unstable cornea?

[maya]

I'm an American living in Seoul where LASIK happens to be really popular. My vision is pretty bad so I decided to have LASIK performed on my eyes. I went in for surgery yesterday & although the doctor made a flap in both eyes he told me that because my cornea is "unstable" he did not use the laser on my eyes. He told me that after cutting the flap the surface was irregular and this was suprising because all of my test results showed that I was a good candidate for the surgery. This was explained further explained to me as follows: although my cornea thickness is normal they were softer than expected leading to this irregular surface after the flap was created therefor the surgery could not be safely performed & reliable results could not be guarunteed. I was refunded my money & the doctor told me if I heal well that I can return for another procedure within a month. The doctor told me that although this situation was unexpected but I will heal 100%.

Meanwhile I am terrified. My vision is different than it was before (better actually) but I'm told it will stabilize within a month and go back to the way it was before. I can't help but wonder if he made a mistake while making the flap.

He told me that if I come back in a month by using a different keratome & making a deeper cut the surgery can be succesfully be performed but I am doubting the wisdom of allowing my eyes to be cut twice.

Meanwhile I must care for my eyes as if I had the surgery in order to prevent infection and I don't know what to do. I have never heard of this complication before & although I scoured the internet before the operation & subjected myself to 4 hours of testing before the surgery I never heard of such a complication. Is the doctor being dishonest? Was this malpractice? Is he giving me good advice?

Any advice would be greatly appreciated.

Maya

[pavel_g]

It seems strange to me that the doctor proceeded with second flap after the problems with the first one. It is also unclear to me what exactly the surgeon thinks to do month later... If the problem is the condition of your corneas, as your surgeon told, why other microkeratome will do better job? If the problem with the microkeratome he used, in this case that exactly what he should tell you!
I think you should get second opinion about what was wrong with the flaps and about what to do now.

[doppelganger]

Maya,

First, are you sure your surgeon cut flaps in both eyes without performing surgery in the first? In the U. S. that would border on malpractice, and would definitely violate standard-of-care. Standard-of-care is to cut a flap in the first eye (usually the right eye), and if it is irregular the surgeon replaces the flap without performing an ablation, and then aborts any planned work on the fellow eye. If all goes well, after several months (3 to 6) the patient can try again at a deeper depth. In any case, based on what you've said, what happened to you is that apparently both of your flaps (if, indeed, your surgeon actually cut flaps in both eyes) were irregular, probably partial-thickness buttonholes. He did the right thing by laying them back down without performing any ablation, and chances are very good, barring any complications, that your vision should return to "normal" in a few weeks. Assuming all goes well, you can try again in 3 to 6 months (I prefer 6), at which time the surgeon will attempt to cut flaps beneath the existing ones. For instance, if the first flaps were at ~130 um, he will cut the new ones at ~160 um. You are right to be concerned about doing this. It is somewhat risky. The main risk is that the second flap could potentially intersect the plane of the first flap and dislodge a sliver of corneal tissue. If this were to happen you would likely end up with a lot of irregular astigmatism and more or less garbage vision, which might, or might not, be correctable with RGP contact lenses (which you might, or might not, be able to wear). So, the risk, though small, is also serious. Another way to go is to have PRK/LASEK/Epi-LASIK performed over the first flap(s). This would avert any further risks of flap complications. The only problem here is that surface laser over an existing flap is known to significantly increase the risk of clinical haze. This haze problem is often prevented by prophylactic use of Mitomycin-C (.02% for ~20 seconds), but researchers speculate that there is a small risk this could lead to corneal thinning or necrosis months to years later (due to long-term DNA/RNA disruption). So, long story short, if you want to pursue a refractive surgery solution to your vision problems you have to be prepared to take on some significant risks. Only you can decide if the potential benefits outweigh the risks.

doppelganger

[maya]

Thanks for your informed reply.

I am sure that the doctor cut flaps in both of my eyes without performing laser surgery. It may be illegal in the states but I'm in Seoul Korea right now where I doubt that the same laws apply.

How depressing to hear that about the risks that further surgery entails. I've been waiting for years to have laser surgery on my eyes. My vision has been pretty bad since I was a child & I'd hoped that I could free myself from glasses as soon as I could afford it.

I wonder if you could tell me how, despite all the tests which I was subjected to, such an irregularity in my eyes could be overlooked. Is the doctor to blame or am I really just a freak case that seemed to be a good candidate until the cutting began?

Thanks again for your reply. Patients take a leap of faith when they go in for these procedures and generally we're told every step of the way how safe & succesful this procedure is. It is such a scary thing to have this surgery & then be told it "wasn't successful." I know little about medicine & I'm going to have to deal with any possible negative effects that pop up in the future. Any useful information is appreciated.

maya

[doppelganger]

Maya,

First, let me say that I laid out the more serious risks of trying again so you would know what could potentially happen. But, in all fairness, let me also say that in all likelihood everything would go well the second time around, and you would end up with a good result. Just understand that it is nowhere near risk free. As to what happened, it is hard to say for sure. My best guess is that for whatever reason there was inadequate suction when the microkeratome made its cutting passes. One problem could be that Asian eyes are somewhat morphologically different from Caucasian eyes (I'm assuming you are white). The main differences are the Epicanthal fold, the fact that Asian eyes tend to have smaller eye sockets as well as narrower interpalpebral fissures than Caucasian eyes, and Caucasian eyes tend to be deeper set in their sockets than Asian eyes (Koreans, in particular). Proper placement of the microkeratome's suction ring on the sclera is critical to maintaining proper suction. It could be that your doc is so unaccustomed to Caucasian eyes that he did not take into consideration the slight but distinct morphological and anatomical differences between Asian and Caucasian eyes. That's just speculation, but in normal practice the incidence of bad flaps is less than one in 500, so the chances of randomly getting two consecutive ones is less that one in 250,000 -- unless there was a systematic problem with the keratome, or the placement of the suction ring. My guess is the latter.

doppelganger

[Cindy]

Hi Maya,

I'm sorry that you have had a bad experience and I certainly understand your worries.

The term 'unstable cornea' can indicate any of a number of conditions that none of us can really comment on with any certainty. Your surgeon will know what condition presented itself at the time of your surgery so you might consider making a phone call and asking him directly to clarify.

I had a condition present itself during surgery on my first (right) eye also. My pre-operative tests indicated I was a good candidate for LASIK and it wasn't until the flap was made that my condition was discovered.

It seems to me that what you need to know for your own peace of mind is a) the health of your eyes in the immediate, b)the exact name of the condition that presented itself during surgery and, c) an explanation of why things went badly for you.

There is a section in the main LaserMyEye website called 'Roadmap for the new complications patient' that you might find helpful as you begin to assess your situation.
http://www.lasermyeye.org/patients/postop/roadmap.html

Please know that many of us here have been where you are. More than a little scared, unsure of what happened and why, and what it all means for the future. Try not to overwhelm yourself. As you stated, you must now take care of your eyes while they heal. That's the first order of business.

Take care,

[Rebecca Petris]

Dear Maya,

Welcome to D'Eyealogues! I'm very sorry to hear what has happened with your eyes and I can understand that you would be very concerned. I hope that you will find both clarification about the possibilities and reassurance about the current situation here. PLEASE NOTE however, that we (and most other individuals posting here) are not doctors and can't offer medical advice and frankly don't even want to speculate about malpractice. What you can find here, I believe, is some support from people who have "been there" and some ideas about what questions to ask and how to get more/better information than perhaps you have right now.

First, regarding having flaps and no ablations in both eyes: Yes, this is very unusual, and requires explanation. What would normally be done in a case of a flap complication on the first eye is precisely what the poster "doppelganger" stated: lay it down, and don't touch the other eye. The reason for this is that any complication on the first eye may very likely be due to a pre-existing condition and/or anatomical feature which is probably present in both eyes; therefore, (barring some specific explanation to the contrary) your second eye would also be at heightened risk.

Second, what happened? It sounds like as a minimum you've had some epithelial defects. "doppelganger"'s explanation is a possibility. However I think from your description that a more likely explanation is what Cindy is, I think, alluding to: a condition affecting the epithelium (outer surface of the cornea) in which it does not adhere properly to the tissue below. This is called ABMD (or EBMD). Can you have ABMD and still pass all the tests to get LASIK? YES. But it would become apparent when the flap is cut on the first eye. Which is exactly what it sounds like happened with you (hence they aborted surgery on that eye). All speculation, but the point here is just to arm you with some possibilities so that you can frame some questions to get more information.

What to do now? First of all find out specifically what has happened. In the section of the website that Cindy posted a link to, there is a checklist of questions you can ask; you may want to print that and take it to an appointment. What you want to find out is the MEDICAL term(s) for what has been described to you as a "soft" or "irregular" cornea.

What to do in the future (more surgery or not)? Well, I don't normally make adamant statements about what someone should or shouldn't do but these are peculiar circumstances and it seems to me that if you had flap complications on BOTH eyes, then irrespective of the reasons for those complications, attempting more cuts or even flap lifts sounds like it simply could not possibly be in your best interest.

Why is your vision better now? Swelling (edema) will change your prescription. When the swelling goes down, you should end up pretty much where you were.

Should you be terrified? Absolutely not... please! Follow all post-op instructions carefully. If you start experiencing any dry eye symptoms, discuss this with your doctor too. If you feel uncomfortable about whether you are getting the right information even after repeated visits, and/or don't get answers to the questions about what kind of complication(s) you had, seek a second opinion. There is nothing like peace of mind. Information empowers and I firmly believe that all complications patients have a right to know exactly what is happening to them.

Good luck and please let us know how things go.

[Rebecca Petris]

By the way, Maya, what is(was) your prescription? Are you farsighted?

[doppelganger]

Maya,

Rebecca Petris makes some good points; however, based on what you said, I don't think she is correct that your flap problem was likely corneal abrasions due to EBMD. This is because if your flaps had been normal except for large abrasions, many surgeons would have gone ahead with the ablations, anyway. Standard-of-care permits this. And, even if the surgeon decided the best thing to do were to lay the flaps back down and try again later after the abrasions had healed, he would not cut new flaps under the old ones (as you say he plans to do); he would just lift the old flaps -- since at that point they would presumably be normal and healthy. So, based on what you said (including the fact that your vision is still "normal" -- which it definitely would not be if you had large corneal abrasions), I still think the flaps were likely structurally irregular, and the most common structural irregularity that precludes ablation is a partial-thickness buttonhole. Please check with your doctor. Then tell us what he says. Inquiring minds want to know ;-).

doppelganger

[Rebecca Petris]

Dear Doppelganger:

While we greatly appreciate all helpful tips given to patients, I respectfully ask you to bear in mind the following two points before posting further in these forums:

1) Please read the description of this specific forum. Comments from the public are welcome in the Open Forum. Patients who want comments from the public will post there. If you feel the need to post to someone who has not posted there, you can post in the Open Forum with a link to this thread.

2) It is not the intention of this website to either encourage or incite patients to legal action. Neither is it our purpose to diagnose patients over the internet (nor to facilitate internet diagnosis by either qualified or unqualified persons). All we want is for patients to get the best medical care they can and get support from those who have been through similar experiences.

Thank you for your cooperation.

[doppelganger]

Dear Rebecca Petris,

You stated above that you do not want me to post replies on this (Q&A) forum because it is reserved for responses by "LaserMyEye volunteers or consultants." That's fine. However, below are a list of a few recent posters replying to questions on this forum. Are they all LaserMyEye volunteers or consultants? If not, please indicate where I can check their status so I can determine who is, and who is not, an authorized LaserMyEye volunteer or consultant. Also, if some of them are not LaserMyEye volunteers or consultants, where can I find your public notifications to them that they should desist from posting on this (Q&A) forum?

(1) dianat
(2) 20/20 Hindsight
(3) kurt
(4) Llamarck
(5) Allan(1of3prcnt)
(6) lucy
(7) lilacbear33
(8) Millar S
(9) Diogeneyes
(10) KevinO
(11) LS4540
(12) dianedmdj
(13) Mel
(14) Nancy Ellen
(15) pavel g

Also, you indicate that "apparently authoritative statements about what took place in their surgery..., unless accompanied by a statement of one's specific qualifications in the field of ophthalmology or optometry, (are inappropriate)." Since that is your position, why then did you state to Maya that, "Second, what happened? It sounds like at a minimum you've had some epithelial defects. 'doppelganger's' explanation is a possibility. However, I think from your description that a more likely explanation is what Cindy is, I think, alluding to: a condition affecting the epithelium (outer surface of the cornea) in which it does not adhere properly to the tissue below. This is called ABMD (or EBMD)." This conjecture on your part is likely wrong for the reasons I noted, but, more importantly, where is your "statement of specific qualifications in the field of ophthalmology or optometry," that permits you by the rules of this forum to make such a statement to Maya? Or do the rules simply not apply to you?

doppelganger

[Cindy]

Oh for Pete's sake, doppelganger...lighten up.

I would really like to know ( in a new thread posted in the Open forum) what you believe are the current parameters of 'standard of care' for LASIK.

Poor Maya, her thread has been hijacked. Please, let's return it to her.

[maya]

That's alright. Again, I appreciate the time & effort that people have taken to provide me with advice. This is a difficult thing to go through, especially so far away from home- I am dealing exclusively with (medical) people who are not native English speakers. So it's nice to have some comfort & contact. Here, most of my friends can't believe this has happened cause they have never heard a LASIK horror story. Also there's a cultural difference too which makes the clinic employees a little afraid of me: especially after what's happened. Legal action (whether it is warranted or not) is not an option as I can barely order a bowl of soup over here.

There's a bit of a time difference which means I'll be able to post an informed reply a little bit later today. I'm visiting the doctor after work to have my right contact removed. Apparantly my left eye is healing faster so I had the contact removed yesterday (after two days). It's been three days & I still have to get the right one removed.

The doc nervously giggles every time he mentions the fact that my vision is temporarily twice as good as it was before surgery. He's embarassed so I'm trying to be understanding although you can be sure that I'm not laughing. This whole situation sucks. I'm just thankful that it seems I'll be back to the way I was before: nearsighted in the -5.75 neighborhood, not ideal but better than other possibilities. I'll have to talk to the doctor to find out exactly. I'm definitely also astigmatic.

Next time I hope to have a better idea of what actually happened.

maya

[Rebecca Petris]

Great. Best of luck, glad you're seeing him so soon. Do let us know how it goes, and hang in there!!

[doppelganger]

Cindy,

I think your advice to "lighten up" is good, but misdirected. I merely responded to the post Rebecca Petris aimed at me, and pointed out apparent inconsistencies and contradictions in her statements.

Also, I would be happy to answer any particular question you have regarding standard-of-care in LASIK. As you know, many things can happen before, during, and after LASIK surgery, so I am not so foolish as to try to outline an all-encompassing set of guidelines that apply to any and all situations. However, if you have a specific question about a particular aspect of standard-of-care as it relates to LASIK I will be happy to respond. LASIK surgery has greatly enriched the lives of many, many people, but, sadly, it has also brought pain and suffering to an unfortunate minority of others. Adherence to proper standard-of-care could have prevented much of this suffering, so it's an important subject to consider.

Maya: Please do let us know exactly what your doc says happened with your flaps. Your case seems quite unusual.

doppelganger

[maya]

I visited the doctor today & asked him the medical name for what happened to me. He told me that the misshapen flap was a result of my "stiff" corneas. He told me that he has performed this surgery on many Koreans with stiffer corneas succesfully, that somehow "western" corneas are different. However when confronted with the term "buttonhole flaps" he admitted that that was what had happened during surgery. So he cut the first eye, got a messed up flap & then did the second one anyway. From what I understood my corneas were a little stiff before surgery but within the normal, operable range. I've done a lot of internet research & it seems like buttonhole flaps are pretty rare & usually the result of improper patient selection or improper microkeratome selection. How depressing.

[Rebecca Petris]

Maya,

I'm more than a little confused by the terms that he's been using. First it was "soft" corneas and now it's "stiff" cornea. Neither of those conveys much of anything to me. (I knew of a case with a loose epithelium that sounded like what you were first describing, but obviously I was wrong.)

That's why I'm SO SO glad you know now what it was! That's the first and most important step. Next is for you to heal well!

About the causes: You mentioned improper patient selection or microkeratome selection. Yes, probably the most common causes. I am trying to remmeber whether it's Asians that have flatter corneas than Caucasians. I would have thought that would make a surgeon particularly cautious about operating outside his "usual" patient group, and I really don't like the fact that your second eye was attempted. On the other hand, in fairness (not that this is comforting, I'm just mentioning it) it's also worth keeping in mind that buttonholes can & do happen to good surgeons.

Well I'm glad you've got that first step out of the way. Were you able to get a sense of whether it was only the buttonholes, or was your epithelium roughed up by the microkeratome?

[Cindy]

Hi Maya,

It can be kind of a blow to find out 'what really happened'. You think you want to and are ready to hear it but it's always tough. At least now you know. Here is a link to a page on the LaserMyEye main site that discusses buttonhole flaps:
http://www.lasermyeye.org/patients/l...uttonhole.html

[doppelganger]

Maya,

Thanks for getting back to us about your doctor's diagnosis. Based on your previous comments, it was pretty obvious that buttonhole flaps were the likely problem, and your doctors unfamiliarity with Caucasian eyes the likely proximate cause. Buttonhole flaps are rare, but they do eventually occur to all surgeons performing large numbers of LASIK surgeries, regardless of how skilled or careful they are. It's a known risk with the procedure. But two consecutive buttonholes is extraordinarily rare, and in properly screened patients indicates either a problem with the keratome, or a problem with the surgeon. In your case, as I mentioned previously, it is likely the problem was with the surgeon -- specifically, his relative inexperience with Caucasian eyes. In any case, barring any unforeseen complications, the chances are good your eyes will heal nicely and your vision will return to where it was. If at some point you do consider trying again, please keep in mind the cautionary notes I pointed out in a previous post, and if you ultimately decide to go ahead be sure to use a top surgeon very familiar with eyes such as yours.

doppelganger

[Llamarck]

Maya,

Keep in mind that once a LASIK flap is created you will always have an interface (the corneal integrity is never restored). That's why flaps can always be lifted later. We now know your original flaps are unsuitable because of the buttonholes. This means that you would indeed need to have additional flaps cut in your corneas before laser 'treatment'. I use the word treatment in the very loosest possible sense

The interface can be a problematic place and it is common that patients end up with debris in the interface...ever heard the term 'junk under the flap' ? Do you really want multiple interfaces?

There was a study conducted at Emory on post-mortem LASIK corneas demonstrating that all corneas that had LASIK had pathology. One thing that worried me was the finding of an increase in dense granules in the interface over time. So the farther the patient was from surgery, the more dense granules in the interface. Not a pleasant prospect.

I can't believe a cornea with an interface has the same refractive properties as an intact cornea. This may be why all of us post-lasiks see those fine daysparkles when there is reflection or glare. The interface could also contribute to the loss of contrast sensitivity experienced after LASIK.

You may have had a tremendous blessing that you are healing well from your attempted surgery with no lasering. Lasering introduces its own set of problems. The laser can and typically DOES induce permanent distortions in your corneas called 'higher order aberrations'. You may have just dodged a bullet. Be happy with your glasses and with the fact that you have 'correctable vision' with glasses or contacts. Many here on this bulletin board do not, as a result of refractive surgery.

By the way, doppleganger, you are wicked smart! Don't disappear on us! Did you have a bad refractive surgery?