Therapeutic Raytracing Customised Surface Ablation For Visually Function–Symptomatic Patient After Femtosecond Lasik: Comprehensive Diagnostic Protocol With Rgp Confirmation, Ray-Tracing Wavefront Analysis, And Functional Vision Restoration.

To demonstrate that excellent uncorrected distance visual acuity may mask significant functional visual impairment after prior under-the-flap PTK for rainbow glare in post-myopic LASIK eyes. We present a structured diagnostic protocol integrating photopic and mesopic contrast sensitivity (cycles/degree), off-label ray-tracing high and low order aberrations analysis, diagnostic RGP validation of corneal optical origin, anterior-segment OCT flap assessment, and mandatory dilated crystalline lens and macular OCT evaluation to exclude non-corneal causes. The aim is to validate corneal optical degradation and justify a safe ray-tracing–customized surface enhancement-off-label- strategy in safety-critical visual demands.

A post-myopic femtosecond LASIK patient, previously treated with under-the-flap PTK for rainbow glare, private-jet pilot, with persistent photopic and mesopic visual symptoms (halo, glare, ghosting) despite 20/20 uncorrected distance visual acuity. Functional testing revealed reduced contrast sensitivity across spatial frequencies under both photopic and mesopic conditions. Ray-tracing analysis using the Alcon/Wavelight Sitemap device and Wavelight Plus algorithm of the EX500 excimer laser, demonstrated minimal refractive error, but higher-order aberrations, predominantly coma, consistent with low optical quality.

A comprehensive exclusion work-up included meticulous crystalline-lens assessment, dilated fundus examination, and macular OCT to exclude lenticular scatter or posterior pole pathology. A diagnostic rigid gas permeable (RGP) lens trial produced clear subjective improvement, supporting a corneal optical source of symptoms. Anterior-segment OCT documented flap architecture and thickness, supporting a surface-based approach without flap relift.

Ray-tracing–guided customized surface ablation was performed to rehabilitate effective optical quality. Postoperatively, contrast sensitivity improved markedly in both photopic and mesopic ranges, ray-tracing analysis showed substantial reduction in total higher-order aberrations and coma, 2 lines of vision gained, while the patient also reported significant improvement in mesopic visual performance.

Post-LASIK eyes previously treated with under-flap PTK may demonstrate preserved Snellen acuity yet significant contrast sensitivity loss and coma-dominant higher-order aberrations, impairing functional vision under photopic and mesopic conditions. A hierarchical protocol incorporating contrast sensitivity profiling, ray-tracing wavefront analysis, diagnostic RGP confirmation, anterior-segment OCT, and exclusion of lenticular and retinal pathology enables precise localization of corneal optical degradation. Ray-tracing–guided customized surface enhancement can restore contrast sensitivity, reduce higher-order aberrations, and meaningfully improve mesopic visual performance in visually demanding professions such as aviation.