LAL+ Full Release Just Happened

My last post was on 29 Aug, following my last appointment was 28 Aug - we were going to delay next refraction and adjustment for another week, but scheduling got in the way - I had another trip planned and doc wasn’t available the first week for what would have been 4 Sep.
On the 28 Aug refraction I was OD (two adjustments); Plano 0+50, OS (one adjustment): -2.25 +1.75 (doc) +1.00 (tech).
My impressions at that point was OD was pretty darn good, and OS was a bit fuzzy. Both sphere seemed appropriate for mono-vision. (I was wanting something akin to my PRK experience).

Appointment on 26 Sep:
Visual Acuity:
OD: 20/15/J7 (solid 20/15! J7 was a disappointment, though, but about the same as with PRK)
OS: 20/20/J1+ (not as solid as OD, but really good - tech/nurse was very surprised given the sphere)
Auto Refraction:
OD: Plano +0.25 (0.25 D less sphere than 29 Aug)
OS: -1.25 +0.75 (0.25 D less sphere than 29 Aug)
Manifest Refraction:
OD: Plano (0.50 D less cylinder)
OS: -1.50 +0.75 (0.75 D less sphere, and 0.25 D less cylinder)
Note: Doc just did not think YAG was appropriate at this point - we discussed YAG as being extremely common - and potentially more common with LAL silicone material). After review of AR and MR, and my continuing assessment of OS just not being as clear as I would like it, we decided to target removing the 0.75D cylinder. We kicked around idea that this might reduce the amount of what could be EDOF with such good distance vision, but his experience seemed to indicate most times not being able to remove all the cylinder. So, did the cylinder adjustment on the LDD.
Another note: The AR has always been lower differential that MR, typically my AR has been between -1.25 and -1.50 in sphere, and between +0.50 and 0.75 cylinder. Turns out this is pretty close to what the last MR was …

My sense, following this, the second adjustment to the left eye, is that OS is a bit clearer, but I may have lost a line on distance - it is early and still very subjective at this point (I’ve been wrong, before, on my assessment). Next appointment is 10 Oct, so will status after that.

Hi. I am always anxious to hear how you are doing. Hoping your vision is really good after the astigmatism adjustment. Wondering if they could get all the astigmatism.

So, appointment Sep 26 we adjusted my OS (non-dominate) to remove the cylinder. My assessment following that adjustment is that I may have lost a line on distance vision, meaning I had shifted myopic, and also that I had lost some mid vision (say from 2' to 4').

Last week my MR (tested by the tech and the surgeon) was -2.00 and 0 cylinder ... meaning the adjustment worked, BUT had the effect of also increasing myopia - my subjective assessment prior to the objective MR was generally accurate.

There was no indication of increasing PCO, or other ocular surface disease, but the surgeon did think my OD looked dry.

10 Oct 24
Visual Acuity:
OD - 20/15/J7 (was still hoping for better than J7)
OS 20/25/J1+ (I read it all, but would describe the 20/25 as pretty hard to get to)
Refraction:
AR OD +0.25 +0.75; OS -1.25 +0.25
MR Tech (same Tech each time) OD -0.25 +0.75 (some cylinder increase); OS -2.00 0.00 (last adjustment corrected cylinder, but may have increased the sphere)
MR Doc (same Doc each time) OD -0.25 +0.75 (some cylinder increase); OS -2.00 0.00 (last adjustment corrected cylinder, but may have increased the sphere)
As I noted prior to going in, I provided my assessment:
1. OD – a bit shorter (less clear distance) (confirmed – a bit more myopic and some cylinder where was Plano last (no LDD in between)
2. OD – not as good closer as prior to second LDD (same J7 but still less clear closer?)
3. OS – from 15”-40” seems a bit less clear (maybe confirmed since myopia increased from -1.5 to -2.00)
4. OS – lost a bit of distance? (confirmed – decreased from 20/20 to 20/25 (it was a tough to get to 20/25)
OD - Doc thinks some dry eye is affecting the cylinder, so will wait to check for stability next appointment
OS - Doc thinks have some irregular astigmatism, agrees the LDD eliminated cylinder, but affected sphere, wants to wait and if stable then will address sphere by going back towards -1.5
Doc did not see increasing opacification, so waiting on YAG
I think I’ll change eye drops - using Systane Complete PF right now - recommendation?
Doc wanted to wait to do anything further to either eye - another appointment in two weeks. On OS - he said if script is stable he felt confident in dialing back the myopia to -1.50 (hopefully with zero cylinder) and that this should get the slightly longer near back that I lost due to zeroing out the cylinder and hopefully not changing the cylinder. I asked about trialing contact, but he felt since we are only 0.5D apart, it might not be useful. On OD - he was concerned dry eye had affected the MR, so wanted to wait prior to doing anything else.

I did not expect the astigmatism adjustment to affect your intermediate vision - distance yes. The astigmatism needed to be addressed before the sphere which you will adjust next? It is complicated. After you wait 2 weeks - maybe you will neuroadapt to the OS -2.0? Do you read J1+ very often?
I do remember Optase eye drops being recommended on a video. I have watched many videos, however, I would not be able to find it.
Thank you, your ability to journal! You are fortunate to have such a good surgeon. Especially since they do 2 refractions.

Checking in with you. I think you just recently had an appointment with your opthamologist. Are you going to do another adjustment? Thank you for posting! It means a lot.

Sorry, forgot to post. Last appointment was on 24 Oct.
- My assessment going in that I shared with the surgeon/staff was that OD was doing pretty great, but would appreciate more mid, and that OS had lost the range between 15’ and 32” that I used to have prior to removing the cylinder in LDD adjustment #2 (this is bothersome as that is a sweet spot for computer work, and car dash, etc). I think the reason is so bothersome is the OD is only getting J7 - hence the lack of overlap between the two eyes in an area that is so useful to most of us.
- OD VA was 20/15 and J7 (J7 same as last four refractions - not particularly happy with it, but appears to be what it is)
- OS VA was 20/25-2 and J1+ (the J1+ was at about 12”)
- Refractions:
(Staff) OD Plano OS -2.25 +0.50 (SE -2.50)
(Surgeon) OD Plano OS -2.25 0.0 (SE -2.25)
AR OD +0.25 +0.25 OS -1.75 +0.50 (SE -2.00)
- Discussion:
1. OS – refraction shows myopia increased, hence the loss of VA in the 15-32” range. No change in PCO – surgeon said could wait and do Nd:YAG at any time as it does not usually affect much (Bradley Barnett). Still a bit dry, so gave me Xiidra samples. Decided to wait another two weeks, and if consistent to dial myopia back to around -1.50 (this would be the third adjustment). I had provided a graph with Spherical Equivalents plotted from the time of surgery - while not definitive, it helped support the discussion and aligned with numbers and my subjective assessment.
2. OD – not sure doc agrees I should be seeing J3/4 and although only seeing J7 should wait to assess in a couple of weeks prior to doing anything else. He tried to set expections considering how really good I was seeing with OD - really solid 20/15 and not able to make it any better at the phoropter. No evidence of clinically significant PCO.
3. My thoughts - I want the 15-32” area back - if the final adjustment gets back closer to -1.50D sphere, and nothing else changes, I think that will be about right. Since I am former PRK, and have data from multiple refractions showing that as the sweet spot since I don’t want to wear glasses for anything

Note - we did not adjust. Another appointment on 7 Nov- I may try wearing a contact lens on the OS at around -1.25 to assess if a lesser blend is substantively better than the -2.25 ... better would be retaining the J1+ while buying back some of the 15-30" acuity. No hurry.

Hello. I am curious if wearing the -1.25 contact is working to give you back the 15 to 30 in? If I do the LAL, wearing contacts will be an important part of diagnosing my future refractions. Not sure how reliable that process is? 11/7 not too far away!

I have not tried contacts, yet. Probably need to do that prior to committing to the last adjustment.

Hi All,

I shared the following with doc at appointment today (7 Nov 24):
- OD consistent and quite good with VA of 20/15 (tested at home)
- OS (non-dom) is too near (ie - between 6' and 12-15" is J1+, but it begins to blur past about 15", whereas before the second adjustment (which removed the cylinder) I had the same VA out to around 28-32” or so.

Visual Acuity:
- OD 20/15 and J7
- OS 20/25-1 and J1+ (the J1+ was tested at 12-14”)

Refractions:
(Staff) MR OD Plano OS -2.25 +0.25 (SE -2.125)
(Surgeon) MR OD Plano OS -2.25 +0.25 (SE -2.125)
(Staff) AR OD +0.25 +0.25 OS -1.25 +0.25 (SE -1.125)

- Discussion:
1. OS – stable so can now look for best spot on the blended to monovision curve
2. OD – about where we are going to end up - Plano and 20/15 is pretty darn good!
3. No indication of clinically significant PCO, so no YAG for now. No other issues. No real indication of significant dry eye.
4. Decided to test run at -1.50 by wearing 0.75 contact lens. I could tell immediately once it was placed that the eye was seeing longer than the 12-15”- quite startling, almost, after a few weeks at -2.25. Told the tech I could see her better than when I walked in - and, when I got into the car, the instruments and dash area (well outside the 15”) was much clearer. As I type this on my computer screen - about 32” - it is way better. And, I think this “bought” a line back on distance - at home, after long day, I think I can almost get 20/20. Will wear for two weeks (remove and clean once then reinsert).

As a BTW, my reading indicates that the LAL+ is not working out well for former refractive surgery patients. In many cases, surgeons are recommending only the use of the LAL for any eyes that have had RK, PRK, or Lasik treatments. LAL+ are being used effectively for non-refractive surgery patients.