved soon.
Dr. A.S. Desai : I guess IOL implants would be inevitable since there are early cataracts which are bound to progress with time and eventually require surgery.
Customer: How long does corneal edema take to resolve? Like before I am worse in the morning...probably +3 but have not been measured first thing.
Customer: Do you think I have any hope of getting normal vision back again with IOL and RK? And do you think that my vision might return to pre bleph op levels or should I give up hope?
Dr. A.S. Desai : You must not give up hope. Corneal edema should get resolved over 6-8 weeks time but can take longer ( a few more months) if the endothelial count of the cornea is less.
Customer: I have had orbscan last week and full examination under dilation. Would that not have picked up edema? Can I have a test of the endothelial count. It has been 4.5 mths now and the only thing tha has improved is my astigmatism which has disappeared in the right eye. I just can't believe I did this to myself and have now lost my perfect eyesight forever.
Dr. A.S. Desai : Performing a cataract surgery with IOL implantation post - RK is definitely a challange even to the best of surgeons. It not only requires thorough planning regarding the exact IOL power claculations but also the placement of the incision. But it is possible to do so and should be considered if the cataracts begin to progress.
Customer: What do you think about getting contacts if I can tolerate them? Do you think it will compromise my already unstable corneas or put me at increased risk of infection?
Customer: Do you think it is possible to get plano vision with my RK and cataract surgery? I have 4 RK scars which the ophthalmologist says are quite deep.
Customer: By the way thank you for taking so much time with me but I am feeling quite anxious and you are being very reassuring.
Dr. A.S. Desai : It can be very challenging to get 20/20 vision with cataract surgery post-RK, but with definite planning a lot of complications can be avoided. I guess it is possible to do so however.
Customer: I do have access to my pre RK information. Would you advise waiting and putting up with my poor vision or going for it now?
Dr. A.S. Desai : Contact lenses are a temporary option provided the cornea is clear ( no edema). With proper precautions and good hygeine, the risk of infection can be avoided. Endothelial cell count of the cornea can be done with the help of a specular microscope.
Dr. A.S. Desai : I would suggest that you wait for a few more weeks or months and look for improvement of vision ( allow complete healing of the surgery scars). In the meanwhile we can keep an eye on the progress of the cataracts. If they progress then the decision to undergo surgery can be more firm.
Customer: D'you think I should get an endothelial cell count done? Would this shed any light on the situation? I guess the question I want you to answer is do you think that there is any hope of my eyes returning to pre op status. How long do you think that ultimate healing of surgery scars( I assume you mean bleph scars )will take place?
Dr. A.S. Desai : Yes, I meant blepharoplasty scars . Endothelial cell count would only help if the corneal edema remains persistent and does not resolve even after months. I would be positive in assuming that your vision should improve in the coming months . Most scars usually take 8-12 weeks to heal and have good integrity.
Customer: In that case I am almost 18 weeks post bleph. Should something not have happened by now?
Dr. A.S. Desai : Yes, 4 months + is long enough for bleph scars to heal. But I guess it would help to give more time. In the meanwhile you could request your ophthalmologist to go for an exam by a cornea specialist ( just to know if there any subtle stromal edema lurking there due to any reduced endothelial cell count).
Customer: Can stromal edema be treated? What effect does it have?
Dr. A.S. Desai : Yes it can be treated. If present it can cause blurring of vision .
Customer: Dr Desai you have been very helpful and I am grateful for your time and patience. I think I have exhausted all your answers and now I will just have to wait and see.
Dr. A.S. Desai : I am glad to have assisted you today. I am afraid that conclusive answers could not be given however.
Customer: I know and I appreciate that. Many thanks
Dr. A.S. Desai, Ophthalmologist
Category: Eye
Satisfied Customers: 2113
Experience: MS Ophthalmology with 11 years of surgical expereince
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