Post Lasik Strong Myopia...leave with a -2.00?

[Uncle Fester]

Curious to hear your experience and opinions.

Had a -8.00 undergo Lasik recently. She was torn about whether to correct to 20/20 or leave some nearsightedness. Her MD was understandably waffling so as not to get blamed if she didn't like the final correction.

I told her and my experience is most myopes over a -6.00 who wear glasses instead of contacts for their primary correction miss the habit of seeing up close without glasses and are happier with a -2.00 final power.

FWIW- She made a point of coming back to me saying she would have been terribly disappointed if she had gone for the full correction.

What say you???

MD's and OD's comments especially sought.

[braheem24]

Depends on the personality, But if wanting to keep near optimized I would opt for...

-1.00 Dominant
-2.00 Non-Dominant

[Dr. Bill Stacy]

First off, I'm kind of surprised that anyone is getting LASIK these days, given the fact that the interface never really heals well, leaving the eyeball structure permanently weakened and susceptible to loss of the eye from relatively minor impacts. Most docs in my area are only recommending PRK these days, because no such risk is involved, not to mention much less scary procedure that has very low complication rates.

That said, I like your idea, although I'd recommend a more moderate approach, maybe -1.00 target O.U. which would be great for doing a lot of things without Rx, like computing, dining, etc. If she is a total bookworm (or Kindleworm) then the -2 might be ok, but begs the question, how old is she?

[Robert Martellaro]

Curious to hear your experience and opinions.

Had a -8.00 undergo Lasik recently. She was torn about whether to correct to 20/20 or leave some nearsightedness. Her MD was understandably waffling so as not to get blamed if she didn't like the final correction.

I told her and my experience is most myopes over a -6.00 who wear glasses instead of contacts for their primary correction miss the habit of seeing up close without glasses and are happier with a -2.00 final power.

FWIW- She made a point of coming back to me saying she would have been terribly disappointed if she had gone for the full correction.

What say you???

MD's and OD's comments especially sought.

Although targeting distance vision for myopes after cataract surgery is not necessarily in the client's best interest, I would would think that a twenty or thirty something myope would not be happy with a -2 D outcome after cosmetic refractive surgery. However, your client is clearly presbyopic, and appreciative of the heads-up WRT the variety of refractive outcome choices that are available postop, but are rarely discussed preop, especially with cataract surgery.

[Uncle Fester]

Thanks for the replies.

Braheem- Please refresh my ever more feeble memory to determine dominant eye.
Dr Stacy- Patient is 50ish. Loved she could see her cell phone held at a "normal" distance. Will not mind the new much thinner glasses!
Robert- Yes for a younger patient.

[fjpod]

Making someone plano or even +.25 when they have been -3 or -7 their whole lives can be devastating, if you do it in their 40's. This is true even with cataract surgery and IOLs. It is a discussion you have to have with the patient.

You don't tell us how old your patient is. If they are in their 20s or early 30's, I would recommend going for full correction. If they are over 40, I would recommend leaving the non-dominant eye at -1.00. When doing monovision, trial it for a couple of months with CLs.

I would have the discussion about near vision and try to get them to understand.....BUT THEY WON'T. They will misquote you in the future.

I'm a 3.50 presbyopic myope myself, and I just don't get the fascination with "I just want to wake up and see what time it is without putting my glasses on, so give me surgery". Personally....I love to be able to see a serial number on a computer up close, or the date on a coin with no glasses.

Every patient is different. Personalities are different. Their visual demands are different.

[Paul Smith LDO]

Thanks for the replies.

Braheem- Please refresh my ever more feeble memory to determine dominant eye.
Dr Stacy- Patient is 50ish. Loved she could see her cell phone held at a "normal" distance. Will not mind the new much thinner glasses!
Robert- Yes for a younger patient.

Dominant eye test, take both hands form a circle or triangle, place in front of your eyes opened while looking at a stationary object. Close your left eye, if image doesn't shift, your right eye dominant.
I've had similar conversations with presbyop's and have gone so far as to show them their vision as a -2.00. I hope to do the same for myself when cataract season opens for me.

[fjpod]

Another test for eye dominancy, is the +1.50 test. Take a +1.50 trial lens and put it in front of one eye while the patient is looking at a Snellen chart at distance, with both eyes open and with their habitual correction, if any, in place. Ask them if they see a blurring. Then put the lens in front of the other eye and ask them in front of which eye does the lens cause more blur. So, if the greater blur is in front of the right, then the OD is dominant and vice versa. I think this test is more dependable.

Keep in mind, though, these dominancy tests depend on not having things like strabismus, amblyopia, or other pathology....

[icmor]

I went from -12.00 to plano with small cyl. Being presbyopic, I really did miss the ability to see up close. (lens surface inspections, and trying to find progressive markings.) I since had an eye injury which caused a traumatic cataract. The MD set me up post CE with a -1.25 in the one eye. I am what they call 20/happy. I can do most things without glasses for distance and near. Working with small screws and very up close work, I use my progressives. I never would have considered mono vision, but it works great for me. But, yes, losing near vision after lasik took quite an adjustment.

[jakemoore]

Uncle: I discuss presbyopia with refractive surgery candidates over 38 and recommend blended/monovision to most people. Ultimately it depends on what the patient wants and does all day. I also discuss the option for refractive lens exchange with a presbyopia correcting IOL (PRELEX). Patients come to me seeking both LASIK and PRELEX. I also discuss LASIK as an option when patients come asking for PRELEX. I would do -2 if a patient asked for it but most want some distance. I'm much more likely to do plano to -0.50 in the dominant eye and -1 to -1.50 in the non-dominant eye.

Dr. Bill: 80% of refractive surgeons including myself recommend LASIK as the primary choice in refractive surgery and do Surface Ablation in certain cases. 20% will only do Surface. Surface has its own set of problems including pain, time off work, fluctuating vision and haze. Pain is the big one. I have significantly higher costs in providing all laser LASIK compared to Surface, but make up for it in chair time and happy patient referrals.

[Scooby Snacks]

Making someone plano or even +.25 when they have been -3 or -7 their whole lives can be devastating, if you do it in their 40's. This is true even with cataract surgery and IOLs. It is a discussion you have to have with the patient.

You don't tell us how old your patient is. If they are in their 20s or early 30's, I would recommend going for full correction. If they are over 40, I would recommend leaving the non-dominant eye at -1.00. When doing monovision, trial it for a couple of months with CLs.

I would have the discussion about near vision and try to get them to understand.....BUT THEY WON'T. They will misquote you in the future.

I'm a 3.50 presbyopic myope myself, and I just don't get the fascination with "I just want to wake up and see what time it is without putting my glasses on, so give me surgery". Personally....I love to be able to see a serial number on a computer up close, or the date on a coin with no glasses.

Every patient is different. Personalities are different. Their visual demands are different.

I had LASIK way back in 2000 at age 23, right after it was approved in the US, and that's all I wanted: to see the alarm clock. I wasn't terribly nearsighted, about your level, but it was enough that I needed glasses for everything and I wasn't a good cl candidate because I also required a moderate prism in my glasses for which I also had muscle surgery later. I think age should factor in with level of correction. Younger patients benefit more from full correction due to the lack of presbyopia. And my results were excellent. I was 20/20 the next day, but I did end up paying for the full correction later: I became presbyopic early (age 38) and I'm back in the prism as well. But I'm still thrilled. I got my LASIK procedure done for free and 15 years of no glasses.

I did a lot of LASIK consultations when I was an ophthalmic technician and worked at one of those cut rate LASIK places for about five seconds. I couldn't believe how many patients were standing in line to have a surgeon perform LASIK for $400 or even less per eye! A place that advertises that the doc has completed 25,000+ procedures should NOT be bragging about this, IMO. That suggests that patients are being herded down an assembly line, the operation is completed faster than is safe for the patient with post-op exams at a minimum, then rushed out the door to perform the next one. Those places are all about $$$, not patient well being. Feeling I was not doing right by the patients was the reason I stopped working at this facility.

[optical24/7]

Uncle: I discuss presbyopia with refractive surgery candidates over 38 and recommend blended/monovision to most people. Ultimately it depends on what the patient wants and does all day. I also discuss the option for refractive lens exchange with a presbyopia correcting IOL (PRELEX). Patients come to me seeking both LASIK and PRELEX. I also discuss LASIK as an option when patients come asking for PRELEX. I would do -2 if a patient asked for it but most want some distance. I'm much more likely to do plano to -0.50 in the dominant eye and -1 to -1.50 in the non-dominant eye.

Dr. Bill: 80% of refractive surgeons including myself recommend LASIK as the primary choice in refractive surgery and do Surface Ablation in certain cases. 20% will only do Surface. Surface has its own set of problems including pain, time off work, fluctuating vision and haze. Pain is the big one. I have significantly higher costs in providing all laser LASIK compared to Surface, but make up for it in chair time and happy patient referrals.

I sure hope you have these mono patients trial it with CL's 1st. I see way too many dissatisfied patients that had mono done with their IOL's that never tried it 1st and only went by what the doc said were the benefits of mono vision.

[rbaker]

Curious to hear your experience and opinions.

Had a -8.00 undergo Lasik recently. She was torn about whether to correct to 20/20 or leave some nearsightedness. Her MD was understandably waffling so as not to get blamed if she didn't like the final correction.

I told her and my experience is most myopes over a -6.00 who wear glasses instead of contacts for their primary correction miss the habit of seeing up close without glasses and are happier with a -2.00 final power.

FWIW- She made a point of coming back to me saying she would have been terribly disappointed if she had gone for the full correction.

What say you???

MD's and OD's comments especially sought.

I say: This is clearly a discussion best held between the patient and HER physician. The involvement of any other third party is pointless and inappropriate. I do realize, however, that opinions are like anal sphincters. Everyone has one.

[adoc]

I agree with Uncle Fester that it is inconceivable to take a myopic patient and deprive them of their ability to read without glasses. This is a setup for a dissatisfied patient. Hyperopic patients will not complain with that type of result since they were never able to read without glasses to begin with; but myopic patients will feel as if they've lost something. Therefore, I offer most patients monovision. Lasik and IOL's are somewhat different when you're blending. With Lasik you may need at least 2D of myopia in the non-dominant eye for a patient to read adequately (or about 1D of myopia for intermediate vision). However, with IOL you can actually get surprisingly good reading with a -1.50 to -2.00 myopia. The only problem that I've found is that you can't leave too much of an anisometropia regardless of what approach you use. Typically I will aim for -0.25 to -0.5 in the dominant eye and then try to aim for -1.75 to -2.25 in the non-dom eye (basically, an anisometropia equal to or less than 1.50D). In my hands this has worked very nicely in almost all patients.