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Category Archives: Dr. Visits

DALK Checkup – A Few New Nuggets of Info

Lexington Farmer's Market

Well, today was a routine checkup.  Topography, pressure check, eye test.  Pretty much the same as the last time.  Dr. Holland removed two sutures as we continue “suture roulette.”   The graft looks great, and we’re right “on track.”

I did learn a couple of things today:

  • Peak rejection time is 8 months out from surgery.   This is for PK or DALK.  I thought it would be earlier.  This means that I must be extra diligent for RSVP symptoms between now and early next year.
  • The first sign of rejection will be redness and light sensitivity, not pain.   You should never wait for the pain if redness and pain are present.
  • When Restasis is part of your post-op drops routine, you should usually use it last.   So, for me, it’s Steroids, Pressure Med, then Restasis.
  • He suggested that I might go ahead and use Restasis in my right eye if allergies get bad again.  I think I’m through the worst of Fall allergies, however.
That’s it.
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Oh, I really do appreciate all the messages I get about how much people are enjoying the blog.  Thanks much.
 
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Posted by on September 29, 2011 in Dr. Visits, Surgery-Story

 

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5-month DALK Follow Up – 20/30 Corrected Vision – 5 sutures out!

Had a very good 5-month visit today where 5 sutures were removed.  We’re playing “suture roulette” now, chasing the astigmatism around my cornea.

My astigmatism went from 9 diopters to 4 diopters, which is excellent.  I’m now seeing 20/30 corrected!   The graft is also healing very well.  My steroidal dose was cut in half and my eye pressure is now stable/managed.

For the first time in 10+ years, when they adjusted the settings on the eye testing optics, I reached a 20/30 level of vision.  It used to be a pure blur.  They used to flip the lenses around and I’d say “same, same, same”…it never got better or worse.  But now, it’s like it should be.

Dr. Holland said if I was in a hurry, I could possibly get fit for contacts, but I’m going to wait and let the graft heal as long as possible.

It couldn’t have been a better visit.    Back in 8 weeks.

Roulette Wheel Photo by Photo: Heather Rai

 
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Posted by on August 5, 2011 in Dr. Visits, Recovery, Surgery-Story

 

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Managing Intraocular Eye Pressure Issues with my Corneal Transplant (and… 2 more sutures out!)

Topography - to map the surface of the cornea and guide suture removal

Well, I just returned from anther follow up with Dr. Holland post-corneal transplant.  The graft and optic nerve look good, but my eye pressure is still too high – a condition known as “steroid-induced intraocular pressure.”  I’m among a small number (8%) of people who seem to have steady, ongoing eye pressure rises with use of steroids.

We’ve adjusted the type of steroids I’m using, and I’ll be taking a drop to reduce eye pressure as well (the drop is normally used for Glaucoma patients.)   I was also relieved to learn that there were no other reasons my eye pressure was rising (such as tissue or structural complications from surgery.)   Apparently that can happen with full-thickness graft, though rare.  I will be happy when the pressure is moderated – as I don’t like the sound of Glaucoma one bit!   What I think is going on is that I will be using a tiny amount of steroids – far less than most people.   This means I must be alert for any irritation symptoms.

Vision was stable, not that much better.  They claimed astigmatism was down, but I’m not seeing it.  I worked hard to see eye chart numbers.   I wish I’d brought my glasses so they could have evaluated those.  I think it will show I can see pretty damn good through them (despite the old prescription.)

But in terms of graft recovery, things looked good enough to remove a couple more sutures.   This time, the removals had a bit more of a pinch and I was slightly sore afterwards.   Tylenol and back to work.  Next time I might ask them to delay the numbing drops until right before the process itself.   There is this unpredictable delay between numbing drops and when Dr. Holland actually does the removal.   Last time, it didn’t hurt at all.    This is similar to how it went during surgery – my pain meds started wearing off before the procedure was done.  Ouch!

One Niggle… I’m consistently impressed by the Cincinnati Eye Institute Staff, but sure wish they’d dump the blaring TV’s in the waiting room.   It’s not just them, it’s everywhere.  Doesn’t anyone else like to pull out a book to read anymore?

 
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Posted by on July 1, 2011 in Dr. Visits, Recovery, Surgery-Story

 

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Post-DALK Corneal Transplant Visit – 2.5 Month Follow-Up – The First Sutures Removed

Corneal Topography - GraftReporting in after my 2.5 month follow up visit with Dr. Holland at Cincinnati Eye Institute.

During this visit I had usual vision checks, numbing drops,  eye pressure check and topography taken of my grafted cornea.  The eye pressure was a bit high, so I’m cutting back on steroids to a lower frequency.  The topography was successful (first successful one I’ve had since around 2003, my cone was just too steep.)  I tested to 20/60 with pinhole (which reduces effect of astigmatism.)

Corneal Roulette – Suture Removal to Adjust for Astigmatism, Tension

Dr. Holland identified some “tight” and “loose” areas on the sutures via the topography.  He then showed me where he’d be removing sutures.   I really like how Dr. Holland stops to let the patient view the diagnostic tactics.   I have 24 stitches, and it’s impossible to keep them all at the same tension.  Also, the cornea heals at different rates, meaning you might get tension in one area and “slack” in another.

Before the suture removal, the assistant gave me numbing drops and antibiotics.  Then they gave me four more numbing drops, the comment being “you want your eye to be nicely numbed for this part.”   Yikes..   Anyway, the anxiety was for nothing.   I rested my chin on the rest and the assistant pulled open my eye gently with a swab.  Dr. Holland viewed through the microscope and in literally 10-12 seconds, snipped two strategically placed sutures, almost before I realized it.  He then used tweezers to pull out the microscopic threads and before I knew it this was over.  He showed me the sutures – they are like butterfly eyelashes (as my daughter used to say) truly tiny.   Then, antibiotic drops were used (and will be used for a few days) since the suture leaves behind an entry point for potential bacteria.

So, the removal of the sutures was 100% pain free.

Interestingly Dr. Holland told me that if we stabilize the astigmatism, we’d stop taking sutures out – leaving them in place for years.    This would promote a very solid wound healing process.   Some patients have sutures out more quickly based on astigmatism situations.

Droopy Eyelid after Corneal Transplant

After surgery, as my swelling went down, my wife and others noticed that my left eyelid was a bit droopy – a bit more closed than it should be.  Dr. Holland explained that this is probably due to the spreader which was used during the operation which caused a contusion of the muscle.  For most people, it will gradually recover within a year.  If not, there is a simple procedure to adjust it.   No matter what, he said you shouldn’t do anything until a year had passed.   He said the bright side was that it provided slightly more protection to the eye.

Restasis is an Anti-Rejection Drug – News to Me

I think that I know quite a bit about corneas, DALK, etc, but today proved I have a long way to go.  I thought I was taking Restasis for tear production, but actually it was to prevent rejection.  Mark that down in your note book.  Dr. Holland also told me that Restasis was good for combating allergies and is in FDA trials for that indication!   Okay.. bottom line, use the Restasis whether or not your eyes are moist.   Dr. Holland said that it was a steroid-sparing allergy drop.   They’ve used it for hay fever conjunctivitis for a long time.

Eye Pressure Still a bit High

Dr. Holland told me that 8% of patients react to topical steroids, such as durasol, were prednisolone  was a bit weaker and caused less pressure.  It’s only a problem while I’m on steroids, which, for DALK, would taper steroids over a year or so.    I was slightly concerned about what effect higher pressure might have on my eye.  Dr. Holland explain that the only thing that would be a concern was the optic nerve – and mine was just fine and there was nothing to worry about.   Postscript: eye pressure continues to rise, new drops started.

Astigmatism after DALK Surgery

How much astigmatism, and how it will progress during post-op recover, is highly variable.   Some patients have high astigmatism until sutures are removed, while others have low astigmatism until they’re removed and suddenly have a lot.  It’s all normal, and we just have to wait and see where it will go.  If there is a lot of astigmatism after all sutures are removed, we will discuss PRK with a laser to fix it.  For me, I’m minimally nearsighted right now, and will likely remain so for ever.   My corrected vision is 20/60 at this moment.   He said another patient at his office recovering from DALK was 20/25.  Nice.

 
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Posted by on May 26, 2011 in Dr. Visits, Recovery, Surgery-Story

 

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Outstanding 1 Month Visit – Corneal Transplant Follow Up

I had my one month (and a week) visit to Doctor Holland today and all went very well.   He said my transplant was healing better than most, and my vision continues to improve.  The astigmatism is taking front and center but they said that this will begin to be addressed in my next appointment when a few sutures may be removed.  This is done strategically based on the topology.  Dr. Holland told me this was the reason he uses so many interrupted sutures… it allows for “Suture Roulette” where he can tweak things very precisely while keeping sutures in place to allow healing to continue.

I didn’t get the number, but could see some pretty small letters via pinhole.   Interestingly, I learned that the pinhole is a measure of  “potential” vision or “correctable” vision.  So I have some seriously high hopes!

The only concern was a minor increase in interocular pressure (trend…18 to 20 to 27 mmHg) – both doctors say that this is due to the Durezol steroid (I have been on a high dose) and it was nothing to be alarmed about.  They changed my steroid to Pred Forte – a weaker steroid – to manage this.  I was told that around 8-10% of patients fall into a category “Steroid Responders” – a genetic condition… who have a pressure response to steroids.   I had no inflammation on my eye so the reduction in steroid should not have any downside.  They told me that I was out of the high risk timeframe for “RSVP” type symptoms and that the steroids are there just to prevent any chance of rejection.

I mentioned my itchiness and they said I could take Zyertec for it… but if that didn’t do the trick they’d subscribe an allergy drop.  I don’t like adding variables to the mix if I have a working solution, so don’t plan to ask for the drop unless things get bad.

I was also told I could stop wearing a shield at night if I wanted.

As far as how I feel – It’s great!   I can drive at night and have very, very little pain.  I have no complaints at all and so far I’m very, very glad I had this done.

Back in six weeks!

 
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Posted by on April 14, 2011 in Dr. Visits, Recovery, Surgery-Story

 

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Corneal Transplant – 2nd Follow Up with Dr. Holland

Cross-section of Corneal Tissue (approximate)

It’s now been 8 days since the surgery.

I worked half a day and went, with Heather, to Edgewood to see Dr. Holland for my “1 week” follow up appointment.  The Cincinnati Eye Institute office was very busy.  We waited 2 hours to see the doctor – so I will never go there in the afternoon again and never on a Friday!  Lesson learned.  The rest of my appointments will be early morning and early in the week.

After we finally got in, the technician checked my vision (strangely, the test was conducted with the band-aid contact lens inserted and affecting my vision.)  I did not get the exact measurements, but I had improved three steps beyond last time on the pinhole.

After Dr. Holland came in, he checked the epithelium (see illustration, top section) to see that it had healed over properly so he removed the bandaid contact lens after numbing my eye.  He used tweezers to remove it, and it did not hurt at all.  As soon as it was out, however, I could feel the dryness start.   Unexpected.

Transitions are always tough.  It was not really pain I felt, but a tickle-itch sort of feeling with a mild burn.   Dr. Holland said that the bandaid lens was holding moisture in before, and I would need to supplement that from here on – these lenses have pros and cons.  But cell growth was great.

This solution works for me during the day... I use a gel-tube version of it at night.

Dr. Holland looked me over well with slit lamps with and without florescent die, checked eye pressure and gave me a clean bill of health.   The cornea is clearing, the sutures looked fine, and I was good to go.  I am now to stop using the antibiotic but continue with the steroid and Restasis (tear medicine.)   Now, he said I should expect fluctuations in vision – and that we’re in the long slog of a slowly-healing cornea.

I will be going back in a month, and he may do a topography for the first suture removal, but the decision to remove them will be made on the fly based on the topographies.  I knew this.   He also said that Heather did not need to come with me for those appointments.  I’m glad because it’s a lot of trouble for her to come and wait for me.

I’m to continue wearing my shield at night, and he said sunglasses during the day.   This “wound” is still fragile and I need to take care of it.

We had Buffalo Wild Wings and headed home.  I got very dry on the ride and wished I had brought lubricant.  Once home, I added Systane and it helped a lot.   As I write this, the irritation seems to be fading after a Tylenol

The journey continues…

Click kitten to see my eye on Day 8 - with bandage lens removed. You can see sutures more clearly.

Postscript: 3/19/11.    Eye really feels raw today.  Hoping this is temporary.   Last night I used a gel-type lubricant before bed and that worked really well.   Steroid drops definitely have a burn now when they go in.   These are some things to expect I guess.

 
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Posted by on March 18, 2011 in Dr. Visits, Recovery, Surgery-Story

 

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More Keratoconus Questions Answered

Okay here are the keratoconus questions I brought with me to my second consultation along with the answers I received (aggregated from all answers, but mostly from Dr. Holland.)   After the appointment I sat in the car and wrote down every answer I could remember.  And here are the results:

Q: Have  I tried all available contact lens ideas?  [I have a semiscleral lens]
A: Yes, I’d say you’ve reached the end of that option with the scleral lens.  Most people never get to a scleral solution.  You have advanced keratoconus, very steep cornea and very thin cornea… the lenses you have are the most comfortable that are possible.  If this isn’t working, you’ve extinguished your options.

Q: Does my Scarring rule out most novel ideas?  Is my scarring that bad?
A: Yes, your scarring is centered and cannot be fixed.  Most other things, such as cross-linking, corneal rings, etc. will not help.  Also you have so much steepness that these options would not flatten your cornea enough no matter what the scarring.  They can work for mild cases. If your right eye started showing KC, we might consider those approaches.

Q: What about Nerve Endings?  Right now, my eye feels like it has a bad sunburn.  What happens with your eye sensation after the graft?
A: At first there will be none, but they will grow back in 3-4 months.  Your “burning” pain is coming because your steepness prevents a good tear film from forming – you have dry eye all the time.   The center of your cornea is drying out, and this is part of the problem.

Q: Corneal neovascularization – do I have it?  Are there any pre-graft procedures I need to address it?  Are the semi-sclarel lenses and their “blanching” causing this?  [why I was concerned]
A: No, you have only superficial case.  No worries there.  You have minimal vascularization.  It becomes an issue when you have two or more quadrants of vascularization.

Q: What should I expect in terms of vision compared to what I have now?   (bad)
A: It’s hard to tell – some patients see better right away.   Given the level of steepness and scarring you have, I think you’ll see better pretty soon.  You may be able to try a contact lens or glasses prescription within 3 months.  We may take sutures out bit by bit, but typically we wait until a year’s passed.  After about a year, we may want to do a laser procedure to get rid of residual astigmatism.
(postscript 3/17/11:  My vision was immediately better – dramatically so….  see later posts for more detail.)

Q: I just keep reading about problems with cornea grafts on the web.  Is it just that they are the only ones that post?
A: Yeah.. but there’s another thing.  The numbers are skewed by non-compliant patients.  That is, 22-23 year olds that don’t follow the post-op regimen – drops, suture care, etc.   You are old enough to know that this is important, and I expect you to do really well.  With someone like you, we’re looking  at a 97-98% success rate.  Also, always better to ask us than read online.

Q: I am concerned about rejection – I read so many stories online
A: Well, not with DALK.  You have to almost try to get rejection with DALK for it to happen.    You’ll see studies that show 5-7% rejection rate, but the numbers are affected by non-compliant patients.  With a healthy eye, and a compliant patient, we’re looking at less than 3%.

Q: Could you tell me about graft lifetime with DALK and PK?
A: With DALK, you should be good for life.  If we perforate, and convert to PK, the lifespan can be 15-20 years.   Your steepness and scarring mean the odds are probably 70-80% of us being able to successfully complete a DALK.  (postscript 3/17/11:   DALK successful – but barely – thanks to Dr. Holland’s skill, we did not convert to PK) As young as you are, you’d expect to have a second graft if we do PK.  With a PK, 70% of the epithelial cells are lost in the first 5 years.   With a DALK, you’ll lose around 10-11% of the cells in the first year, and then it stabilizes.  The vision is the same with both.  You would expect to have another PK at 60 years old or so – and the rejection rate would be higher.

Q: What’s going on with artificial corneas – by the time I’d need a second PK?
A: The problems with these are pretty significant, especially considering the success of normal grafting.  Then news keeps talking about them, but the success rate of donor corneas just makes it a no-brainer.   They have way more glaucoma, way more infections, etc.   The eligible cornea donors is so much greater than the current donation rate – and we use corneas up to age 75 in the USA (Australia even older.)   For DALK, the age of the donor doesn’t really matter.

Q: Do you order your tissue “PK ready?”
A: Yes, in every case.  (he was impressed that I even know what this meant.)

Q: If I have a problem at home (1:15 hours away) would I rush up here or get with someone in Lexington?
A: I know many of the guys down there, but most likely you’d just come in the next day.

Q: BIKING and surgery – I bike commute – will I be able to?
A: You’ll want to give this a week or two, you’ll want to protect your eyes really well.

Q: What about post-op astigmatism?
A: We always try to avoid it, but there will be astigmatism with a new cornea.  It’s impossible to get the donor cornea perfectly positioned.    For you,  refractive surgery will be the likely best option to finalize that vision improvement.

Q: How many DALKs have you done?   (dear reader, do not forget to ask this question.)
A: We’ve been doing it routinely for around three years, and I do over 200 grafts per year – 60-70 are DALKs.   (note:  This is a LOT of DALKs)

 
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Posted by on February 5, 2011 in Dr. Visits, Pre Surgery, Surgery-Story

 

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Keratoconus Consultation #2: Dr. Edward Holland – Corneal Specialist

I just finished my second informational meeting with Dr. Holland and must say it was excellent.  I cannot begin to describe the differences in the staff between the Corneal Surgeons’ staffs between Lexington and the Northern KY team.  They are more professional, friendlier, and more knowledgeable at every step of the way.  I am not going to call out the Lexington surgeons by name here, I’ve no intent to stir things up, but if you’re in the area and needing Corneal work, you owe it to yourself to visit more than one.

Off to Edgewood.

After “working” half of a day in Lexington, I grabbed the GPS and an audiobook and made the 1:15 drive to Edgewood, KY (essentially a suburb of Cincinnati on the Kentucky side of the river.)  After a yummy lunch at Panera and a few minutes checking email on my laptop, I went to the office.  I saved their office as a “Favorite” on the GPS because I have a feeling I’ll be coming here a few times!

Checking in was the usual – insurance card, verifying contact information, etc. at the desk went quickly and I noticed that the waiting room was full of people.  I also noticed that the average age of people there was well, well older than me – possibly by 25 years or more!   I sat down to read my RSS feeds and noticed that they had a very strong public WIFI for us.  Nice!  I barely got the first one on the screen before they called my name .  I felt mildly guilty, like you do in the “Fast Pass” line at Disney… until I realized that the other patients were there to see the cataract specialist, not the cornea doctor.

Feelings During the Visit

I realized as I walked to the back rooms that my anxiety about today had turned into a sort of strange excitement.  Still concern, but I felt like I was doing the right thing and taking steps to make life better – not only for me, but for my family who has to deal with my grumpiness when my eyes are hurting.  Dr. Holland’s reputation and the staff’s treatment bolstered this feeling.

Dialated Pupil - Kerataconus

Staff Knowledge about Keratoconus is Critical

I sat and spoke with a technician, who asked why I was there – did a basic vision test, including a pin-hole check.  .  I quickly established a great rapport with her and realized that she was not only smart about corneas, but it seemed more informed than the doctors I’d met about my condition earlier in Lexington.  She knew a ton about the transplant – having sat in on many operations, including the DALK procedures.  I was able to get a whole different perspective on the surgical process, etc. from her.   She also wanted to do a topography – and I told her my cone was too steep for the equipment, but we did it anyway.   Sure enough, the computer choked on my data as usual.  I’ve not had a successful topography since 2003… the equipment just isn’t able to help after a certain point.

My eye pressure was checked and they dilated my eye to examine the retina and optic nerve.  Doing it only in my left eye made me look kinda cyborg-like, and my daughter got a kick out of it.   All was golden – my eye is very healthy.  Except for that damn cornea.

Find a Great  Cornea Specialist… even if you have to drive or fly there!  Go to someone who does 50 or more grafts annually, preferably a mix of DALK and PK who has surrounded themselves with knowledgeable technicians and staff.  Your eyes are your window on the world – this is not the time to compromise.

I also ended up talking to a good, retina-surgeon friend on my front porch last year  – and she made quite an impression with her recommendations… “don’t compromise when it comes to cornea surgery, period.”  So I’ve learned a lot.

Bottom Line

If you have Keratoconus, and feel that the Doctor is treating you like the rest of his patients or that the technicians don’t understand the disease due to the “rarity” you owe it to yourself to find another expert, even if you have to drive or fly

 
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Posted by on February 3, 2011 in Dr. Visits, Pre Surgery, Surgery-Story

 

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Keratoconus Consultation #1: Dr. Edward Holland – Corneal Specialist

image: fromereye.com

Once I felt that a transplant was my only viable, long-term option, My wife and I went to Cincinnati Eye Institute to visit Dr. Holland.  I brought her along because I thought they might dilate my eyes, plus it’s nice to have a second set of ears.  I’d been to a few other surgeons in Lexington – some highly regarded – but for some reason I felt less comfortable with them and their answers.

Dr. Holland impressed me from the handshake forward.  He was well versed and spoke with confidence about the situation.  He seemed quite comfortable with new techniques, such as DALK, where my other surgeons had said that PK was the way to go.

As we began, Dr. Holland pulled out the eye chart and covered my right eye.  I just sat there, looking at the blur.  “That’s what I thought” he said.  “Contacts are not cutting it for you anymore.”

I had formulated a lot of questions for him…

Q: Is the Femtosecond laser promising for me – should I postpone my surgery until this is more available in the USA?
A: It is promising for making the cut more precise, but few have it right now.  The jury’s still out on how much it helps over an experienced surgeon.

Q: I’ve heard good things about Deep Anterior Lamellar Keratoplasty (Is a DALK surgery possible for me – or will Penetrating Keratoplasty be the only option?
A: I think you have an 80% chance of a successful DALK.  That will be our goal, but we can convert to PK if needed.

Q: Other corneal surgeons I spoke with seem to avoid the DALK option, saying it’s inferior visually.  Why?
A: Sometimes it’s a matter of practice.  You get comfortable with a way of doing things.  PK is very good, and done well the outcomes are great.  DALK takes a lot of practice.

Q: Does my eye look generally healthy?
A: Yes.  I don’t see any other underlying issues.

Q: Why do I feel pressure/aching occasionally?
A: With the poor vision, your eye is probably in a constant strain to focus.  That can cause aching.

Q: What is the reason for the constant “sunburn” feeling I have?
A: The epithelial layer of your eye has a lot of nerve endings.  When it’s stretched or rubbed, it can feel like stinging or burning.

Q: Are “intacs” an option for me?
A: No, because you have too much scarring.   They can flatten the cornea, but the scars would still be there and you’d be unhappy.

Q: What is the success rate with eyes like mine?
A: Excellent.  Kerataconus patients are usually the happiest with a transplant.

Q: Should I wait?
A: It’s up to you, but if you want to go forward, we need a month’s notice.  There are complications if you let advanced KC progress also.  Unfortunately, it doesn’t really get better.

Q: What’s the healing time?
A: Around a year.

Q: Is there a chance of acute hydrops?  Ruptures of other types?
A: Probably not – and that is treatable.

Q: What’s my potential visual outcome… will night driving be better?
A: Our goal is 20/20 without correction.  After healing, you should be far, far better than you are now.

Q: Is it possible that there are better scleral or semi-scleral lenses that would help me avoid surgery?
A: There are options, such as Boston’s $5000 lenses… but your scarring is going to always get in the way of good vision.

Q: What about rejection?
A: DALK reduces the risk of rejection – but it happens.  Almost all the time it’s treatable if you take care of it pretty quickly.

 

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