Nystagmus

Discussion by Dr. Chynn about how he treated Jacob:

We had Jacob schedule a “Remote Second Opinion”, where he paid $500 by credit card, and he then called me on my cellphone using FaceTime (if he had an iPhone) or WhatsApp video (if he didn’t) so I could see the extent of his nystagmus & strabismus (eye turn) with my Fellow, or junior eye surgeon studying with me for 1 year to learn how to deal with these complex issues.

Jacob had a high-amplitude, rapid nystagmus in both eyes, and a right esotropia (eye turned in). He also had a prescription of -9.25 -3.25 x 180 in both eyes, which puts him in the extreme myopia + extreme astigmatism categories, with a visual acuity in each eye with glasses of 20/80 (without he could only “count fingers”). He also had moderate esotropia (eye turning in) of his right eye.

We performed a manifest refraction of both eyes and got him seeing 20/70 out of each eye, or 1 line better on the eye chart than with his current prescription, which was under-correcting his astigmatism. With his head turned, his nystagmus was less, and he also said when he was drunk it was less. So, I told him that I would probably be able to perform my non-cutting LASEK procedure on him without using the fixation ring. That’s a special instrument I designed that I can use to hold his eye in place if his nystagmus would be too bad under the laser, so the laser would treat the center of his cornea.

On the day of surgery, we gave Jacob Valium, FDA-approved dissociative anesthetic, and nitrous oxide (laughing gas) to calm Jacob down, because he was very nervous (partially because he had both never worn contacts before, nor had any prior surgery). I also told him to turn his head under the laser to put his eyes in the direction of gaze where his nystagmus was least (this is called the “null” position). By these methods, I was able to perform the non-cutting LASEK without using a fixation ring, and my J&J/AMO/VISX Star4 SR laser was able to track his eyes, since it captures a digital image of his eye at 60 Hz (60x/second), and uses iris tracking (other lasers sometimes use retinal tracking, which is impossible in nystagmus).

Immediately after surgery, Jacob was seeing 20/100 out of each eye without glasses, which was good. We told him to keep both eyes closed and sleep as much as possible over the next few days, so the skin of his eye that we removed would grow back. He came back to our clinic 1 week after surgery to have his bandage contact lens removed, by which time his vision had already improved to 20/80, which means he was already seeing as well as he did with glasses—without them!

We worked with his local eye MD, who saw him once a month, decreasing his steroid drop from 3x/day, to 2x/day, to 1x/day over 3 months, then he was off all his drops except artificial tears. We also worked with his local optometrist to give him contacts with a very mild prescription at 3 months postop, so he saw 20/50 with both eyes open. So, Jacob was able to accomplish his goal of independence by passing his driver’s license, and having a new, better life!