Floaters are one of the most irritating complaints, as patients offer an array of different descriptions, such as black spots, bugs, spider webs and strings. Patients also complain that floaters affect their daily life, and they don’t want to hear their optometrist say, “Your brain will get used to them.” Fortunately, a few treatment options exist to address floaters, including vitrectomy or vitreolysis.
A patient should be symptomatic for at least four to six months before recommending treatment. Additionally, the symptoms should be equivalent to the exam findings. Good candidates report impaired vision with certain activities and should have no previous retinal tears or detachments and no significant corneal or lens pathology that would impair a view of the vitreous.
Vitreolysis is becoming more familiar to both practitioners and patients. It is the least invasive choice to combat floaters. The surgeon aims a YAG laser at the vitreal opacities to degrade them into smaller fragments and move them away from the visual axis. The YAG laser features a fast-pulse rise time of four nanoseconds and a small spot size.1 Typically, about 150 to 200 pulses with approximately 3mJ to 8mJ of energy are used to treat the vitreal opacities.2 The amount of energy depends on the size, number and location of the opacities.1 One surgeon notes that location is key to determining the number of shots; for example, if the floaters are more posterior, less energy is necessary.1 If a patient has multiple vitreous opacities, a vitrectomy may be a better option. Patients should be seen within a week to check intraocular pressure (IOP).
|To ensure safety during vitreolysis, the surgeon should keep the floater in focus while the retina is out of focus.3|
The treatment zone should be approximately 2mm to 3mm away from the lens and 2mm to 3mm from the retina.1 These parameters are important to keep in mind to lower the risk of inducing a retinal defect, causing lens damage or pitting, or any IOP elevation.1
Risks and Benefits
While vitreolysis is a much less invasive procedure than vitrectomy, there is no guarantee that the floaters will be completely gone from the patient’s vision, but hopefully they will be less bothersome. Nonetheless, an observational study shows that 93% of patients (296 eyes) were satisfied following YAG vitreolysis.1 In a randomized clinical trial comparing YAG laser vitreolysis with sham YAG vitreolysis, 54% in the YAG laser group reported improvement in symptoms versus 9% in the sham group.2 No adverse effects were noted. Another study recorded complication rates as low as 0.1% with vitreolysis.2
Risks of vitreolysis include the possibility of retinal breaks or detachments, along with cystoid macular edema. Patients may also be at risk for damage to the crystalline lens or intraocular implant and increased IOP.4
Vitreolysis has been around for many years, but it’s starting to gain more attention because more physicians are performing the procedure and patients are looking for a less invasive way to remove their pesky floaters. Overall, vitreolysis is quite safe, painless, effective and helps improves patients’ quality of life.
Dr. Schiffbauer practices at Virginia Eye Consultants.
1. Singh IP. Treating vitreous floaters: patient satisfaction and complications of modern YAG vitreolysis. Paper presented at the American Society of Cataract and Refractive Surgery Annual Meeting, May 7, 2016; New Orleans, LA.
2. Shah CP, Heier JS. YAG laser vitreolysis vs sham YAG vitreolysis for symptomatic vitreous floaters: a randomized clinical trial. JAMA Ophthalmol. 2017;135(9):918-23.
3. The evolving view of laser vitreolysis. Cat Refract Surg Today. https://crstoday.com/articles/the-evolving-view-of-laser-vitreolysis/the-evolving-view-of-laser-vitreolysis-2. Accessed March 5, 2019.
4. Hahn P, Schneider EW, Tabandeh H, et al. Reported complications following laser vitreolysis. JAMA Ophthalmol. 2017;135(9):973-76.