Onward, recovering corneas

Day Eight (January 13): The last two mornings have started out fairly well, each one with more clear vision than the day before. Over the course of the day though, things blur up again and I am using moisturizing eye drops every 20-30 minutes, if not more often. When my eyes are moist though, my vision is great – sharp at both near and far distances. Probably not 20/20 yet, but getting there. I expect to be able to work again next week without too much hassle, although I'll probably be going nuts with the eye drops. The real challenge is going to be weather I can see the snow this weekend while I'm snowboarding!

I'm starting to question my decision to do both eyes at once. Obviously there's nothing I can do about it now, but if I could go back in time and have a little future-me meets past-me conversation (think Bill and Ted's Excellent Adventure, not Back to the Future), I would probably tell myself to go with one at a time, if only to be able to work more quickly and fight some of the boredom of not being able to read much of anything for very long. That said, I've managed to write and post these notes over the past week, so obviously I can do some computer work. It's just been in pretty short bursts, with a fair amount of audio-stimulation in between. On the good side though, I've managed to listen to a bunch of episodes of Bob Dylan's Theme Time Radio Hour, which is fantastic stuff. What a character.

Follow up appointments and the battle of the blur

Day Four (January 9): Things were very blurry when I woke up in this morning. The ghosting I noticed yesterday was much more distracting. The TV screen was still marginally watchable, but reading any sort of print was nearly impossible, althoug I did find that I could increase the font size or decrease the resolution of my computer screen and stand a few minutes of reading through the blur. Despite the sloppy vision, there was very minimal irritation, and what there was was in my right eye.

This was the day of my first follow-up appointment, when I might have the bandage contact lenses removed. When the optomestrist – the third one I've seen so far at the clinic – checked my eyes, he explained that the healing was looking good in terms of pattern and progress, but that the corneal epithelium had not yet completely covered the operated area. He estimated about 95% closure, with a small spot in the center of each eye that had yet to heal. This was also why my vision was blurry: the epithelial cells were regrowing and reconnecting right in front of my pupil, and thus refracting light in interesting ways. The decision was to leave the bandage lenses in for another two days (at least), to allow for the first part of healing to finish. Once the lenses are out, the optometrist explained that I'd notice a fairly quick improvement in terms of blurriness, but that it would take another week or two until it was all resolved, and after that my vision would become increasingly sharp. Before he let me go, he had me read lines on the Snellen chart. Despite all the blur, I was able to rattle off the 20/40 line (but had no real hope at 20/30 or better... yet), which both of us were quite happy with.

Day Six (January 11): After a slightly less blurry day yesterday, I woke up this morning with pretty clear vision. No real discomfort in my eyes behind the bandage lenses either. I managed to do a little bit of work in the morning, still with low resolution and large fonts. And then I went in for my second followup visit. This time I saw the same optometrist who had done my consultation. She seemed to remember me (although having my chart in her hand probably helped) and was very personable, answering all my questions again. After a quick look in each eye and telling me that everything looked “fully cooked and ready,” it was time to pull out the bandage lenses. I was a bit nervous, having read someone's blog about how it was a challenge to get the lenses out after they had become stuck to the regrowing epithelial cells, but this went smoothly. It was a bit strange not removing my lenses myself, after years of doing it almost every night, but I have no complaints about the optometrist's skilled and gentle touch. With the lenses out, my eyes immediately felt a bit gritty, and my vision was slightly more blurry than with the lenses in. The doctor explained that I should be very liberal with my use of lubricating drops, because the fragile new cells could dry up and dislodge, thus slowing my recovery. As I made my way home on the subway, I probably dropped my eyes five or six times. This afternoon, I've hardly been able to read or write, because my vision blurs within a minute or two of putting drops in. Fortunately, I've got my playlist of podcasts to get me through. My vision should clear gradually (and I think the doctor said pretty quickly) over the next week. I've got another followup appointment booked for February 1. In the meantime, it's my regular regime of antibiotics (until Friday) and Lotemax (until further notice). That and patience as I wait for my world to become crystal clear so I can fully enjoy the benefits of this surgery.

Recovery Weekend

Day 1: Once we arrived home, I took a couple more ibuprofen and almost immediately went to bed. The anesthetic had obviously begun to wear off, and I felt like someone had stuck a couple pieces of 40 grit sandpaper inside my eyelids. Not pleasant. My face was still beet red and my eyes were watering uncontrollably. I kept my sunglasses on, because even with my eyes closed the soft light inside the apartment felt way too bright. I slept for about an hour and decided to get up and lay on the couch. I made Nikki keep the lights out, and wore my sunglasses over my closed eyes while she watched TV. Throughout Friday evening, the sensation of torn contact lenses and cutting hundreds of super-potent onions continued. Really not pleasant. I was able to pry my eyes open long enough to throw in a round of drops before bed, and went to sleep.

I woke up twice in the night, once around 2:30, and again close to 6:00. I didn't think much about it at the time, but not only was my vision remarkably clear (cliché alert: I could finally see the clock beside the bed), but my eyes didn't hurt at all. By 7 I was ready to get out of bed, which is highly unusual for me. Threw in some more drops, put my sunnies on, and sat down on the couch. I was feeling much better.

Day 2 (January 7): I was expecting more of the blur and irritation of Friday, but that didn't really happen. My eyes remained sensitive to light, and I lounged around with Nikki most of the day, watching TV with my eyes half open and my sunglasses on. By sundown I asked her to take me out for a walk, and we went over to the Highline, walked down to 23^rd, and tried to go grab dinner at the Little Cheese Pub, only to find that it was closed and had been gutted. We went for wine and tapas at El Quinto Pino instead. After eating we walked back home, stopping in at 192 Books to grab some reading material for our growing number of nephews and nieces. My eyes weren't painful or too blurry, and there was minimal irritation for the rest of the night.

Day 3 (January 8): I woke up Sunday morning with a bit of a gritty feeling in my eyes, and some blurriness. I was expecting this. The doctors (and everything I had read online about PRK) had warned me that my vision would get worse before it got better again. This is because the corneal epithelial cells are regrowing over top of the reshaped cornea, from the outside edges in towards the center. As they begin to cover your pupil, they refract light and cause all sorts of fun things like ghosting, starbursts, double-vision, and general blur and haze. I'm told this goes away eventually. The irritation came and went throughout the day, and the haziness stayed pretty constant. This time, rather than a torn lens and onion cutting, the feeling was more like a little bit of dust or dirt in my eye. Manageable, but still not a lot of fun. We went out again, this time in the afternoon, to a cafe near home. Nikki did some reading while I sat and looked around through blurry eyes. I managed to flip through the day's edition of the New York Post (which doesn't get any better when you can barely make out the words... it's still garbage). This blurriness was different from my uncorrected vision. Before surgery, I could still reasonably read up close, even without glasses or contacts, and even though I couldn't make out anything beyond half an arm's length away. Now, everything's equally blurry, no matter what the distance. And it's not like the sort of unclear blur of myopia. It's more like the ghost images you'd see on an old TV as signals crossed in the air and through your rabbit-ears.

PRK Surgery; or, this just got real.

January 6 came quickly, and I was right on time for my 2pm appointment. The first step was to sign-in and pay-up. I signed several informed consent forms, including the “simultaneous bilateral PRK” form, because I had been thinking about revising the plan to split the surgery into two procedures. I would make my final decision after discussing it with the doctors, but I wanted to make sure my recovery was well underway and any complications dealt with before an upcoming research trip to Kenya. After signing the forms and paying the fees, I was given a tiny bottle of water and a little yellow valium in a cup. Very helpful, because even though I felt well-informed and ready, I was still a bit anxious... nervous excitement.

After my visit to the paperwork office, I was taken upstairs to the main area of the clinic to be measured again. Prior to the surgery, I had to wear my glasses instead of contacts for a week to let my corneas relax in case they were bent from wearing lenses. The measurement procedure was the same as during my consultation, although this time I had a different, yet still very informative, helpful, and personable optometrist working the machines and interpreting the results. The corneal topographies were essentially the same as before, and everything looked good to go. I asked her about doing both eyes the same day, and she asked a few questions about what my plans were for the next two to three weeks. Knowing that I can crank up the font size and bring down the screen resolution on my computer, where most of my reading and almost all of my writing gets done, she said it should be fine. I wanted to finalize with the surgeon, but we agreed that most likely I would do both eyes today.

After the digital examination, I was taken to another room where the optometrist performed a classic exam with the Snellen chart and a phoropter (you know, the thing that hangs in front of your face while the optometrists asks you whether you see more clearly with #1 or #2?). The optometrist seemed pleased that I didn't “overcorrect” in my perception of the charts, and explained how this test would help them to program the lasers for optimal results. She also explained the PRK procedure again, and told me that I could expect a 4-6 hour period of major discomfort sometime in the next two or three days, which would ideally happen tonight, after the surgery. She described it as a sensation of wearing torn contact lenses, but being unable to remove them because it wasn't in fact torn lenses but actual trauma to my corneas and corneal epithelium. Good times, but the sooner the discomfort, apparently the sooner the healing.

I spent another 15 or 20 minutes waiting in the exam room before the surgeon came in to discuss the two-eye option and answer any questions. As during the consultation, we finished up pretty quickly, and he told me about having seen a National Geographic special on Pompeii (everyone thinks I'm an archaeologist when I say “anthropologist”). After a few minutes of that, he popped up out of his chair and told me it was time to set up the laser, and that someone would come get me in a couple minutes for my surgery. Here we go!

An assistant came to get me in just a few moments and led me around the office into the surgery suite. In this room there were a whole bunch of large pieces of equipment, including what looked like air-conditioners and computer server racks. I was sat down on a reclined chair in between two of the big machines and dressed in a baby blue cap to hold my hair back. I was then told to lay back so the assistant could position me under the machine. Next was another round of drops in my eyes, anaesthetic I presume, followed by a patch over my right eye. The surgeon arrived, sat down at my head and began to work. A speculum clamped my eyelids open and he told me to keep looking at the small red light above me, inside a small-ish circle of white light. It was blurry. At this point I realized that one of the assistants was sitting down towards my feet, holding my hands down on my lap. I hope this is standard procedure and not some indication that I'm a twitchy, flinchy patient.

With my eye propped open, the surgeon began to apply a few more drops, and before I knew it, there was a blurry object in my line of sight. This was the electric-toothbrush-like instrument scraping away my epithelium. I couldn't feel it, but I could see it, and when he was done – in what felt like a few seconds – it seemed as if I was looking through a frosted window.

Next instruction was to keep looking at the red light. Laser time. The excimer laser makes a clicking noise as it fires, and some people say they can smell an odour. Apparently it's the gases used to make the laser work, and not corneal cells being vaporized. I didn't smell anything, but I did notice my vision becoming increasingly clear as the laser changed shape and position to reshape my cornea. Still, no sensation of pain or pressure or anything like it.

After 30-40 seconds of laser beams vaporizing bits of my cornea, I was done. The surgeon flushed my eye with a cold – and I mean cold – fluid, placed a clear bandage contact lens on my eye, and removed the speculum. At that point my eye slammed shut and refused to open for more than half a second, even when I tried to do it.

On to the next eye, with exactly the same procedure. The only difference was that I could feel the scraping, ever so slightly, as if something was scratching my eye. I also though I could feel the laser hitting my cornea, which I'm not sure is even physiologically possible. At any rate, the whole thing was over in 10 minutes or less. Before I knew it I was standing up again and being led into a darkened recovery room, where I kept my eyes closed and had a brief conversation with the guy who had been lasered before me.

After a short period in the recovery room, an assistant came in to explain (for the fourth time now, which I appreciated) how and how often to apply the three different types of medicated drops I was given. There was diclofenac as a painkiller, ofloxacin as an antibiotic, and lotemax as a steroid to moderate the healing process. All of those, a couple minutes apart, four times a day. Plus ibuprofen as an anti-inflammatory every four hours whether I felt pain or not. The assistant gave me a first round and told me to repeat the series before bed tonight. Then she stood me up and walked me out into the main waiting area where I sat until Nikita came to pick me up for our cab ride home.

Funny side note: I had been carrying my glasses with me from room to room throughout the day. During the surgery, the assistant placed them next to the monitor the surgeon would watch as he performed the procedure. In the recovery room, they were put up on a shelf above my chair. And for all I know, that's where the are today. I certainly wasn't thinking about them as I sat and waited to go home, and I've forgotten to ask about them during both of my follow up visits. It's not that I need them, obviously, but I kind of wanted to donate them to charity.

As I sat in the waiting room, some of the staff asked a couple times whether I had someone coming to pick me up (by the way, it's not Nikki's fault I sat and waited... the text I sent before the surgery didn't go through. Boo to AT&T, especially downtown, where they can't seem to manage a stable signal!). Eventually, one of them brought over some ibuprofen, water, and tissues, so I could wipe the steady stream of non-emotional tears off my face. It was involuntary, and non-stop. One of them, and I couldn't see who, said to me “don't worry, I was a big baby when I had mine done too!” I laughed, I think.

When Nik eventually got me out of there, we headed downstairs and tried to get a cab – at about 5pm on a Friday near Grand Central Station. Took a while, but eventually we sorted something out. I was effectively blind, keeping my eyes closed and wearing my stylish new sunglasses, despite the sun having set earlier. As we drove over to our side of town, I opened my eyes just a sliver ever so often and saw the bright lights of the city in clear, but a bit runny and watery, vision.

PRK vs LASIK

You can find information on the differences and similarities between PRK and LASIK all over the interwebs, but I might as well give a quick summary here. Both use an excimer laser to ablate portions of your cornea, which changes the way that light is refracted into you eye, through your lens, and onto the retina, from where it is transformed into signals your brain can interpret as images. The difference between them is that with LASIK, a tiny blade or another type of laser is used to make a flap out of part of your cornea. This flap is then laid back out of the way so the excimer laser can go to work on a deeper layer of your cornea. Once that's done, the flap is put back in place, giving you almost instantly improved vision. Apparently, discomfort is minimal and healing is very quick. I know several people (including my sister) who have had LASIK done and loved it. They were all back up and at 'em the very next day.

With PRK – photorefractive keratectomy – the procedure is different. In PRK, no flap is created. Instead one means or another is used to remove your corneal epithelium, the thin transparent layer of skin that covers your cornea. In my case this was done with a kind of brush, which the surgeon initially described as similar to an electric toothbrush. Once the epithelium is removed, the excimer laser goes to work on the surface of your cornea, thus the term “surface ablation.” Because no flap is created and the surface layers of your cornea are reshaped with the excimer laser, PRK is supposed to leave your eye structurally stronger than LASIK. There's also no risk of dislodging the corneal flap in the future (which I'm told is very rare and requires a lot of force, as in from an airbag in a car crash, but nevertheless a possibility). On the other hand, PRK is less comfortable (some would say “more painful”) than LASIK and requires a substantially longer healing period before patients can work again. I was told to expect up to two weeks of very blurry vision preventing me from reading either at distance or close up. You can see a video of PRK on youtube here.

Consultations

Before deciding on a surgeon and a procedure, I went to three different practices for consultations. I won't go into detail about the first two, but I will say that clinic #1 (specialists in LASEK) turned me off a bit because of the surgeon's propensity to toot his own horn. Not that I actually met him, but his website is littered with references to MENSA membership and digs at his “rivals.” Not terribly cool. The people I did meet there, including one optometrist and one receptionist/finance/scheduling person were friendly and nice, but I wasn't yet sold on the idea of a non-LASIK procedure.

The second clinic was, like the first, a pretty flashy operation with a nicely designed office and modern furniture. There I met with a technician who measured my eyes using what I presume was a corneal topographer. He told me I was a candidate for LASIK. I then met briefly with an opthamologist to discuss any questions about the procedure. After that, I met with their sales person, who booked me for mid-January at a lower price than clinic #1 had quoted. So far, so good. And then I went home and did some more online research about complications. That's when I found out that the head surgeon at clinic #2 had a malpractice judgement against him, the basis of which was that he had advised two patients who were not suitable candidates for LASIK that they would be fine. After performing the procedure, both developed severe complications (corneal ectasia). That freaked me out a bit - no, wait, a lot! - and I decided to get a third opinion.

The third clinic I visited was Ny Eye Specialists, run by Dr Ken Moadell. He claims a reputation for being conservative and for turning away up to 30% of people who come in for consultations as poor candidates for LASIK. After reading about potential complications – and probably getting unnecessarily worried – this was the kind of input I wanted.

Arriving at clinic #3, I was a bit turned off at first. It's a large, busy space, with a less-than-posh atmosphere; certainly less flash than clinics 1 and 2. The staff were immediately nice and helpful though. After waiting for 30 minutes or so and watching, with a slightly malfunctioning headset, an introductory video about the surgeon and the procedures, complete with testimonials from patients and staff, I met with an optometrist to examine my eyes. She did an excellent job of not only evaluating my corneas and giving me her recommendation, but also explaining what she was doing, how she and the machine were doing it, and why. Beyond that, she actually turned the monitor displaying the digitized images of my cornea and showed me what she was talking about. This made me feel very comfortable and informed. The important info here was that although my corneas were of exactly average thickness (550 microns), the shape of my corneas was irregular, meaning that LASIK was not the preferred option in her opinion.

After the optometrist's examination, I met with the surgeon who would be operating the laser to correct my vision. This was a new experience for me, as it had not happened at either clinic #1 or #2. After looking at printouts of my corneal topographs, the surgeon confirmed the optometrist's opinion that LASIK would be less ideal and that PRK would be safer, and told me that he would not perform LASIK on my eyes, but would do PRK if I chose to have it done. He explained that, given my perscription (OS -4.25, OD -4.75 with a 0.25 astigmatism), the thickness and health of my corneas, and my age, he expected a very high likelihood of very good results (20/20 vision or better). He then discussed the pros and cons of PRK surgery, explaining the procedure in detail, and recommended that I have the surgery done in one eye at a time at least a few weeks apart, which would allow me to get back to work more quickly, minimize the risk of simultaneous infections in both eyes, and allow him to adjust the second procedure based on how the first eye healed to prevent over or under-correction.

Satisfied that I was as well-informed as I was going to get, and confident in this clinic's more conservative assessment of the most appropriate treatment for my eyes, I booked my first surgery for January 6, with the second eye tentatively scheduled for January 24. The quoted price was higher than either clinic #1 or #2 (much higher than #2, but actually very close to clinic #1), but I was particularly impressed with the quality of the staff and their efforts to respond to all my questions.

Laser Eyes: Why?

I've wanted to have my vision laser corrected pretty much since I first heard about the possibility. I can remember seeing ads in the newspaper at least as far back as high school and wanting to do this to get rid of my annoying glasses and contact lenses. I have been in glasses since I was 11 or 12, but didn't really start wearing them regularly until I was about 14. I switched to contacts as soon after that as I could, using sports as an excuse. I always hated the way glasses felt on my face (a problem I don't seem to have with sunglasses) and especially disliked the lack of peripheral vision. I found wearing contacts a reasonable compromise: usually not too uncomfortable or limiting, but always disappointing when I took them out and could no longer see. Traveling with contacts has also been an annoyance. Carrying around bottles of solution, especially with the ridiculous restrictions on carry-on liquids took up space in my bags and often caused messes. I also disliked lenses for swimming. With goggles, it's no big deal, but without I wouldn't risk opening my eyes underwater for fear of having a lens drift out of my eye, leaving me unable to see when I surfaced.

After saving money and biding my time, I finally was able to take action towards the end of 2011, and made plans to have laser vision correction in early 2012. This is how it's gone down so far: 

1: Consultations

2: PRK vs LASIK 

3: Surgery Day

4: Recovery Weekend

5: The Battle of the Blur

6: Onward, Recovering Corneas