LASik complications Treatments

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Always seek the advice of a doctor before changing your treatment plan.

The list below is modified from the 2017 recommendations of the Tear Film & Ocular Surface Society. This file is not meant as medical advice.
 

Level 1 - the basics:

a. High dose omega-3 fatty acids from fish oil (up to 3 grams/day of combined EPA & DHA for women, up to 4 grams/day for men).  

Paula's fish oil picks: 1) Nordic Naturals Omega-3 liquid (this is the one I currently take), 2) Nordic Naturals Ultimate Omega liquid, 3) Nordic Naturals ProOmega 2000 softgels, 3) Carlson The Very Finest Fish Oil liquid, 4) Garden of Life Platinum Omega 3 Fish Oil soft gels, and 5) Viva Naturals Omega-3 Fish Oil softgels. Update 18 January 2021: If you prefer a two-in-one product (fish oil plus GLA), Nordic Naturals makes a product called Complete Omega which includes GLA from borage oil. Update 2/9/2021: My top fish oil pick is Nordic Naturals Complete Omega liquid, which contains borage oil/GLA.

Gamma-Linolenic acid (GLA) has a synergistic effect with omega-3s, so you may see more benefit by combining fish oil with a source of GLA like borage oil.

b. Determine if you are using any systemic or topical medications that aggravate dry eyes, and modify treatment accordingly (after speaking with your doctor).

c. Preservative-free artificial tears. If diagnosed with meibomian gland disease or fast tear break-up time, try lipid-containing artificial tears.

d. Lid scrubs and warm compresses (see Matt's video: https://youtu.be/_7mY0KVI1NE ).

Level 2 - If above options are inadequate, consider:

a. Punctal plugs and/or moisture chamber goggles to conserve tears.

b. If you wake up with dry eyes, try gel or ointment at bedtime. Another option is wearing an eye shield at night, such as EyeSeals or Tranquileyes.

c. Prescription drugs such as Xiidra or Restasis (Note: These drugs are widely prescribed for treatment of dry eyes, but not everyone actually benefits from them.)

d. In-office procedures to treat meibomian gland dysfunction (MGD) such as meibomian gland probing, Lipiflow, and intense pulsed light therapy.

Level 3 - If above options are inadequate, consider:

a. Autologous serum tears (AST), which are eye drops made from your own blood. (Although the Tear Film & Ocular Surface Society placed autologous serum tears under level 3, if you have had recent eye surgery, it's probably best to start this treatment as soon as possible).

b. Scleral lenses

Level 4 -  If above options are inadequate, consider:

Amniotic membrane grafts (Prokera)

Surgical punctal occlusion (cautery)

Always seek the advice of a doctor before changing your treatment plan. 

Document Guide

Neuropathic pain is one of the most severe complications of refractive surgery. During this surgery a massive amputation of sensory nerve endings takes place. When these amputated nerves fail to grow back normally neuropathic pain can evolve. The neuropathic pain can appear immediately after surgery or after a delay of months or even years. Neuropathic pain can be continuous or be evoked by certain triggers like dryness, wind, touch or light. Pain triggered by light is also referred to as photoallodynia. The hallmarks of neuropathic pain after refractive surgery are pain (aching, stabbing, electrical, pins and needles, burning) and light sensitivity/ photoallodynia. 

Dry eye feeling may or may not be apparent at the same time. Neuropathic pain tends to be chronic and is hard to treat, can be very intense and may lead to despair. This document is developed to detail the current known treatments that are being successfully used for neuropathic corneal pain. 

Part 1 is advice by Michael Brouwer, a physician from The Netherlands who has experienced ocular neuropathic pain following refractive surgery.

Part 2 are extracts from studies that discuss neuropathic corneal pain. 

Table 1. Topical Treatments for Neuropathic Corneal Pain ...................................................................... 3 

Table 2. Systemic Pharmacotherapy for Neuropathic Corneal Pain..................................................4 

Table 3. Consider these alternatives for neuropathic pain ....................................................................... 5 

Part 1 

First choice for ocular treatment of neuropathic corneal pain are neuroregenerative therapies such as autologous serum tears (AST) and plasma rich in platelets (PRP). These blood-derived agents contain growth factors, promoting recovery of damaged nerve tissue. It may take up to nine months before effects can be noted. Meanwhile the intense pain often needs treatment with medication against neuropathic pain. For some people scleral lenses may help. These lenses protect the cornea against dryness, which could be one of the triggers for pain. Scleral lenses are large contact lenses that rest on the sclera and create a tear-filled vault over the cornea. However, for many patients with neuropathic corneal pain scleral lenses fail to be effective because the ocular surface can be easily triggered by the soft touch of the lens margins. When ocular solutions do not work or have not worked yet, oral medication against neuropathic pain may be used to dull the often intense pain. For all medications against  neuropathic pain patients need to be prepared that it may take up to several weeks before the effects on pain can be evaluated. Meanwhile it is likely that someone will have to face side effects. Slowly increasing of the dose may prevent frustration from side effects. First line medications against neuropathic pain are tricyclic antidepressants such as amitriptyline and nortriptyline. Alternatively anticonvulsants such as pregabaline and gabapentine can be tried. Alternatives for these first line options are the SNRI antidepressants (duloxetine or efexor) and other anticonvulsants (for example, topiramate or carbamazepine). When pain is acute or intense, opioid pain medication may be necessary. The NMDA antagonizing opioid methadone may be more effective against neuropathic pain than commonly used opioids. Different therapies may be combined, for example, the treatment can be a combination of amitriptyline, pregabalin and methadone all together. For every prescription the prescribing doctor needs to know about your present medication, allergies and contra indications. A relatively light treatment could be low-dose naltrexone (LDN). Please note that LDN cannot be combined with opioids. In my own situation autologous serum tears (AST) were the key factor for my recovery. Their mechanism is to restore damaged nerves and studies indeed show nerve growth after AST treatment and most importantly, of course, recovery from pain. My pain used to be 12 out of 10, sky high. After four months of use I could feel the first improvements. Nowadays after 3 years of use, I am often without pain or just a slight irritation.

Part 2 Click Here to View Documents

Always seek the advice of a doctor before changing your treatment plan.

The two most common causes of night vision problems after corneal refractive surgery (RK, LASIK, PRK, LASEK, SMILE, etc.) are:

1) residual refractive error (need for glasses)

2) your pupils dilating larger than the fully corrected area of your corneas at night.

In many patients, the problem is both.

For problem 1: If you have residual refractive error (meaning, if your vision can be improved with glasses), you should have glasses made for night driving. In some cases that’s all it takes to alleviate night-time vision problems. Even if you're 20/20, you may still benefit from glasses. I know this goes against common thinking, but having surgery changes everything. Step one, always, is to see an optometrist who is not affiliated with your surgeon for a new eyeglasses exam. Even if the prescription is small, have glasses made to see if they help at night. Soft contact lenses **may** also be an option if the problem is simply need for glasses.

For problem 2 (minor night vision problems): For MINOR forms of night vision problems that are not correctable with prescription glasses, over-minused night-driving glasses may help. For example, if your glasses prescription is -.50, have your optometrist prescribe -1.00 lenses. This is probably not a good option for older people who can't tolerate over-correction due to presbyopia.

For problem 2 (mild to severe night vision problems): Glaucoma drugs such as Pilocarpine and Alphagan reduce pupil size and may improve night vision problems. (These drugs are not FDA-approved for patients without glaucoma, but some doctors will prescribe them off-label to patients with night vision problems.) Pilocarpine has a stronger pupil constricting effect leading to a VERY small pupil. It carries small risk of retinal detachment and risk of brow ache (headache). Alphagan may dry and irritate your eyes, and may lose its pupil-constricting effect with repeated use. You may experience a pupil-size rebound effect (pupil size larger than normal) temporarily upon discontinuation of Alphagan. So, it's best not to use it chronically. Ask your doctor about trying Alphagan if you suspect your pupils are large -- if it works, keep a bottle handy for occasional use.

For both problems, mild to severe, and all other causes of night vision problems after corneal refractive surgery: Hard contact lenses are the best option for reducing night vision problems. A pair of well-fitting rigid (hard) contact lenses, such as scleral lenses (large diameter hard lenses that sit on the white part of the eye) may be quite comfortable and provide dramatic improvement in vision. Scleral lenses are usually well-tolerated by patients with dry eyes. The challenge is in locating an optometrist who specializes in fitting rigid lenses on irregular corneas. I cannot overstate that the skill of the optometrist is the key to success with scleral lenses.

WHAT DOES NOT WORK:
Don't waste your money on high-tech, high-definition glasses that claim to be designed based on wavefront technology, ZEISS i.Scription glasses, or glasses that claim to reduce glare while driving at night. My understanding of so-called "free form" lenses is that they are more precise in correction of normal refractive error -- instead of increments of .25 diopters, they correct smaller increments which is intended to provide sharper vision. Glare-blocking glasses or anti-glare coating on prescription glasses reduce the kind of glare from reflections that all eyes see, even unoperated eyes, but they DO NOT, let me repeat, DO NOT correct surgically-induced "glare" (starbursts), halos, ghost images, and double vision. It is not possible for glasses to correct post-surgery visual aberrations which are caused by an irregularly shaped cornea. None of these glasses are intended to correct irregular astigmatism in ***post-surgical eyes***, which is what causes higher order aberrations (halos, starbursts, "glare", double vision, ghosting, etc.).  These special glasses may or may not help improve vision quality for the eye that hasn't had any corneal refractive surgery but they are useless if you've had corneal refractive surgery.  So, don't be fooled by the hype.