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Eye floaters

This story is part of a series on the current progression in Regenerative Medicine. This piece is part of a series dedicated to the eye and improvements in restoring vision.

In 1999, I defined regenerative medicine as the collection of interventions that restore tissues and organs damaged by disease, injured by trauma, or worn by time to normal function. I include a full spectrum of chemical, gene, and protein-based medicines, cell-based therapies, and biomechanical interventions that achieve that goal.

Have you ever noticed specks or strings drifting across your vision?

If so, you may be one of the estimated 70% of people worldwide who experience eye floaters at some point. While this condition is not typically considered severe, it can still be frustrating and uncomfortable, affecting your vision and quality of life.

Usually, the brain ignores these floaters, and they go unnoticed. However, when they increase in number or become more concentrated in a particular area, they can cause annoyance or discomfort.

There are several treatments available to help ease the symptoms of eye floaters. This article will discuss the different options and advances in artificial intelligence that can educate patients and enhance the management of this common condition.

What are Floaters?

Eye floaters are specks or strands that can appear in the field of vision and move around when the eyes move. These floaters are caused by the shrinking of the vitreous, a gel-like substance that fills the eye. The vitreous becomes more liquid and less gel-like as we age, causing the collagen fibers to clump together and form specks or strands.

Diagram of floaters but Exeter Eye

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While most floaters are harmless and do not require treatment, some may indicate a severe eye condition, such as retinal detachment or inflammation. Aside from that, eye floaters can be distracting and, at times, concerning significantly when their numbers increase. Some individuals may experience significant interference with their vision, compromising their quality of life and overall well-being.

Treating Eye Floaters

Fortunately, several current treatments address eye floaters, with various approaches depending on the individual's condition and overall severity of symptoms.

Laser Floater Treatment (LFT) is a non-surgical procedure performed in the office that is used as one of the current treatments for eye floaters. LFT uses laser light to dissolve eye floaters, reducing their visibility in the patient's field of vision. It has emerged as a viable alternative for people who are hesitant to undergo surgery, as it poses minimal risk of complications and is a less invasive option than surgical treatments.

Studies have shown that LFT is effective in treating eye floaters. One such investigation , which assessed the safety and effectiveness of YAG laser vitreolysis as a treatment for vitreous floaters, concluded that LFT is a suitable option for patients hesitant to undergo surgery due to its minimal risk of complications. The study also found that LFT shows promising results in improving subjective and objective outcomes for symptomatic floaters. However, given the limited available evidence, further research is needed to determine the exact role of YAG laser vitreolysis in treating vitreous floaters.

Another current treatment option for eye floaters is vitrectomy, a surgical procedure that involves removing the vitreous, the jelly-like substance inside the eye where the floaters are suspended. This approach is relatively uncommon and is typically reserved for extreme cases where the floaters interfere significantly with the individual's vision. Vitrectomy carries some risks, including infection and retinal detachment.

Eye floaters can also be treated through medical management and patient education, especially if an underlying medical condition causes them. For instance, if the floaters result from inflammation or bleeding due to diabetes, controlling or treating the underlying condition can help alleviate the floaters.

The Role of Patient Education in Treating Floaters

Educating patients regarding eye floaters and related disorders is paramount to successful treatment. Patients should understand the condition, including its causes and available treatment options. Additionally, they should be informed about the risk factors, such as age, eye trauma, and specific medical conditions that can lead to eye floaters. By being mindful of these risk factors, patients can take preventative measures to avoid the development of eye floaters.

The study published in Investigative Ophthalmology & Visual Science examined AI chatbots for patient education on retinal floaters. The study assessed multiple AI chatbots and their ability to help provide practical and actionable patient education. It also highlights AI systems' accuracy in answering questions related to floaters from a retinal specialist point of view.

The researchers found that both ChatGPT™ and Google Assistant™ had weak scores, indicating the bots were inadequate in providing in-depth specialist information. Additionally, while AI chatbots can be a helpful tool for patient education, they should not replace the need for a qualified healthcare professional. Patients must be encouraged to seek medical advice and not rely solely on AI chatbots for diagnosis and treatment.

To a Clearer Future

Eye floaters are a common condition that can be uncomfortable and negatively impact one's quality of life significantly as the number of floaters increases. Fortunately, several treatments are available for eye floaters, including Laser Floater Treatment (LFT). Studies show that LFT effectively treats vitreous floaters and has promising results in improving subjective and objective outcomes for symptomatic floaters.

As technology advances and shapes the healthcare industry, the future of eye floater treatment looks promising. Integrating artificial intelligence and human expertise can improve patient care by providing accurate and tailored information and guidance to patients and caregivers, helping them make informed decisions about their health. We can look forward to a future where AI and human expertise work together to provide the best possible patient care.

To learn more about the eye, read more stories at www.williamhaseltine.com

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• Ophthalmology

Safer eye floater treatments come with a burst of nanobubbles

Between invasive surgery or risky laser therapy, people suffering from severe eye floaters have no great treatment options. now, with the development of a safer and less invasive nanoparticle-based therapy, people with floaters may finally get their vision and quality of life back..

Stephanie joined Drug Discovery News as an Assistant Editor in 2021. She earned her PhD from the University of California Los Angeles in 2019 and has written for Discover Magazine,...

Clumps of collagen

Surgical incisions clear out floaters, an explosion in the eye, nanobubbles bust up floaters.

Sometimes they sit just out of sight in the corner of your eye. Other times they waft across your vision, and when you shift your gaze to look at them, they fly out of sight. These pesky obstructions, commonly referred to as floaters, are a visual phenomenon caused by small clumps of collagen in the eye called vitreous opacities. 

While floaters are very common, they are typically unobtrusive enough that people ignore them. Sometimes, however, floaters can be so dark and numerous that they obscure large swaths of a person’s vision. These severe floaters impair people’s ability to drive, work, and simply enjoy their lives, often leading to depression (1).

“There are millions of people in the world suffering from floaters,” said Yannis Paulus, a vitreoretinal surgeon and clinician scientist at the University of Michigan. “Currently, they’re stuck with bad options,” he added. The only available treatments have a significant number of risks.

These treatments include vitrectomy, the surgical removal of the clear gel-like vitreous of the eye that contains the collagen clumps, and laser vitreolysis, shining high-energy light pulses directed at the fibers to break them apart. Vitrectomy is more effective than laser vitreolysis, but patients have experienced retinal tears, detached retinas, and vitreous hemorrhage with both treatments.

While investigating how to make vitrectomy and laser vitreolysis safer and more effective, scientists are also developing new nanobubble-based technologies that may prove even safer and less invasive than the current treatments, improving the quality of life for the many people around the world suffering from disruptive floaters.

The most common cause of floaters is simply getting older. In young eyes, collagen fibers bound to hyaluronan molecules hold together the gel-like structure of the vitreous. As people age, the collagen and hyaluronan begin to dissociate, and the gel becomes more liquid-like, causing the collagen fibers in the vitreous to collapse onto each other and form clumps, which are perceived as floaters.

People over 60 years old often begin to see more floaters due to their vitreous pulling away from the back of the eye in a phenomenon called posterior vitreous detachment. But because this de-gelling process happens faster in people with nearsightedness, nearsighted people in their 20s, 30s, and 40s can also experience floaters.

For people who notice a sudden burst of many new floaters, ophthalmologists first check for any signs of retinal detachments or injuries to the eye. But after ruling out an acute cause, doctors usually suggest that people wait a few weeks or months to see if their floaters seem to fade or become less noticeable. Usually, people experience some neuroadaptation, and the brain tunes out the floaters. But if the floaters don’t get better and they continue to detrimentally affect daily life, people return to their doctors seeking help.

“Unfortunately, the most common form of treatment is to dismiss them and ignore them and send the patient home frustrated and unhappy,” said Jerry Sebag, a vitreoretinal surgeon and floaters researcher at the Vitreous Macula Retina (VMR) Institute. “I started to realize that these patients are being dismissed because we had no way of identifying if they really have a problem, or if they're just overreacting to something that we all experience.”

Sebag and his colleagues developed quantitative assessments to measure how floaters affect people’s vision. They demonstrated that they could use quantitative ultrasound to characterize the density of the entire vitreous with floaters showing up as points and lines of increased density (2). Sebag’s team also reported that floaters decreased a person’s contrast sensitivity , meaning that people with floaters were less able to distinguish between differences in shading and patterns (3).

“With a quantitative component, it enables you to classify conditions as mild, moderate, and severe,” said Sebag. “It enabled me to select patients for treatment.”

The most effective way to treat floaters is to physically remove them. By performing a surgery called a vitrectomy, surgeons remove the vitreous from the eye and replace it with a clear gel.

While there are risks of retinal tears and detachments during vitrectomy, “you can usually identify those problems during the surgery. If you see a torn retina, you can laser it during the operation,” said Jason Hsu, a vitreoretinal surgeon and researcher at Thomas Jefferson University.

Vitreoretinal surgeons have recently made improvements to vitrectomies to make these retinal tears less likely. For example, they now use smaller gauge instruments to perform the surgery, meaning that they can make smaller incisions. Sebag has adapted his vitrectomy procedure with this modification and improved the method so that it doesn’t induce a posterior vitreous detachment during the surgery. With these safety modifications, Sebag’s team reported in a clinical study of 195 eyes from 145 patients that vitrectomy led to a 94.1% reduction in vitreous echodensity, indicating successful removal of the vitreous opacities that cause the appearance of floaters (4). The patient’s contrast sensitivity also improved to the level of healthy control eyes after surgery. Out of the 195 eyes operated on, there were three retinal tears and three retinal detachments, but these were successfully repaired during the surgery.

While vitrectomy is relatively safe and effective at treating severe floaters, it does lead to an increased risk for developing cataracts (5). Because of this and because other long-term risks of vitrectomy are unknown, Sebag and other vitreoretinal surgeons hesitate to operate on younger patients.

“I just haven't followed people for 30 years, so I can't answer that question,” said Sebag. As an alternative to vitrectomy, some ophthalmologists turned to a risky and somewhat controversial treatment: laser vitreolysis.

Rather than physically removing the vitreous opacities that cause floaters, some ophthalmologists have tried blasting them apart with pulses of a yttrium-aluminum-garnet (YAG) laser.

“It's not like a typical laser beam that we think of like in Star Wars or something where it's burning tissue. The YAG laser is like a little explosion in the eye,” said Hsu. “It’s almost like evaporating some of the tissue with this high concentrated energy.” This process breaks up large aggregates of collagen into smaller pieces, reducing the appearance of floaters.

Ophthalmologists have used YAG lasers for decades to remove cloudy layers of scar tissue that form after cataract surgery and in the treatment of specific kinds of glaucoma, but their use to treat floaters is relatively new and somewhat controversial.

In the only clinical trial so far investigating the effectiveness of YAG laser vitreolysis for floaters, 54% of the patients who received the YAG treatment reported improvement in the appearance of floaters (6). None of the patients in the trial experienced any adverse effects.

There are, however, substantial risks associated with YAG laser treatment. The laser energies needed to blast apart the fibers that cause floaters are double or triple that of the energies used for the other more routine uses of YAG lasers. Even with the higher energy laser pulses, a person may need to sit through multiple sessions of YAG laser treatment to effectively break up a bothersome floater. In some instances, surgeons have focused the laser too close to the front or back of the eye, causing direct damage to the lens or the retina.

Citing these concerns, Inder Paul Singh, an ophthalmologist at the Eye Centers of Racine and Kenosha, explained that newer YAG lasers allow for better illumination of the vitreous, which helps ophthalmologists more easily orient themselves in the eye, decreasing the risks of damaging vital structures.

“Not every floater is a good candidate for YAG laser vitreolysis,” he said, but for example, if “the floater is in the middle of the vitreous where you can correlate signs and symptoms well, this can be a fantastic opportunity to avoid something like a vitrectomy and not to make [the patient] suffer living with it.”

While Singh has had much success treating floaters with YAG vitreolysis in his practice, that has not been the case for many other doctors.

“There is no protocol to guide the use of YAG laser, either in terms of which patients to select or in terms of how to really do the treatment in a reproducible scientific fashion,” Sebag said. He is organizing a study on how to make YAG vitreolysis more reproducible and safer using quantitative ultrasonography, among other methods, to measure outcomes.

Singh agreed that proper training on how to perform YAG vitreolysis is integral to successful floater treatment.

“The laser is not unsafe. It’s we as doctors who can be unsafe,” he said. “It's important for doctors to feel comfortable understanding where they are in the vitreous and learning how to maximize that view.”

He and others are investigating the use of systems to track floaters more accurately in the vitreous and the use of the more efficient femtosecond laser rather than a YAG laser for floater treatment, which would decrease the number of laser sessions needed to destroy floaters.

With the current risks associated with both vitrectomy and laser vitreolysis, researchers are looking for new strategies to treat floaters.

Before presenting his research at the Academy of Medicine in Belgium years ago, Stefaan De Smedt, a drug delivery researcher at Ghent University, had never considered nanobubbles as the next frontier in eye floater treatment. He and his team were interested in using vapor nanobubbles, which are produced by shining a laser at nanoparticles, as a method to deliver nucleic acids into cells.

When scientists shine a laser of a certain frequency at nanoparticles that are close together, the nanoparticles absorb the energy from the laser, which heats up the solution surrounding the nanoparticles, causing the liquid to evaporate and create nanobubbles. These nanobubbles expand and then pop tens to hundreds of nanoseconds after they form (7), leading to the creation of a mechanical force that can poke a hole in a cell membrane.

“I was talking to an ophthalmologist, [and] he said maybe it could be useful as well to see whether this kind of nanobubbles could be valuable to destroy aggregates,” De Smedt said.

Intrigued by the possibility, De Smedt and his postdoctoral fellow Félix Sauvage began testing the ability of vapor nanobubbles produced by different kinds of nanoparticles to destroy the collagen aggregates that cause floaters. In a new study published in Nature Nanotechnology , De Smedt and Sauvage, working in collaboration with Sebag, Paulus, and others, reported the success of nanobubbles produced by gold nanoparticles and an ophthalmologic dye to destroy collagen aggregates in vivo for the first time (8).

The researchers demonstrated that both gold nanoparticles coated in hyaluronan and the ophthalmologic dye indocyanine green (ICG) preferentially bound to and destroyed human vitreous opacities that had been isolated from vitrectomy patients in Sebag’s practice. Because the particles specifically bound to the collagen aggregates, the creation of nanobubbles only occurred at the aggregates. This means that even if the laser shines on a place in the eye with no nanoparticles or dye, no nanobubbles will be created to potentially damage other structures in the eye.

“The threshold to generate bubbles is very high,” explained Sauvage. “We have a selective manner to trigger the generation of bubbles.”

Encouraged by how well their technology worked in an ex vivo system, De Smedt’s team searched for the best animal model to test it in vivo . This proved to be somewhat of a challenge, because, as Paulus quipped, “you don't have a mouse telling you that it has floaters in its vision.”

The team finally landed on rabbits with their relatively large eyes, which are closer in size to those of humans, making them ideal models.

De Smedt, Sauvage, and their colleagues injected rabbit eyes with collagen fibers to give the rabbits vitreous opacities, then they either injected the gold nanoparticles or ICG and shined laser pulses into the rabbits’ eyes. They found that they only needed to use an average of five laser pulses to completely remove the collagen aggregates.

“When we saw that data about how effective it was, it was pretty stunning to me,” said Paulus. When the team assessed the safety of their technique, they found that it had no adverse effects on the rabbits’ retinas.

Because the nanoparticles and dye bind directly to the collagen fibers, the researchers could remove the vitreous opacities from locations in the eye that would be impossible using a YAG laser, such as close to the retina. Similarly, the aggregation of the particles allowed the researchers to use a lower energy laser to induce nanobubbles than that required for a YAG laser to break up fibers, vastly improving safety. 

This technology also improves on vitrectomy because it does not require a risky surgery, rather simply an injection of nanoparticles or dye into the eye. Eye injections are a common procedure for vitreoretinal surgeons, Paulus added.

“It's taking two things that we do in essence almost independently — these eye injections and the laser — and combining them,” he said.

Moving forward, De Smedt and his team are interested in investigating the pharmacokinetics of their gold nanoparticles and ICG in humans. While both gold nanoparticles and ICG are biocompatible, only ICG is biodegradable, making it the more likely of the two to move forward into future human clinical trials.

“Certainly, there's additional work in terms of clinical trials that we need to do before this is readily available for everyone, but I think it would really be a game changer in terms of the ability to treat these floaters in a manner that's minimally invasive with low risk. And I think it would really transform our care for patients,” said Paulus.

Although De Smedt did not initially set out to develop new treatments for floaters, he now understands what a non-invasive and effective treatment would mean for people suffering from floaters. After his team published their first paper on nanoparticles and floaters (9), he and Sauvage received hundreds of questions from people all over the world asking about the potential of the technology to treat floaters.

“I try to imagine how it feels to open your eyes and to feel always depressed about the fact that you cannot really see,” De Smedt said. “It can contribute to giving vision back to people, which means to give quality of life.”

• Kim, Y-K. et al. Psychological Distress in Patients with Symptomatic Vitreous Floaters. Journal of Ophthalmology   2017 , 3191576 (2017).
• Mamou, J. et al. Ultrasound-Based Quantification of Vitreous Floaters Correlates with Contrast Sensitivity and Quality of Life. Investigative Ophthalmology & Visual Science  56 , 1611-1617 (2015).
• Garcia, G.A. et al. Degradation of Contrast Sensitivity Function Following Posterior Vitreous Detachment. American Journal of Ophthalmology  172 , 7-12 (2016).
• Sebag, J. et al. Long-Term Safety and Efficacy of Limited Vitrectomy for Vision Degrading Vitreopathy Resulting from Vitreous Floaters. Ophthalmology Retina   2 , 881-887 (2018).
• Yee, K.M.P. et al. Incidence of Cataract Surgery after Vitrectomy for Vitreous Opacities. Ophthalmology Retina   1 , 154-157 (2017).
• Shah, C.P. & Heier, J.S. YAG Laser Vitreolysis vs Sham YAG Vitreolysis for Symptomatic Vitreous Floaters: A Randomized Clinical Trial. JAMA Ophthalmol   135 , 918-923 (2017).
• Xiong, R. et al. Comparison of gold nanoparticle mediated photoporation: vapor nanobubbles outperform direct heating for delivering macromolecules in live cells. ACS Nano   8 , 6288-6296 (2014). 
• Sauvage, F. et al. Laser-induced nanobubbles safely ablate vitreous opacities in vivo. Nat Nanotechnol (2022).
• Sauvage, F. et al. Photoablation of Human Vitreous Opacities by Light-Induced Vapor Nanobubbles. ACS Nano   13 , 8401-8416 (2019).

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October 2023 | Features

Managing Vitreous Floaters

The latest advances in imaging and surgery can help patients with vision degrading myodesopsia..

J. Sebag, MD, FACS, FRCOphth, FARVO

AT A GLANCE

• Studies show that patients with vision degrading myodesopsia (VDM) would be willing to exchange 1 year of each remaining decade of life just to be rid of their floaters.
• Vitrectomy is a safe and effective treatment for VDM and can normalize contrast sensitivity within 1 week of surgery.
• Researchers are investigating the use of nanoparticles to enhance laser ablation of vitreous opacities.

Vitreous floaters are a common symptom, estimated in one survey to affect two out of every three individuals, with one in three reporting visual impairment. 1 When vitreous floaters measurably degrade vision, the diagnosis of vision degrading myodesopsia (VDM) can be established based on objective, quantitative criteria. 2 The psychological features of depression and perceived stress associated with VDM have been extensively documented. 3-5 Studies have further determined that patients with VDM would be willing to exchange 1 year of each remaining decade of life just to be rid of their floaters. 6 This article explains the pathophysiology of VDM and the emerging treatment approaches.

THE AGING PROCESS

Vitreous is a clear gel in youth but undergoes significant structural changes with aging and myopia. 7 The gel state and transparency of normal vitreous result from an intricate interaction between collagen and hyaluronan, which are initially homogeneously distributed throughout the vitreous body (Figure 1). 8 Vitreous opacification results from fibrous liquefaction, a progressive process that begins in youth and advances more rapidly in myopic eyes, leading to myopic vitreopathy (Figure 2, Video 1). 7,9,10 Fibrous liquefaction features dissociation of hydrophilic hyaluronan molecules from collagen, resulting in the formation of liquid vitreous and crosslinking/aggregation of vitreous collagen into structures that interfere with light passing through the center of the eye, casting perceptible shadows. When fibrous liquefaction of the vitreous body occurs in tandem with dehiscence of vitreoretinal adhesion, the result is a posterior vitreous detachment (PVD), the most common cause of vitreous floaters and VDM. 2,11,12

Figure 1. Postmortem dissection of the sclera, choroid, and retina off the vitreous body, which remained attached to the anterior segment of a 9-month-old child. Although the fresh, unfixed specimen is composed of 98% water and situated on a surgical towel in room air, its solid gel consistency is maintained by the collagen/hyaluronan matrix. Reprinted with permission from Sebag J. Vitreous—in Health & Disease. Springer; 2014.  Specimen courtesy of the New England Eye Bank.

Click to view larger

Figure 2. Postmortem darkfield slit microscopy of whole human vitreous with the sclera, choroid, and retina dissected off the vitreous body. The vitreous bodies of an 11-year-old (A) and a 14-year-old (B) feature a homogeneous structure with no significant light scattering, except at the periphery where the vitreous cortex is comprised of a dense matrix of collagen fibrils (see Figure 3). The vitreous structures of a 56-year-old (C) and a 59-year-old (D) feature macroscopic fibrils in the central vitreous body with an anteroposterior orientation. In the eyes of an 88-year-old (E, F), central vitreous fibers are thickened and tortuous. Adjacent to the large fibers are areas of liquid vitreous, at times forming pockets called lacunae. Reprinted with permission from Sebag J. Vitreous—in Health & Disease. Springer; 2014. 

Video 1. Myopic Vitreopathy. Video courtesy of Carl Glittenberg, MD, and Susanne Binder, MD

Even in the absence of the pathologic effects of anomalous PVD, the separation of the posterior vitreous cortex from the inner limiting membrane (ILM) can significantly disturb vision, due to light scattering. This is caused by the high density of collagen fibrils in the outer vitreous and/or folding of the outer vitreous, which is forced into a smaller surface area after separation from the ILM (Figure 3, Video 2). Opacities in the central vitreous and the outer shell of the vitreous body result in floaters and, in advanced cases, VDM.

Figure 3. Scanning electron microscopy of the posterior aspect of the posterior vitreous cortex demonstrates dense packing of collagen fibrils (white bar = 10 μm). Reprinted with permission from Sebag J. Vitreous—in Health & Disease. Springer; 2014 .

Video 2. Posterior Vitreous Folds After PVD. Video courtesy of Martin Snead, MD

VISUAL SIGNIFICANCE

Recent investigations have determined that floaters can have a measurable effect on vision. While visual acuity is unaffected, studies have detected profound degradation in contrast sensitivity; one study found contrast sensitivity declined by 91% compared with age-matched controls. 12 Investigations have correlated this degradation in contrast sensitivity with PVD, vitreous density by ultrasonography, and quality of life as measured by the National Eye Institute Visual Function Questionnaire. 10,13,14 With the advent of quantitative ultrasonography to objectively assess vitreous structure and by measuring contrast sensitivity to evaluate visual function, clinicians are now able to quantitatively determine VDM severity to help guide management.

TREATMENT ADVANCES

Although Nd:YAG laser vitreolysis has been widely employed to treat vitreous opacities, no definitive studies prove its efficacy. 12,15-19 Thus, the United Kingdom National Institute for Health and Care Excellence (NICE) concluded that evidence on the safety and efficacy of Nd:YAG laser vitreolysis in the treatment of vitreous floaters is inadequate in quality and quantity. NICE officially recommended that Nd:YAG laser vitreolysis should only be used in the context of research and be done by retina specialists. 20

In contrast, vitrectomy is a safe and effective treatment for VDM. 12,21-23 In one study of 139 consecutive cases, contrast sensitivity normalized within 1 week of surgery and remained normal for years thereafter. 23 Moreover, vitrectomy for VDM was found to be more cost-effective than cataract surgery, amblyopia therapy, and retinal detachment (RD) repair. 24

To mitigate complications such as cataract and RD, limited vitrectomy was developed to preserve 3 mm to 4 mm of retrolental gel vitreous and avoid surgical PVD induction. In a series of 195 cases, the incidence of retinal tears and RD was markedly reduced to 1.5% compared with traditional vitrectomy with surgical PVD induction, which has a reported incidence of 30% for retinal tears and 6.8% to 10.9% for RD. 23,25-27 Furthermore, the historically high incidence of cataract surgery following vitrectomy for floaters was reduced to 18% (mean follow-up of 20 months) in one study and 16.9% (mean follow-up of 32 months) in a larger study of limited vitrectomy for VDM. 23,28 In these studies, cataract surgery was required in patients with a mean age of 64 ± 7 years. Importantly, when cataract surgery was performed, there were no complications related to the previous limited vitrectomy, perhaps due to the preservation of intact anterior gel vitreous.

PHARMACEUTICAL INTERVENTION

Despite the demonstrated safety and efficacy of limited vitrectomy for VDM for vitreous floaters, advanced therapeutics may be able to address this issue in the future. Pharmacologic vitreolysis has been approved for treating vitreomacular traction but has not been tested in VDM. 29-31

One interesting approach is the use of nanoparticles to enhance laser ablation of vitreous opacities. Designed with gold cores coated with hyaluronic acid, these nanoparticles have an affinity for vitreous collagen. Once bound to collagenous opacities and the detached posterior cortex, they absorb laser energy at levels 1,000 times lower than that which is currently employed for Nd:YAG laser vitreolysis and produce nanobubbles that ablate vitreous opacities. In vitro experimentation followed by in vivo investigations in rabbits have demonstrated efficacy and safety. 32,33

CLINICAL IMPLICATIONS

Our past inability to properly evaluate the structural changes within the vitreous body and their effect on visual function has hampered our willingness to consider vitreous floaters as a disease. While most patients consider floaters a nuisance, some patients may have VDM. We must treat such patients with the same respect and consideration we afford to patients with other vitreoretinal diseases. In addition, we must commit ourselves to the development of novel diagnostic tools and therapeutics to address VDM and improve the quality of life for millions of patients worldwide.

Acknowledgments: Research discussed in this article was supported by the VMR Research Foundation. Alfredo A. Sadun, MD, PhD, FARVO, graciously reviewed this article.

1. Webb BF, Webb JR, Schroeder MC, North CS. Prevalence of vitreous floaters in a community sample of smartphone users. Int J Ophthalmol . 2013;6(3):402-405.

2. Sebag J. Vitreous and vision degrading myodesopsia. Progr Ret Eye Res . 2020;79:100847.

3. Spielberger CD, Gorsuch RL, Lushene R, et al. Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press; 1983.

4. Cipolletta S, Beccarello A, Galan A. A psychological perspective of eye floaters. Qual Health Res . 2012;22(11):1547-1558.

5. Kim YK, Moon SY, Yim KM, et al. Psychological distress in patients with symptomatic vitreous floaters. J Ophthalmol . 2017;191576.

6. Wagle AM, Lim WY, Yap TP, et al. Utility values associated with vitreous floaters. Am J Ophthalmol . 2011;152(1):60-65.

7. Sebag J. The Vitreous - Structure, Function, and Pathobiology. Springer-Verlag; 1989.

8. Chew L, Sebag J. Vitreous. In: Adler’s Physiology of the Eye. 12th Ed [in press]. Elsevier; 2023.

9. Nguyen N, Sebag J. Myopic vitreopathy – significance in anomalous PVD and vitreoretinal disorders. In: Myopia & Related Diseases. Midena, ed. Ophthalmol Comm Soc ; 2005:137-145.

10. Nguyen JH, Nguyen-Cuu J, Mamou J, Routledge B, Yee KMP, Sebag J. Vitreous structure and visual function in myopic vitreopathy causing vision-degrading myodesopsia. Am J Ophthalmol . 2021;224:246-253.

11. Sebag J, Yee KMP, Huang L, Wa C, Sadun AA. Vitrectomy for floaters – prospective efficacy analyses and retrospective safety profile. Retina . 2014;34(6):1062-1068.

12. Sebag J. Methodological and efficacy issues in a randomized clinical trial investigating vitreous floater treatment. JAMA Ophthalmol . 2018;136(4):448.

13. Garcia G, Khoshnevis M, Yee KM, Nguyen-Cuu J, Nguyen JH, Sebag J. Degradation of contrast sensitivity following posterior vitreous detachment. Am J Ophthalmol . 2016;172:7-12.

14. Mamou J, Wa CA, Yee KM, et al. Ultrasound-based quantification of vitreous floaters correlates with contrast sensitivity and quality of life. Invest Ophthalmol Vis Sci . 2015;56:1611-1617.

15. Nguyen JH, Nguyen-Cuu J, Yu F, et al. Assessment of vitreous structure and visual function after neodymium:yttrium-aluminum-garnet laser vitreolysis. Ophthalmology . 2019;126(11):1517-1526.

16. Ivanova T, Jalil A, Antoniou Y, et al. Vitrectomy for primary symptomatic vitreous opacities: an evidence-based review. Eye . 2016;30:645-655.

17. Milston R, Madigan M, Sebag J. Vitreous floaters - etiology, diagnostics, and management. Surv Ophthalmol . 2016;61(2):211-227.

18. Kokavec J, Wu Z, Sherwin JC, et al. Nd:YAG laser vitreolysis versus pars plana vitrectomy for vitreous floaters. Cochrane Database Syst Rev . 2017;6(6):CD011676.

19. Lim JI. YAG laser vitreolysis—is it as clear as it seems? JAMA Ophthalmol . 2017;135(9):924-925.

20. NICE. YAG laser vitreolysis for symptomatic vitreous floaters. October 26, 2022. Accessed March 20, 2023. bit.ly/3OYraWI

21. Delaney YM, Oyinloye A, Benjamin L. Nd:YAG vitreolysis and pars plana vitrectomy: surgical treatment for vitreous floaters. Eye . 2002;16(1):21-26.

22. Mason III JO, Neimkin MG, Mason IV JO, et al. Safety, efficacy, and quality of life following sutureless vitrectomy for symptomatic vitreous floaters. Retina . 2014;34(6):1055-1061.

23. Sebag J, Yee KMP, Nguyen JH, Nguyen-Cuu J. Long-term safety and efficacy of vitrectomy for vision degrading myodesopsia from vitreous floaters. Ophthalmol Retina . 2018;2(9):881-887.

24. Rostami B, Nguyen-Cuu J, Brown G, Brown M, Sadun A, Sebag J. Cost-effectiveness of limited vitrectomy for vision degrading myodesopsia. Am J Ophthalmol . 2019;204:1-6.

25. Tan HS, Mura M, Lesnik Oberstein SY, Bijl HM. Safety of vitrectomy for floaters. Am J Ophthalmol . 2011;151(6):995-998.

26. Schulz-Key S, Carlsson JO, Crafoord S. Long-term follow-up of pars plana vitrectomy for vitreous floaters: complications, outcomes, and patient satisfaction. Acta Ophthalmol . 2011;89(2):159-165.

27. de Nie KF, Crama N, Tilanus MA, et al. Pars plana vitrectomy for disturbing primary vitreous floaters: clinical outcome and patient satisfaction. Graefe’s Arch Clin Exp Ophthalmol . 2013;251(5):1373-1382.

28. Yee KM, Tan HS, Lesnick-Oberstein SY, et al. Incidence of cataract surgery after vitrectomy for vitreous opacities. Ophthalmol Retina . 2017;1:154-157.

29. Sebag J. Pharmacologic vitreolysis (Guest Editorial). Retina . 1998;18:1-3.

30. Sebag J. Pharmacologic vitreolysis – premise and promise of the first decade. Retina . 2009;29(7):871-874.

31. Sebag J. Pharmacologic vitreolysis. In: Sebag J, ed. Vitreous—in Health & Disease. Springer; 2014:799-816.

32. Sauvage F, Fraire JC, Remaut K, et al. Photoablation of human vitreous opacities by light-induced vapor nanobubbles. ACS Nano. 2019;13(7):8401-8416.

33. Sauvage F, Nguyen VP, Li Y, et al. Laser-induced nanobubbles safely ablate vitreous opacities in vivo. Nat Nanotechnol . 2022;17(5):552-559.

Senior Research Scientist, Doheny Eye Institute, Pasadena, California Professor of Clinical Ophthalmology, Department of Ophthalmology, Geffen School of Medicine, University of California Los Angeles, Los Angeles Founding Director, VMR Institute for Vitreous Macula Retina, Huntington Beach, California [email protected] Financial disclosure: Past Consultant (Alcon, Bayer, Bausch + Lomb, Genentech/Roche, ThromboGenics); Patents - Minority (Nanobubble Technology, Quantitative Ultrasonography)

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To Treat or Not to Treat: Management Options for Symptomatic Vitreous Floaters

Broadhead, Geoffrey K. MBBS, PhD; Hong, Thomas MScMed, PhD; Chang, Andrew A. PhD, FRANZCO

∗ Save Sight Institute, The University of Sydney, Sydney, Australia

† Sydney Institute of Vision Science, Sydney, Australia

‡ Sydney Retina Clinic & Day Surgery, Sydney, Australia.

Correspondence: Andrew A. Chang, Clinical Associate Professor, Sydney Institute of Vision Science, Level 13, 187 Macquarie Street, Sydney, NSW 2000, Australia. E-mail: [email protected] .

Received 16 November, 2019

Accepted 10 January, 2020

A.C. has acted as a consultant for Novartis, Alcon, and Bayer. All other authors have no associations to declare. There is no funding or other conflicts of interest associated with this submission. This work has not been presented at any meeting.

The authors have no conflicts of interest to disclose.

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

Vitreous floaters are a common cause for presentation to ophthalmologists, and may significantly affect visual function. In the absence of some more serious underlying pathology such as uveitis, many patients may not experience significant persistent visual impairment from floaters. For some patients, the symptomatic effects of floaters may persist. For these patients, treatment options are available, of which the most commonly reported is vitrectomy. Other treatment modalities have also become more common, notably YAG vitreolysis. Selection of appropriate patients for surgery is often difficult, in part due to the relative lack of objective outcomes with which to measure both visual impairment and improvement post-procedure. Although well-tolerated, vitrectomy does carry with it risks, including iatrogenic retinal breaks, retinal detachment, and in phakic patients, subsequent cataract formation. Techniques such as small gauge vitrectomy, intraoperative examination and treatment of breaks or other worrying lesions, and careful consideration of the need for posterior vitreous detachment induction may help limit the incidence of these adverse events. For other treatment options such as YAG vitreolysis, research and clinical experience remain more limited, and as such the long-term efficacy and risks of these therapies are still unclear. Here, we review the evidence surrounding the role of vitrectomy and YAG vitreolysis in the treatment of vitreous floaters and potential means to minimize therapeutic complications.

Vitreous opacities, or floaters ( Figs. 1 and 2 ), are a common finding that may arise due to a range of different conditions, some of which may be indicative of more significant ophthalmic pathology. The most common cause, however, is the formation of a posterior vitreous detachment (PVD). This occurs when the vitreous collapses inwards, withdrawing from the retinal interface. 1 Depending on the adhesive forces that exist between the vitreous and the retina at the time, PVD may be associated with a retinal tear, which occurs in approximately 14% of patients with PVD. 2 If untreated, these tears can progress to a rhegmatogenous retinal detachment (RRD), with potential loss of sight.

Vitreous floaters themselves, however, when not associated with other conditions such as uveitis or RRD, are generally considered to be benign in nature and do not lead to irreversible losses in visual acuity (VA). In some instances, floaters may be indicative of more sinister pathology, such as malignancies in the case of masquerade syndromes. 3 Clinicians therefore need to consider alternate diagnosis in patients with persistent or unusual symptoms.

A careful clinical examination and history can differentiate between the varying pathologies, including inflammatory causes such as uveitis, acute retinal tears, and even intraocular malignancies. The presence of pain, redness, or systemic symptoms should alert the clinician to the suspicion of other conditions, and a diagnosis of vitreous floaters should be approached with caution in these patients. If there is any concern regarding a diagnosis other than persistent nonpathological vitreous opacities, the patient should be evaluated carefully by a retinal subspecialist and consideration given to further investigations and treatment, such as retinal laser for acute retinal tears.

Despite not markedly reducing VA, floaters can interfere with vision by disrupting light transmission to the retina, 4 and this can be more marked when the floaters are larger and more numerous. This may produce marked visual interference with significant impact upon patients’ quality of life. 5,6 Significantly disabling floaters may be more common in those with refractive error, 7 potentially compounding visual impairment in these patients.

Given that vitreous floaters do not significantly impede common clinical measures of visual function such as VA 4 (as discussed below), it is often difficult for the clinician to assess the degree of visual impairment they create for patients. Recent research on alternate measures of assessing visual function, notably via contrast sensitivity (CS) has assisted in this regard 8,9 ; however, there remains no universally accepted measures of the severity of vitreous opacities and hence no clear thresholds for when to consider intervention to relieve symptoms.

There is also some evidence that patients with symptomatic floaters have higher rates of psychological stress, 10 and may be more prone to seek multiple opinions (so called “doctor shopping”) than other patients. 11 Patients with more severe subjective symptoms have been reported to have more significant psychological distress, 10 and as such may be more likely to seek intervention for their floaters.

For patients whose floaters produce significant visual disruption, treatments are available that may produce symptomatic relief. The current mainstay of treatment is vitrectomy surgery, 12 although alternate therapeutic options such as yttrium-aluminum-garnet (YAG) laser disruption of floaters exist. Vitrectomy is a major surgical intervention, and one of the key challenges in managing floaters is identifying which patients have significant enough visual disruption to warrant surgery. The issue has received particular attention given the specific demographics and the natural history of patients with this condition: a notable subset of patients are young, phakic, have high VA despite floaters, and in many cases will experience partial relief of their symptoms without intervention. 13 However, for patients with significant symptoms, vitrectomy is successful in improving symptoms and is a cost-effective intervention. 14 To better clarify these issues, we review the current evidence surrounding the treatment of vitreous opacities not related to other underlying pathologies such as uveitis or acute retinal tears.

A search of PubMed, EMBASE, and the Cochrane Library was undertaken between November 10 and November 13, 2019, for English language articles published after 1990 using the keywords “vitreous opacity,” “vitreous opacities,” “vitreous floater,” “vitreous floaters,” and “asteroid hyalosis.” References of relevant articles, including review articles, were also reviewed.

NATURAL HISTORY

Vitreous floaters are often described as an acute symptom of PVD, and for many patients, do not cause significant long-term visual disturbance. A number of theories have been advanced as to why this occurs: movement of the floaters either anteriorly or peripherally away from the visual axis, and adaptation of the eye and the brain to the presence of the floaters have been suggested. 14,15 A notable proportion of patients, however, will have ongoing, visually disturbing floaters for months after first presentation.

Asteroid Hyalosis

Asteroid hyalosis is a relatively uncommon condition characterized by multiple vitreous calcifications 16,17 that appear as “stars in the sky” during ophthalmic examination ( Fig. 3 ). Although the exact pathogenesis remains unknown, asteroid has been associated in some investigations with diabetes mellitus and systemic hypertension, 18,19 although this has not been replicated in large population studies. 17,20 Despite its impressive appearance, asteroid generally does not produce significant visual impairment, although in some cases, patients may develop notable visual disturbance, 21 and this may be particularly so when asteroid is complicated by the development of a PVD, although this may relate to the anterior movement of asteroid bodies closer to the lens when a PVD occurs. 22

Floaters Secondary to Other Causes

Floaters, as mentioned above, can also occur due to secondary causes, including uveitis, malignancies, or after ocular procedures, such as intravitreal injections or vitreoretinal surgery with tamponade use. These causes can potentially result in significant irreversible visual loss, and for this reason patients complaining of new-onset or worsening floaters require assessment by an ophthalmologist to exclude potentially devastating causes of their symptoms.

Patient Selection

There are no unanimously accepted guidelines on when patients should be considered for vitrectomy for vitreous floaters. This makes selecting patients for surgery difficult, and this is further exacerbated by the fact that visual acuity does not necessarily correlate with the degree of visual impairment reported. 23 In general, ophthalmologists reserve surgery for patients whose floaters are persistent and cause significant visual disturbance over a prolonged period of time, 24 although assessing this is highly subjective.

More recently, there has been a better appreciation of possible means of more accurately assessing the degree of patient impairment floaters can cause. Of these, the most clinically relevant is likely to be CS, which has been shown in a number of studies to be associated with floater related patient-reported visual impairment, and to also improve after intervention. 5,6 This has given rise to the terminology “vision-degrading myodesposia,” to better describe floaters that impair vision and CS, and to differentiate these from floaters that do not produce significant vision impairment. 14 Other alternate methods of assessing vision (such as straylight) 4 are less familiar to the ordinary clinician, although show promise in a research setting.

The size and position of floaters within the vitreous cavity can also be measured, and imaging may have a role in predicting floater severity. Although optical coherence tomography (OCT) can provide some information particularly for posterior floaters close to the vitreomacular interface, ultrasound, and in particular, quantitative ultrasound is able to provide objective, measurable data on floaters, including measures related to floater density and scatter. 25 This has been shown to correlate to functional measures such as the National Eye Institute Visual Function Questionnaire (NEI-VFQ) scores and CS, suggesting that this technique may aid clinicians in assessing floater severity, 25 although currently it is limited to research settings. In this regard, measurement of floater appearance on clinical examination has also been assessed, however showing only weak correlation with functional measures. 26

Assessing Success

It is also often difficult to gauge the degree of success after surgery. Preoperative VA is often very good (as mentioned above), and this also makes quantifying improvement post-procedure often difficult, as little VA change is thus possible, although some studies have reported modest acuity gains of 1-2 Snellen lines. 27 Gains in other measures of vision have been reported, including improvements in CS, quality of life, and straylight. 4,27–30 As mentioned above, CS is likely the most easily applicable clinical outcome in regular clinical practice, as it represents a relatively quick to perform and interpret measure with well-validated testing procedures.

Further adding to this difficulty in assessing outcomes is recent research on patient satisfaction post YAG-vitreolysis, that showed no difference in functional outcomes between treated patients and untreated controls, despite measurable differences in quantitative ultrasounds measures. 31 This suggests that although ultrasound may assist in identifying patients with significant visual issues, it may be of limited benefit in identifying which patients are likely to have a clinical improvement with treatment and in measuring treatment outcomes.

Of additional concern, many patients obtain their information regarding floaters from internet sites, which in general contain poor quality data. 32 Given the risk of misinformation, it is therefore important that the clinician make every effort to accurately inform patients of both the natural history of the disease and treatment options and their complications. Younger patients in particular seem more willing to endure the risk of blindness associated with surgical complications to achieve removal of floaters, and this needs to be considered when advising patients on potential therapeutic options. 7

Operative Technique

Currently, the most commonly used surgical technique in the treatment of vitreous opacities is transconjunctival sutureless pars-plana vitrectomy (PPV). Initial vitreous removal is undertaken using a standard high speed vitrectomy cutter, removing the vitreous up to the vitreous base, including any floaters within the vitreous. After clearing of the vitreous, some authors advocate induction of a PVD in cases of posterior vitreous cortex attachment, and this can be done with the aid of visualization dyes such as triamcinolone or bromophenol blue. 33,34 However, PVD induction increases the risks of retinal break formation as discussed below. Finally, peripheral retinal examination is conducted and any retinal breaks can be treated with cryotherapy or laser photocoagulation retinopexy. 33 In cases with a notable risk of RRD, it may be appropriate to use a form of tamponade agent including intravitreal gas. 35

Due to the limited surgical steps required, floaters represent a condition whereby smaller gauge (23G or smaller) surgical incisions may be utilized effectively without significantly affecting surgical results. There is growing evidence from recent studies reporting surgical outcomes that small gauge (23 or 25G) vitrectomy is associated with lower retinal break and RRD rates as compared with larger gauge (20G) operations, 36–39 although further prospective studies are needed to formally assess this. Even smaller gauge vitrectomy surgery (27G) has also been used to successfully treat vitreous floater. 40 For treatment of vitreous floaters, therefore, small gauge (23G or less) surgery can be considered best practice. Interestingly, there may be a limit to the degree to which reduction in incision size improves complication rates, with some evidence suggesting that 27G or 25G vitrectomy is not any safer than 23G procedures. 41–44 Modern vitrectomy techniques such as wide-angle viewing systems have also been used successfully in cases of vitreous opacities, and may enhance surgical ergonomics and reduce required endolumination. 45

Complications and Safety

Adverse events are similar between vitrectomy for floaters and for other indications such as epiretinal membrane (ERM) or macular hole (MH). 27,28,46 Postvitrectomy RRD rates are reported to be between 2% and 10%, cataract surgery rates in phakic eyes are 25% to 60%, and rates of other adverse events such as ERM formation or cystoid macular edema are low (≤5%). 23,24,27,28,33,35,47 However, concerns have been raised that the risks of PPV remain too high given the objective level of pathology. 10 One aspect considered crucial in preventing potentially visually devastating complications is careful intraoperative examination for and treatment of retinal breaks, which prevents development of future RRD. 39,41 Additionally, prophylactic treatment of lesions which increases the risk of RRD, such as lattice degeneration, may reduce the risk of future retinal detachment, 48,49 particularly given that these lesions have been associated with a higher rate of intraoperative retinal breaks. 50 Other rarer visual complications, such as postoperative endophthalmitis, have also been reported. 51

An area of procedural debate regarding the safety of vitrectomy for vitreous opacities relates to the deliberate intraoperative induction of a PVD. It has been suggested that PVD induction may prevent later PVD formation via detachment of the remaining posterior vitreous cortex. This in turn would potentially cause recurrence of floaters or RRD, 48 although there is currently little evidence as to whether this in fact occurs. Two recent series investigating PPV for floaters used either core vitrectomy with either no PVD induction 28 or PVD induction in a small group of patients. 27 Both studies reported favorable efficacy with good safety profiles, further raising doubts regarding the necessity of inducing a PVD. PVD induction has been associated with an increased risk of RRD in surgery for vitreous floaters, 33 and for other retinal disorders such as MH or ERM, 52–55 although no causal relationship has been established. It has also been suggested that PVD induction may hasten cataract development, as one series found a lower rate of cataract formation when comparing limited to extensive vitrectomy. 56 Given these risks, and the uncertainty regarding the benefits of PVD induction, this step in the treatment for floaters should be considered cautiously, and patients informed of the potential additional risks associated with this aspect of the procedure.

The other significant concern regarding vitrectomy for floaters relates to the long-term safety of the procedure. This is particularly important given the relatively young age and generally good baseline vision of many patients who are considering surgery. Two series have reported a significant long-term rate of complications, including RRD (5.5%–6.4%) and cystoid macular edema, with irreversible visual loss occurring in some cases. 23,47 Many of these complications, including RRD, were seen up to 3.5 years after surgery, 23 suggesting long-term follow-up is often indicated in what may seem to be an asymptomatic population without overt evidence of significant intraocular pathology.

Given the often younger age of many patients undergoing vitrectomy for floaters, cataract formation and progression are a concern. Most studies report between a 25% and 60% cataract surgery rate within 1 to 4 years of PPV. 23,27,28,47,56 Interestingly, the lower rates of cataract surgery (approximately 25%) have been reported in 2 recent studies of small gauge surgery conducting 25G vitrectomy, although these studies also had a shorter follow-up (mean follow-up 18 months) than other studies. 27,28 Other series investigating the rate of cataract progression after small gauge vitrectomy have reported conflicting results. 57,58 In some cases, preservation of the anterior vitreous has also been advocated as a means of delaying cataract onset by preserving the natural vitreous environment in the vicinity of the lens. 28 Recent longer-term follow-up of a series of patients undergoing small gauge, limited vitrectomy with preservation of the anterior vitreous and not inducing a PVD reported reduced cataract rates (16.9% at an average of 13 months post-vitrectomy). 29 This series also showed a relatively lower rate of retinal tear and detachment (2%). Comparison of limited versus extensive vitrectomy has also been shown to result in a reduced rate of cataract formation in another recent study. 56 Taken together, these studies suggest that these technical modifications are likely to improve the safety of vitrectomy for floaters.

Combined Cataract Extraction/Anterior Vitrectomy

One small series has been published regarding the use of combined cataract extraction/phacoemulsification and deep anterior vitrectomy via a posterior capsulorexhexis followed by intraocular lens implantation (IOL). 59 Although successful in resolving floaters in 8 of the 10 eyes operated on, the study has not been repeated, and it has been suggested that in myopic eyes such procedures may increase the risk of RRD. 60 Other studies investigating combined lens extraction/vitrectomy have generally focused on patients with more permanently vision-threatening pathologies than floaters, such as maculopathy or RRD. 61,62

Multifocal Intraocular Lens Insertion

Vitreous opacities have often been considered a relative contraindication to the use of multifocal IOLs due to the potential effect of floaters in exacerbating the reduction in contrast sensitivity that may occur. 63 As a result, the impact of vitreous floaters on vision with the use of multifocal intraocular lenses has been assessed in a few small series. One previous study showed that for patients unhappy with multifocal lens insertion who also suffered from symptomatic PVD, vitrectomy was effective in improving both visual acuity and visual function as measured by the NEI-VFQ, without any significant safety events during the 6 months of the study. 64 One recent small series (5 eyes) has also evaluated combined phacoemulsification/multifocal intraocular lens insertion and vitrectomy symptomatic vitreous floaters with improvements in visual acuity and floater-based symptoms amongst all participants, although one patient did require subsequent refractive surgery to achieve optimum uncorrected vision. 65 These two small studies suggest that patients with vitreous opacities may still be suitable for multifocal IOL insertion, although further research is needed to fully clarify this.

LASER DISRUPTION

Although vitrectomy is currently the most commonly used treatment for vitreous opacities, other therapies have also been explored. Vitreolysis via the use of a YAG laser is one such option, and aims to disrupt large floaters into smaller, less visually disturbing pieces. This therapy is generally considered most suitable for Weiss rings (a type of floater that results from a PVD where the attachment of the vitreous at the optic disc separates), as these are discrete lesions positioned over the central visual axis. 66 Larger numbers of floaters (>3) or more peripheral lesions have been considered less amenable to laser vitreolysis. 67

Although able to improve vision in some patients, one retrospective comparative study showed that YAG vitreolysis produced moderate improvement in 35.8% of recipients, with significant improvement noted in only 2.5% of cases. In contrast, vitrectomy produced symptom resolution in 93.3% of cases. 68 A recent randomized controlled trial comparing YAG laser disruption with sham laser showed that laser was more effective in reducing symptoms than sham therapy, although it did not result in improved visual acuity. 69 However, it has been suggested that a more appropriate comparison would have been with vitrectomy which remains the mainstay of therapy, and unfortunately at present there are no prospective trials comparing these 2 treatment modalities. 66,70 Additionally, one recent study showed that in a subset of patients treated with vitreolysis, there was no difference in functional measures between those who had received treatment and control patients despite measurable reductions in echodensity on ultrasound, suggesting that vitreolysis may not necessarily achieve symptomatic improvement for a notable subset of patients. 31

There have also been a selection of adverse events reported related to YAG vitreolysis, with significant complications such as RRD and treatment-resistant glaucoma noted in the literature. 67,71–73 It is difficult to quantify the incidence of such adverse events, given that most published series on vitreolysis are small, with at best 50 to 55 participants, and as such larger studies are needed in this area to better quantify the safety of this procedure. A number of recent case series have also reported rapid cataract formation with posterior capsular disruption after laser vitreolysis, 74–77 suggesting that this therapy should be considered with caution in phakic patients.

TREATMENT FOR ASTEROID HYALOSIS

Few studies have investigated treatment of asteroid hyalosis as a separate entity from vitreous floaters, likely because of the uncommon nature of the condition and the even greater rarity of visual impairment caused by asteroid. The limited evidence available supports the efficacy of vitrectomy in improving vision in patients with visually disabling asteroid, 78,79 or in cases where asteroid impairs the ability of the ophthalmologist to accurately assess or treat other potentially more serious pathologies, such as proliferative diabetic retinopathy or vitreous hemorrhage. 80 Successful YAG Laser photodisruption of asteroid has also been reported in one case, although no other reports are available to support the use of YAG laser in this condition. 81 A recent comprehensive review of asteroid hyalosis also noted few instances of reported visual impairment from asteroid, although it should be noted that it can markedly impair fundal examination and lens selection in cataract surgery. 82

CONCLUSIONS

Vitreous floaters may produce visual disturbance in the absence of retinal pathology such as retinal tears or inflammation. For a significant proportion of patients, symptoms will not be severe enough to warrant intervention. However, a subset of patients has persistent visual impairment that may adversely affect a patient's quality of life and work. Currently, no clear objective guidelines exist in selecting which patients will benefit most from treatment, although contrast sensitivity and quantitative ultrasound are promising means of assessment, and contrast sensitivity is likely the most easily applicable of these to regular clinical practice. There are similarly difficulties in assessing the degree of postoperative success, and anatomic outcomes may not necessarily match with improvement in functional outcomes.

Treatment seems to be more effective with the use of vitrectomy to remove floaters as compared with YAG vitreolysis, although currently there are no prospective trials comparing and assessing these treatments. When indicated, vitrectomy for floaters is an effective means of treating what may be a visually distressing phenomenon, although patients should be fully counseled regarding possible surgical complications. Should surgery therefore be undertaken, there are aspects of operative issues that require consideration, which can affect the safety of the procedure. These are:

The safety profile (particularly the risk of RRD, although also potentially the risk of cataract) for the procedure is likely to be improved by the use of small gauge (25 or 23G) surgery compared with larger (20G) gauges, although this has not been formally studied in prospective head-to-head trials.

Surgical induction of a PVD seems to carry with it an increased risk of iatrogenic retinal break formation and potentially also increases the risk of cataract development. Additionally, whether PVD induction produces better surgical outcomes is currently unclear, and thus at present, the authors advise caution in considering PVD induction as a necessary surgical step.

Intraoperative peripheral retinal examination and treatment of retinal breaks and lesions at higher risk of subsequent retinal detachment assist in preventing future complications.

For phakic patients, there is a notable rate of cataract progression even within the first 12 months postprocedure, and patients should be counseled regarding the potential need for subsequent cataract surgery. Preservation of the anterior vitreous may reduce the rate of cataract formation, although this too needs further investigation and research.

Vitreous floaters remain an area of interventional debate, although recent research has helped to better identify means of assessing their impact on vision and newer treatment modalities (such as laser vitreolysis) and ways of improving the safety of existing techniques such as vitrectomy. Further research on this topic, and greater experience with newer surgical techniques such as small gauge vitrectomy, will assist surgeons in better managing the patient group with persistent vitreous floaters.

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• Published: 26 April 2021

Acute symptomatic vitreous floaters assessed with ultra-wide field scanning laser ophthalmoscopy and spectral domain optical coherence tomography

• Gisung Son 1 , 2 ,
• Joonhong Sohn 1 &
• Mingui Kong 1 , 2  

Scientific Reports volume  11 , Article number:  8930 ( 2021 ) Cite this article

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To describe the eyes with vitreous floaters and to analyze the development of acute symptomatic posterior vitreous detachment (PVD). A retrospective review of medical records was performed on patients with the vitreous floater developed for the first time of their life. Peripapillary vitreous opacity (pVO) was searched in Ultra-wide field (UWF) scanning laser ophthalmoscopy and PVD stage was assessed through spectral-domain optical coherence tomography (SD-OCT). 196 patients (55 males and 141 females), who were 58.4 (± 9.1) years old, visited a retinal clinic 9.4 (± 9.1) days after they experienced vitreous floaters. In 196 eyes, pVO was noticed in 122 eyes (62.2%) at UWF. In 106 eyes where SD-OCT data were available, PVD was noticed in 100 eyes (94.3%). Symptomatic eyes showed more advanced stage of PVD (p < 0.001) than symptom free eyes. Eyes with floaters were more myopic (− 0.7 ± 2.2D vs − 0.5 ± 1.9D, p = 0.02), and had lower intraocular pressure (IOP) (14.7 ± 3.2 mmHg vs 15.2 ± 3.0 mmHg, p = 0.02) than the other symptom free eyes. In patients with first floater symptoms, PVD was in progress in most of the eyes not only the symptomatic eyes but also on the contralateral symptom free eyes. Eyes with vitreous floaters were more myopic and had lower IOP than the opposite symptom free eyes.

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Posterior vitreous detachment and paravascular retinoschisis in highly myopic young patients detected by ultra-widefield OCT

Introduction.

Vitreous floaters are entoptic images of opacity in vitreous cavity 1 . Substantial portion of patients visit retina clinics complaining symptomatic degenerative floaters. Although floater symptoms often become asymptomatic within a few months from onset, they do cause visual discomfort such as blurred vision, glare and haze in daily living for months or years 2 . Moreover, degenerative vitreous floaters related with posterior vitreous detachment (PVD) could be more clinically significant because they can be followed by pathologic conditions such as vitreous hemorrhage, retinal tear or retinal detachment 3 . Therefore, characterizing the status of PVD could provide important information on eyes with acute vitreous floaters.

Recently, detailed evaluation of vitreoretinal interface has been possible since the introduction of spectral domain optical coherence tomography (SD-OCT) 4 , 5 , 6 , 7 , 8 . And ultra-wide field retinal imaging (UWF) devices allow us to evaluate posterior pole and wide range of the peripheral retina simultaneously 9 . We hypothesized that the SD-OCT and UWF examination will allow us to identify and record PVD status more accurately. Thus, we investigated patients with acute symptomatic vitreous floaters using these two modalities to determine the relationship between floaters and PVD. By comparing eyes with and without floater symptoms, we also intended to find out when floater symptoms occur on the process of PVD.

The mean age was 58.38 (± 9.14) years old in average, consisting of 141 women and 55 men (Table 1 ). The BCVA of 196 eyes was 0.06 (± 0.10) in average, SE was − 0.70 (± 2.09) diopter, and intraocular pressure (IOP) was 15.05 (± 6.20) mmHg. There was no difference between men and women in BCVA (p = 0.64), SE (p = 0.45) and IOP (p = 0.11). In 33 patients (17.3%), vitreous floaters were found in both eyes. Patients visited our retina clinic after an average of 9.41 (± 9.05) days after symptom onset, and 23 patients (11.74%) had ‘flashing light’ symptom before the floater. 24 patients (12.24%) needed laser treatment on peripheral retinal break which was observed in their clinical visit. In 3 eyes (1.53%), glaucoma was diagnosed incidentally and those 3 eyes were excluded from the pRNFL analysis.

Of the 196 eyes with floater, 97 eyes (49.5%) were emmetropic (− 1D < SE < + 1D), 61 eyes (31.1%) were myopic (SE ≤ − 1D) and 38 eyes (19.4%) were hyperopic (SE ≥ + 1D). Myopic eyes tend to present vitreous floater symptoms earlier (r = 0.406, p < 0.001, Fig.  1 ). This was the same for both the male group (r = 0.352, p = 0.008) and the female group (r = 0.463, p < 0.001). In addition, thinner pRNFL was observed in Myopic patients (r = 0.299, p = 0.011), and SE was not significantly related to central macular thickness (CMT) (r = 0.072, p = 0.471).

X-axis presents the age when the first vitreous floater symptom occurred, while Y-axis presents the spherical equivalent value in diopters (D). The oblique line of best fit is showing a positive correlation between the spherical equivalent value and age. (r = 0.421, p < 0.001 in the Pearson’s correlation analysis).

Peripapillary vitreous opacity (pVO) was observed in 62.2% (122 out of 196 eyes) in the UWF image. Among 106 symptomatic eyes where SD-OCT data were available, PVD was identified in 94.3% on SD-OCT. PVD was staged based on the morphology of the vitreomacular interphase assessed with SD-OCT, from stage 0 to 4. In 106 symptomatic eyes, 6 eyes were categorized as stage 0, while 8 eyes as stage 1, 6 eyes as stage 2, 5 eyes as stage 3 and 81 eyes as stage 4. Interestingly, almost every eye with the pVO had the evidence of PVD on SD-OCT (98.7%, 75 out of 76 eyes). While, 75.0% (75 eyes out of 100 eyes) of eyes with SD-OCT proven PVD had pVO on UWF images.

We compared the ophthalmologic examination results of the symptomatic study eyes with floaters and the symptom free contralateral eyes without floaters in 163 patients who had symptoms only in the unilateral eye (Table 2 ). The eyes with floaters were more myopic than those without floaters (− 0.7 ± 2.2D vs − 0.5 ± 1.9D, p = 0.02), and had lower intraocular pressure (14.7 ± 3.2 mmHg vs 15.2 ± 3.0 mmHg, p = 0.02). Visual acuity (0.06 ± 0.11 vs 0.04 ± 0.08, p = 0.09), CMT (259.4 ± 20.2 vs 260.0 ± 19.5, p = 0.56) or pRNFL (100.7 ± 11.6 μm vs 100.5 ± 11.4 μm, p = 0.08) did not differ between the two groups. More pVO on UWF (63.2% vs 18.4%, p = 0.04) and more advantaged PVD stage on SD-OCT (p < 0.001) was observed in the eyes with floater symptoms than the symptom free collateral eyes.

We could verify a high degree of agreement on the interpretation of UWF and SD-OCT images between two investigators (GSS, MGK) In UWF image analyses, the judgments were in agreement in 190 eyes (96.9%). Regarding SD-OCT image analyses, the ICC value between the two investigators was 0.977. There were six discordant interpretations on UWF images of myopic eyes with tessellated fundus. And there were three disagreements on SD-OCT images where background reflectivity of vitreous cavity was difficult to be determined as vitreous body or not.

Additional ophthalmological analyses were performed on 33 patients with floater symptoms on both eyes (Supplementary Table 1 ). The comparison was conducted between eyes with earlier floater symptoms versus eyes with more recently occurred floater symptoms. BCVA, SE, IOP, CMT and pRNFL thickness were not different each other (p = 0.48, 0.39, 0.24, 0.65, 0.71 respectively). The prevalence of the pVO on the UWF were not different between 2 groups, (57.6% vs 36.4, p = 0.505) neither so PVD stage (p = 0.90).

This study provides novel information regarding the vitreoretinal interface of patients experiencing their lifetime’s first floater symptom. Meanwhile, through this study, we were able to confirm several facts that have been reported about PVD in previous studies. First, the first vitreous floater in life showed at an average age of 58.4 years, similar to the previous studies 10 , 11 , 12 , 13 . The female predominance of PVD in this study (72% in female) has been also reported several times in previous studies 10 , 13 . In addition, the earlier onset of PVD in the myopic eye in this study has also been reported in several other previous studies 10 , 14 , 15 .

The usefulness of SD-OCT in the diagnosis of PVD was recently presented in a previous prospective study. Moon et al. 16 analyzed 124 eyes with PVD examined using ultrasonography and SD-OCT and showed the usefulness of adding peripapillary OCT scans in the diagnosis of PVD considering lower inter-examiner agreement of ocular ultrasound scanning. Our data could be convincing evidences supporting their hypothesis. Instead of ultrasonography, however, we described the inter-correlation of UWF and SD-OCT assessing eyes with vitreous floaters. We believe that our study could describe more ‘real world’ clinical situation than their data analyzed from prospectively enrolled patients.

Most of the eyes with floaters had PVD in progress, and the proportion was 94.3% as determined by the SD-OCT. Interestingly, PVD was also progressing in most of the asymptomatic eyes. We confirmed the evidence of PVD assessed with SD-OCT in 89.5% of the symptom free contralateral eyes. This inconsistency between presence of PVD on SD-OCT and absence of subjective symptoms could be explained by the PVD stage of the opposite symptom free eye which was earlier than the other symptomatic eye. In other words, the degree of detached membrane might be relatively small to be noticed in earlier PVD stage. Since this study is cross sectional, it was difficult to accurately determine at which point the floater occurred during the PVD process. However, we could confirm that the eyes with floater present more advanced PVD stage on SD-OCT and more eyes with pVO on UWF than the symptom free contralateral eyes.

The fact that the eyes with floaters were more myopic and had lower IOP can be explained in relation to changes in the eyeball as PVD progresses. Myopic eyes have longer axial length, so maybe easily affected by the shrinkage of the vitreous body. We can also infer that a more myopic eye in a single person might expect earlier vitreous floaters than the other eye. Meanwhile, the measurement of low intraocular pressure in PVD eyes can be explained by the fact that stiffer vitreous in eyes without PVD may present a stronger rebound than liquefied vitreous in eyes with PVD during the measurement of IOP.

Peripapillary vitreous opacity presented on UWF could be thought as a convincing evidence of PVD. This can be intuitively understood, because the pVO is likely to be found in UWF after PVD initiation. Weiss ring, which is the representative form of pVO in the advanced stage PVD, is noticed when complete PVD occurs after the detachment of the vitreopapillary adhesion. Also in this study, almost every eyes with visible pVO were proven to have PVD through SD-OCT examination. For a few exceptional cases (2 eyes, 2.67%), pVO could be positioned perpendicular to the front, difficult to be photographed. Considering this, if Weiss ring is observed in UWF, ophthalmologists who are practicing in the environment without SD-OCT equipment could be more confident in the presence of the PVD.

Based on this study results, retinal examinations of both eyes are recommendable on the patients complaining of floaters. This is because described above, PVD was occurring in 89.5% of the contralateral eyes even without subjective floater symptoms. If early-staged PVD findings on SD-OCT are observed in the opposite eye, the patient can be explained in advance that floater symptoms may also occur in the symptom free eyes. In addition, in 6 eyes (1.95%) of the study cohort, a peripheral retinal break requiring laser photocoagulation treatment was found in the opposite eye rather than in the symptomatic eye.

Despite high degree of agreement, discrepancy in the interpretation of UWF and SD-OCT tests between the two investigators should not be ignored. In 6 UWF images, there was a disagreement whether the spots on the photos to be judged by vitreous opacity or peripapillary pigments. The ambiguity got bigger in myopic eyes with tessellated fundus. In 3 SD-OCT images, it was difficult to determine whether PVD stage be categorized into stage 1 or stage 2. Serial checks-up of the test, correlations with the stereoscopic fundus examination findings or performing swept-source OCT covering more extensive retina could be helpful approaches for solving the discrepancy.

Although it is useful to examine UWF and SD-OCT together in patients with vitreous floaters, yet detailed medical history and meticulous retinal observation through a microscope should not be overlooked. This is because floater symptoms are not necessarily caused by PVD. If we listen to the patients carefully through detailed medical history, we can better understand the patients-reporting ‘floaters’ symptoms. Thorough retinal examination should be performed to conclude whether vitreous opacities are related with PVD or not.

We are mindful of the limitations of this study, such as its retrospective and cross-sectional nature performed on single-ethnic population background. In addition, section bias should be mentioned as we analyzed only the patients who visited clinic. In addition, SD-OCT was performed on 106 patients (53%) who were willing to pay for the examination. However, as we know of, this is the first attempt to analyze lifetime’s first vitreous floaters using both of the UWF scanning laser ophthalmoscopy and the SD-OCT images. We believe our study might provide useful information to ophthalmologists regarding vitreous floaters and PVD in real clinical world. Further prospective studies might warrant for more useful information of when and in what percent the vitreous floater symptoms fades away.

We retrospectively analyzed the medical records of patients who visited our retina clinic due to newly developed vitreous floaters within a month from July 2017 to May 2020. All patients received thorough ophthalmological examination including BCVA, manifest refraction, IOP (NT-530P, Nidek, Aichi, Japan), retinal examination after mydriasis, SD-OCT (Version 5.3.2.0; Heidelberg Engineering, Heidelberg, Germany) and UWF (Optomap, Optos PLC, Dunfermline, Fife, Scotland, UK) were performed. We conducted SD-OCT line and raster scan in all eyes centered at the fovea. Automatic real-time (ART) mode was activated when horizontal and vertical line scans were conducted with 25 frames averaged. In the raster scan image, a 30 × 25 degree 2 area was covered with 31 b-scans (consisting of 768 A-scans), which are 9.0 mm in length, and spaced at 240 μm apart. The peripapillary region was scanned using a circular scan 12° in diameter, centered on the optic disc (Fig.  2 ). Every retinal examination was performed on both eyes. All the images information was assessed by saved data on digital files before in-depth analyses.

Ultra-wide field scanning laser ophthalmoscopy (UWF) and Spectral Domain Optical Coherence Tomography (SD-OCT) images of patients who experienced floater for the first time in their life. ( A ) PVD stage 1. 59 year-old male. No definite change was noticed around optic disc in UWF. Note subtle change which is presenting the initiation of PVD (Posterior Vitreous Detachment, white arrow). ( B ) PVD stage 2. 60 year-old female. No definite change was noticed around optic disc in UWF. In the macular SD-OCT image, perifoveal posterior vitreous detachment (PVD) is in progress (white arrows) remaining posterior vitreous attached to fovea. In glaucomatous SD-OCT, PVD is in progress in some part of the optic disc margin (arrow), while most of the optic disc remains attached to the vitreous body. ( C ) PVD stage 3. 61 year-old male. Note two pVOs (peripapillary vitreous opacity, white arrows) noticed around the optic disc. In the macular SD-OCT image, PVD occurred throughout the entire macula. In the glaucomatous SD-OCT image, PVD is in progress while about half of the optic disc margin is detached to the vitreous body (a wide bidirectional arrow). ( D ) PVD stage 4. 66 year-old female. Note a dense pVO (white arrow) resembling a Weiss ring. In the macular SD-OCT image, reflectivity of vitreous body is not observed in hollow vitreous cavity. In glaucomatous SD-OCT image, reflectivity of vitreous body is not observed either. A shadow of pVO (arrow) is identified.

Study subjects and vitreous floaters

Eligible subjects were adults older than 20 years old who experienced acute symptom (onset ≤ 1 month) of vitreous floaters for the first time of their life. In patients with floater symptoms in both eyes, eyes with more recently developed floater symptom were selected for the analysis. Exclusion criteria includes history of ocular surgery including cataract operation, history of ocular injections, any retinopathy including diabetic retinopathy or retinal vein occlusion, medial opacity including severe cataract or corneal opacity or eyes with obscure image which were not suitable for proper analyses. Eyes received refractive surgeries were excluded from the refraction analyses.

In this study, vitreous floaters were defined as symptoms of unprecedented amorphous ‘floating’ material. Other confusing symptoms such as fixed spots interrupts visual axis, transient wavy visual disturbance or metamorphopsia were excluded with through history taking. Concurrent subjective symptoms such as headaches, flashes, or ocular pain were asked also.

Analyses of ophthalmologic outcomes

Best-corrected visual acuity was measured with the manifest refraction test and was recorded in logMAR (logarithm of minimal angle of resolution). The spherical equivalent and cylindrical value were expressed in diopter. CMT at the 1-mm center of the fovea was measured using a built-in software (Heidelberg Eye Explorer, version 1.10.2.0, Heidelberg Engineering, Heidelberg, Germany), which recorded the distance between the vitreoretinal surface and the border between the retinal pigment epithelium and the Bruch’s membrane. Peripapillary RNFL (pRNFL) thickness was measured using the identical software.

Analysis of peripapillary vitreous opacity in UWF imaging

The presence of pVO was observed in UWF images taken on the eyes, after pupil dilation. The vitreous opacity found within 3 disc diameters from the center of the disc was included (Fig.  2 ). In cases where it was difficult to judge by pictures alone, the precise fundus examination with indirect ophthalmoscopy was considered together for the determination. The two investigators (GSS, MK) each independently analyzed the image, and for the inconsistencies, the senior investigator (JHS) made a final decision.

Anaylsis of PVD stage in SD-OCT imaging

The staging of PVD was performed base on the previously published paper 17 . In brief, stage 0 = no PVD; stage 1 = PVD at mid-periphery and possible subtle PVD in the posterior retina; stage 2 = PVD, except for persistent adhesion to the papilla and fovea; stage 3 = PVD, except for persistent adhesion to the papilla; and Stage 4 = complete PVD (Fig.  2 ). The two investigators (GSS, MK) analyzed PVD respectively, and the opinions of senior investigator (JHS) were sought for discordant findings.

Statistical analyses

Continuous values were expressed as “average ± standard deviation,” and categorical variables were described as proportions; differences between groups were determined using the Chi-squared test or Fisher’s exact test. Comparison of ophthalmological values between eyes with/without vitreous floaters was performed using the paired t test. Pearson’s correlation analyses were performed among various continuous values. Inter-class correlation (ICC) value was calculated to determine how consistent the two investigators’ interpretations on PVD at SD-OCT images were. All data were inserted into an Excel spreadsheet (Microsoft Corp.) and analyzed using SPSS software (version 23; IBM Corp, New York, NY). A P-value less than 0.05 was considered statistically significant.

Ethics approval and patient consent

This study was approved by the Institutional Review Board (IRB) of Hangil Eye Hospital (IRB number: IRB-20006) and complied with the Declaration of Helsinki in conducting the study. Given the retrospective design of this study and the use of anonymized data, requirements for informed consent were waived by the IRB.

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Gisung Son, Joonhong Sohn & Mingui Kong

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G.S.: design of the work, the acquisition, analysis, and interpretation of data, drafting the important intellectual content, final approval of the version to be published. J.H.S.: design of the work, final approval of the version to be published. M.K.: design of the work, the acquisition, analysis, and interpretation of data, drafting the important intellectual content, final approval of the version to be published.

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Son, G., Sohn, J. & Kong, M. Acute symptomatic vitreous floaters assessed with ultra-wide field scanning laser ophthalmoscopy and spectral domain optical coherence tomography. Sci Rep 11 , 8930 (2021). https://doi.org/10.1038/s41598-021-88371-9

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DOI : https://doi.org/10.1038/s41598-021-88371-9

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Vitreous Floaters With New Intravitreal Drugs Administered by Retina Specialists

• 1 Retina Specialists, Baltimore, Maryland
• Research Letter Silicone Oil Droplet Floaters Following Intravitreal Injection Jacques Bijon, MD; Rusdeep Mundae, MD; Yale Fisher, MD; K. Bailey Freund, MD JAMA Ophthalmology
• Brief Report Presumed Silicone Oil Droplets After Intravitreal Pegcetacoplan Injections Amr Dessouki, MD; Lingmin He, MD, MS; Kaitlyn Park, BS; Howard Chen, MD; Clement C. Chow, MD JAMA Ophthalmology
• Comment & Response Silicone Oil From Syringes—a Potentially Overlooked Issue for Intravitreal Injections—Reply Jacques Bijon, MD; K. Bailey Freund, MD JAMA Ophthalmology

In this issue of JAMA Ophthalmology , Dessouki and colleagues 1 describe symptomatic silicone oil microdroplets in 16 of 55 patients (29%) receiving pegcetacoplan following a single injection using a Luer lock 1-mL syringe sold by McKesson (16-PS1C). It is not unexpected that silicone oil microdroplets would be noted in some eyes following intravitreal injection because they have been reported in multiple studies for eyes receiving bevacizumab, ranibizumab, and aflibercept. 2 , 3 The remarkable feature in this study is the high percentage of patients with symptomatic floaters after a single injection of pegcetacoplan because in prior reports, silicone oil microdroplets were typically discovered after numerous injections of the anti–vascular endothelial growth factor (VEGF) drugs. This finding suggests that there may be some unique features about pegcetacoplan, the McKesson syringe, the 18-gauge 5-μm filter needles supplied by Apellis to draw up the pegcetacoplan, or the 29-gauge needle supplied by Apellis to deliver the intravitreal injection that were associated with this problem.

Read More About

Thompson JT. Vitreous Floaters With New Intravitreal Drugs Administered by Retina Specialists. JAMA Ophthalmol. 2023;141(11):1066–1067. doi:10.1001/jamaophthalmol.2023.4394

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• Science and vision

“Eye care should be attentive to finding ways to try and reduce the burden for patients”

The roundtable.

In a roundtable discussion, hosted in partnership with VivaQuity, OT  investigates how floaters are managed in practice, and explains the research behind a daily supplement that could have significant benefit for patients’ quality of life

Lucy Miller

Laurence Derbyshire

18 April 2023

While floaters can be debilitating, many optometrists will be acutely aware that discussing treatment with patients is not always straightforward – whether because of cost, hesitation around seeking private treatment, or the potential side effects of surgery.

• Dr Frank Eperjesi, optometrist and EyeTools co-founder
• Dr Scott Mackie, optometrist and owner of Mackie Opticians, a Hakim Group practice
• Dr Thomas Kaercher, ophthalmologist in Heidelberg, Germany
• Professor John M Nolan, Nutrition Research Centre Ireland (NRCI) at South East Technological University (SETU).

Identifying vitreous floaters in the testing room

It’s incumbent on the optometrist to further pursue and ask questions of the patient who says they have floaters Optometrist and EyeTools co-founder, Dr Frank Eperjesi

The FLIES study in context: key numbers

• Over 20: how many years Professor John M Nolan and colleagues at the Nutrition Research Centre Ireland have been working on how targeted nutrition can be beneficial to the eye, particularly with regards to macular degeneration
• Four: the number of observational studies that had taken place across Europe before UK-based research began
• Six: years since optometrist Emmanuel Ankamah joined the Nutrition Research Centre Ireland research team to start his PhD investigating the nutrition of the vitreous
• 300: the number of patients screened ahead of the FLIES study
• 60: the number of participants who were recruited onto the trial, after the impact of floaters on daily life, functional data on the size of floaters, and measures of visual function were gathered
• 50%: the percentage of participants who were given the VitroCap N active intervention versus the number who were given a placebo
• Six: the number of months taken to see a benefit to those taking VitroCap N in terms of how they felt in their daily life, their contrast sensitivity, and the size of their floaters
• 20%: the average shrinkage of floaters in 70% of patients taking the VitroCap N
• 70%: the published success rate of the FLIES study.

Making the case for capsules

We must not overwhelm the patient with this knowledge, but show them what this metabolism is like, and explain properly that it’s a long-lasting process, so they fully understand our therapeutic approaches Ophthalmologist, Dr Thomas Kaercher

Incorporating into optometry practice

You can improve a person’s quality of life by advising them to use VitroCap N Optometrist, Dr Frank Eperjesi

You’ve got to set them up properly. I think the science speaks for itself. I think it’s how you then take that and go forward with it Optometrist and owner of Mackie Opticians, Dr Scott Mackie

Using research in practice

Experiences of vitrocap n.

With a decade of experience prescribing the VitroCap N to patients, Kaercher believes that starting the treatment early is key. “When I first see a patient presenting with floaters, I prescribe it for a period of three months,” he said. He emphasised the importance of observing the retina for any change, degeneration or tear, throughout the course of treatment, to ensure patient safety. Mackie believes that discussion is essential, including ensuring that the patient knows that floaters are a different condition to PVDs or retinal tears, and that this is on their record card. He also plans to discuss preventative measures, and to take measurement of low contrast sensitivity both when prescribing VitroCap N and after six months, in order to tangibly highlight the difference the supplement is making. He said: “It’s all to do with the way that you discuss it. Discussion is so important to the patient. Make sure they get it. Give them the information leaflet, and let them reflect on what you’ve said. It doesn’t need to be the hard sell there and then.” Mackie is confident that he has done his due diligence and is ready to start using VitroCap N in practice. “We’ve got 20 patients who are complaining about floaters,’ he said. “So, now that I know much more about it, let’s start.” Patient usage is the only way to spread the message that the treatment works, Mackie believes: “Peer review is great, as of course is double blind placebo – it's fantastic; it’s gold standard. But let’s now find some real patients, who’ve had real advantages.”

Future questions for the research team: “Any time you do a research study and answer a question, you create 20 more questions”

Nolan admits that, while the FLIES study’s results are strong enough to make recommending VitroCap N to the optometry profession safe, there are now other questions that his team hope to answer. Indeed, research on some of the following has already begun:

• What happens after six months?
• Why might some patients not respond to VitroCap N? Is it related to the severity, or whether or not they already have a PVD?
• How do the micronutrients of the vitreous change following intervention?
• What happens if dosages are increased?

Nolan said: “There’s a significant amount of work to be conducted, from this point forward,” emphasising that every time discussions or critiques are given to research “you have a new goalpost.”

He added: “We have a lot more to do, but we’ve enough now to start making safe recommendations to benefit patients – and we should do that.”

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15 Oct New study proves effectiveness of a non-surgical, dietary solution for ‘Eye floaters’

A new study published in the Translational Vision Science and Technology (TVST), an ARVO journal, has revealed that targeted nutrition can significantly reduce ‘eye floaters’ as well as their associated discomforts. This study reports the outcomes of the Floater Intervention Study (FLIES), which was led by the Nutrition Research Centre Ireland (NRCI, Waterford Institute of Technology), in collaboration with local optometrists and the Institute of Eye Surgery at UPMC Whitfield Hospital.

Floaters are spots in your vision like black or grey specks, strings, or cobwebs that drift about when you move your eyes. According to the National Eye Institute, “almost everyone develops floaters as they get older”, but floaters can also occur from a very young age and especially in short-sighted people. Most eye floaters are caused by age-related changes in the vitreous (the jelly part of the eye). Floaters are painless and mostly harmless, but they regularly cause significant visual discomfort and, at times, mental stress for the sufferers. In some cases, floaters may be associated with retinal tears, a potential sight-threatening complication that requires immediate medical attention.

The FLIES trial is the first double-blind, placebo-controlled clinical trial in patients with primary floaters that demonstrated reduction in floater suffering as well as improvements in visual function in the active group compared to placebo, following a 6-month dietary intervention with a formulation consisting of 125mg l-lysine, 40mg vitamin C, 26.3mg Vitis vinifera extract, 5mg zinc, and 100mg Citrus aurantium.

Dr. Emmanuel Ankamah, the main researcher on the FLIES trial, says “I am delighted to see the outcomes of this exciting trial published in TVST, a high impact journal in vision science. Indeed, this trial provides the evidence to support the use of targeted nutritional intervention as a management strategy for vitreous floaters. This gives us more confidence that using antioxidative and antiglycation micronutrients can improve vitreous health.”

According to Professor John Nolan, the Director of the NRCI and Principal Investigator of the FLIES trial, “This study is very interesting, as it is the first of its kind to examine the benefits of nutritional supplementation for patients suffering with vitreous floaters. Notably, a large percentage of patients (77%) on the active supplement demonstrated a reduction in vitreous floaters and associated improvements in vision-related quality of life was seen in 67% of patients. So, while not all participants on the active arm of the trial experienced improvements, this work provides clear evidence that this nutritional intervention is effective for certain patients. We look forward to continuing our studies on this important area of research. While we are hopeful that this research will inform eye-care, and offer an option to eye-care professionals and patients to enhance the health of the vitreous, we strongly advise that patients seek advice from a qualified eye-care professional.”

The FLIES trial was sponsored by Waterford Institute of Technology and ebiga-VISION GmbH through a WIT Co-Fund PhD scholarship (WD_2007_43). To read the newly published study, which is open access and freely available for download, see the manuscript link at Publication https://tvst.arvoj ournals.org/article.aspx?artic leid=2777982

Sean McKinney, Senior Editor

Daring to Treat Floaters

More experts are taking a second look at controversial approaches to resolving these visual disturbances..

C all it a case of mounting evidence eating away at popular wisdom. The use of YAG laser vitreolysis and vitrectomy to treat vitreous floaters has always seemed nearly off-limits to most right-thinking ophthalmologists. But more retinal specialists and some anterior segment surgeons are moving away from blanket views of pathologies, learning more about the nuances of these visual disturbances and intervening with improved techniques and technologies when treatment seems necessary.

In this report, they share their reasons and strategies—and precautions to take to ensure that you proceed with care.

Considering Vitrectomy

Retinal specialists say vitrectomy remains the conventional—if not widely used—treatment for vitreous floaters. Before deciding to operate, they continue to carefully consider risks for complications, such as cataract formation, glaucoma, endophthalmitis, retinal tears, retinal detachment, hypotony, choroidal effusion, suprachoroidal hemorrhage, vitreous hemorrhage, cystoid macular edema, optic neuropathy and phototoxicity. 1,2,3 With these assessments in mind, Chicago retinal specialist Jennifer Lim, MD, says she always takes a hard look at the need for treatment when responding to the many patients who come to her with complaints of vitreous floaters, including high myopes and those with a history of vitreous detachments.

“The patients I treat with vitrectomy have chronic floaters that haven’t abated, usually for at least four months,” says Dr. Lim, Marion H. Schenk chair in ophthalmology, director of the retina service and vice-chair for diversity and inclusion at the University of Illinois-Chicago College of Medicine. “I first want to make sure they’re not accommodating to their symptoms. I also want to find out if the floaters are affecting their adult activities of daily living, such as causing difficulty reading or driving. For extremely troubled patients who report symptoms that haven’t necessarily been in concert with my exam findings, I’ve asked them to undergo psychological assessments to confirm that they’re not affected by anxiety disorders or some form of psychological condition.”

Dr. Lim points out that some patients with chronic vitreous floaters or large Weiss rings can’t perform their jobs, especially when sharp vision is needed. Multiple floaters in the mid to posterior vitreous can cause difficulty in reading, driving, computer usage and concentration, she notes.

 “These are the patients I will operate on,” she notes. “As a retinal specialist, I’ve done a lot of vitrectomies. Admittedly, though, I haven’t done a lot of “floaterectomies.” But I’m now more amenable to doing them than I was three years ago. When indicated, the procedure is extremely gratifying and helpful to the patient. In fact, I just did one of these procedures yesterday.”

To qualify a patient for this surgery, Dr. Lim has learned to use objective data, borrowing from some of the techniques developed by Jerry Sebag, MD, FACS, senior research scientist, Doheny Eye Institute/UCLA and professor of clinical ophthalmology, at UCLA’s David Geffen School of Medicine. Dr. Sebag, also founding director of the VMR Institute for Vitreous Macula Retina in Huntington Beach, California, has advanced the use of pars plana vitrectomy to treat visually-significant vitreous opacities that create what he calls the “visual phenomenon of floaters”—but only in clinically significant cases, which he describes as vision-degrading myodesopsia. 4

He says he uses the National Eye Institute Visual Function Questionnaire, followed by a vitreous floaters functional questionnaire he has developed that’s “more specifically related to the impact of floaters on patients’ well-being and quality of life.” 5 Dr. Sebag explains that he also measures contrast sensitivity function to identify patients who might benefit from a vitrectomy. He and other researchers have discovered that opacities in the vitreous body following PVD in older patients and in association with myopic vitreopathy in younger patients degrade the contrast sensitivity function by an average of 91 percent. 6,7,8,9

Dr. Sebag says he also relies on the “overlooked” value of ultrasonography, which he says can identify structures in the vitreous that help explain degradation of the contrast sensitivity function and the patient’s level of unhappiness and poor quality-of- life. 10,11,12

“When findings are abnormal, I’m comfortable clearing patients for symptom-remedying surgery and recommending vitrectomy,” states Dr. Sebag. 

The “flip side” of using these measures is that this approach can be used to confidently rule out treatment for patients, he notes. “Lots of people have floaters, but fewer have vision-degrading myodesopsia,” he says. “I can legitimately tell a patient, ‘Your case is not sufficiently severe for therapy because your contrast sensitivity function is not as bad as what we usually see in patients who do need therapy.” (Dr. Sebag explains his approach in “Straight from the Cutter’s Mouth: A Retina Podcast,” Dec. 12, 2017, linked here by permission of the publisher. retinapodcast.com/episodes/2017/12/12/episode-78-vision-degrading-vitreopathy-with-dr-jerry-sebag) 

Documenting Floaters

 Like Dr. Sebag, Dr. Lim uses contrast sensitivity testing to determine if a patient may be a candidate for a vitrectomy. “It’s helpful that we can actually document the effects of vitreous floaters in these ways,” she says. “I seriously consider treating patients who are significantly bothered by cloudy floaters, especially when their posterior hyaloid face is thickened or partly opacified, causing them to experience a film over their vision that won’t go away.”

So far, she says she’s avoided complications in patients she’s treated.  “During the past five years, in the fewer than 10 floaterectomies that I’ve performed, no patient has developed cataracts,” she says. “Keep in mind these patients tended to be on the younger side. And if they’re older, many have already had their cataracts removed.” Every case is an exercise in caution, she notes, especially for high myopes, who are at increased risk of retinal tears and detachments.

 “When you’re trying to induce a PVD intraoperatively, you risk inducing tears at the vitreous base, along with a retinal detachment,” she says. “But fortunately I haven’t had any cases of postop endophthalmitis, or any tears or retinal detachments interoperatively.”

Dr. Lim believes that YAG laser vitreolysis, the only alternative to vitrectomy and observation, may be worth exploring because of the recent promise it’s shown. 13,14 “If we had a YAG laser in our office, I might consider trying it on an ideal patient, such as one who has had cataract extraction and who has a Weiss ring,” she says. “I wouldn’t use the laser for small floaters. I’m still dubious about the laser to some extent, though, because it creates lots of tiny floaters.”

Clarifying Floaters

One of the challenges of floaters is understanding their diverse levels of significance, according to Chirag Shah, MD, MPH, a partner at Ophthalmic Consultants of Boston. “Floaters can appear as rings, wisps, sheets, squiggles or other patterns in the central or peripheral vision, varying widely in terms of how they affect patients and how clinicians respond to them,” he says.

When evaluating vitreous floaters, Dr. Shah rules out retinal tears, hemorrhage, inflammation and other pathologies that could be at the root of the problem. He also makes sure the floaters match the symptoms his patient reports. “A discrepancy between what I see and what the patient expresses might indicate that the patient is overreacting to his floaters and, thus, might not be a good candidate for treatment,” he says.

If a patient reports significant floaters that correlate with symptoms—and the patient is sufficiently bothered by the floaters—Dr. Shah follows the patient closely. “I tell the patient that, over time, the brain can often adapt and ignore those floaters. This approach is, by far, the safest option for floaters.”

He notes that most of his patients neuroadapt and cope with the floaters, prompting him to monitor them in the long term. “I try to reassure these patients,” he adds. “It’s very uncommon that I recommend further treatment for floaters, such as a YAG laser treatment or vitrectomy.”

Beyond Reassurance

Dr. Shah takes a different course when he determines that patients are coping with very bothersome symptoms. “Again, the appearance of their floaters has to match their symptoms,” he says. “We discuss the options of observation, YAG laser vitreolysis and vitrectomy. If they have discrete floaters that continue to disrupt their lives, such as a Weiss ring, I’ll refer them for YAG vitreolysis.”

 Sheets of floaters, diffuse floaters and excessive numbers of tiny floaters also pose a challenge that may require a vitrectomy. Dr. Shah turns to vitrectomy only two or three times a year for vitreous floaters. “I emphasize the downsides to the patient, such as a guaranteed risk of cataract formation and a small but real risk of a retinal tear and retinal detachment, as well as risks of infection, bleeding and anesthesia,” he says. “I send them home with literature and tell them to do their homework so that they know what they are getting into. If you can avoid doing a vitrectomy and satisfy a patient with YAG vitreolysis, that is by far the safer way to go.”

Dr. Shah recently joined one of his partners, Jeffrey Heier, MD, to oversee a six-month randomized controlled trial of 52 patients who either underwent YAG laser vitreolysis or weren’t treated. 14 “There was no risk of infection, and only a very low risk of elevated intraocular pressure in patients treated with YAG vitreolysis,” he says. “There was also a low risk of worsening floaters by fragmenting them into smaller pieces with the laser, instead of vaporizing them. It’s important to emphasize that the risks were less than the risks of vitrectomy.”

The risks of YAG vitreolysis include glaucoma, retinal tear, retinal detachment, cataract from striking the lens with the laser and retinal damage from striking the retina, says Dr. Shah. To minimize risks of lens or retinal damage, he recommends ensuring a safe distance between the focal point of the laser and the retina and crystalline lens. In his study, he required the Weiss ring floater to be 5 mm posterior to the posterior capsule of the crystalline lens and 3 mm anterior of the retina, as measured by B-scan.

Bullish on Vitreolysis

I. Paul Singh, MD, a glaucoma and anterior segment specialist in Racine, Wisconsin, has offered laser vitreolysis to dozens of unhappy patients. He accepts referrals from Dr. Shah in Boston, as well as from referring physicians all over the world.

“If a patient isn’t a good candidate for a vitrectomy, then vitreolysis can be a good option,” says Dr. Singh, president of the Eye Centers of Racine and Kenosha. He performs about 10 YAG laser vitreolysis procedures per week, in addition to his 25 cataract surgeries and regular visits with glaucoma patients. “In the case of a Weiss ring, for example, laser floater treatment can be fantastic,” he continues, noting that this treatment typically involves an average of only 1.2 sessions. “We’ve found more than 90 percent of patients who undergo this treatment are very happy. Surgeons can easily identify good candidates and correlate signs and symptoms. If, for example, a patient has a solitary lesion, an opacity, such as Weiss ring, or a mass, the laser can help, especially for patients who are phakic or pseudophakic and who don’t want to undergo a vitrectomy.”

 Dr. Singh says YAG laser vitreolysis poses “very low relative risks,” noting that, in one series of 1,264 cases, he recorded an adverse event rate of 0.8 percent, which included seven IOP spikes, two phakic lenses that were struck by the laser and one retinal hemorrhage. 

 “Four patients had a history of uveitis that didn’t worsen and 27 had diabetic retinopathy and didn’t develop macular edema,” he notes. “Four patients developed vitreomacular traction that resolved immediately.”

 Enough Evidence?

Despite these positive results, many leading retinal specialists say claims that YAG laser treatments can resolve floaters remain to be substantiated and that, currently, only vitrectomy has any proven value. 15,16 Dr. Sing says he’s well-acquainted with this perception. “The problem is that, until recently, we didn’t have great technology to more efficiently and safely take care of significant vitreous floaters,” he notes. “The conventional YAG lasers that we used in the past were designed for posterior capsulotomy and iridotomy treatments. They provided a limited view of the posterior vitreous, making it difficult to identify floaters and membranes to target. The risk of damage to surrounding ocular tissue is also greater if you’re not able to visualize the posterior vitreous.”

He notes that conventional YAG lasers have had non-coaxial illumination towers, which provided illumination from a source that was different than the optical system. “The light was oblique and, as a result, we couldn’t see behind the capsule very well. Identifying many of the clinically significant and symptomatic floaters wasn’t possible.”

Another limiting factor of conventional lasers was that energy delivery wasn’t optimized, he adds. “The laser used now has a truncated energy beam,” he points out. “So, less energy is needed to create optical breakdown. In general, the previous studies done on YAG vitreolysis were done with energy settings that were entirely too low,” he continues. “We’re talking about 1 mJ or 2 mJ. You can actually go up to 4 mJ, 5 mJ, 6 mJ or even 7 mJ, depending on where a floater is located. Also, the previous laser treatments were done with 20, 30, 40, 50, 60 or 100 shots. Often, you actually need to use 400 or 500 shots, depending on the floater itself. So people who have some skepticism about the YAG laser for treatment of vitreous floaters seem to be clinging to concerns from many years ago. Recently, we’ve presented a lot of compelling data on safety and efficacy at the AAO and ASCRS meetings.”

Cutting-edge Vitrectomy

Dr. Sebag, the West Coast clinician and researcher who introduced contrast sensitivity function testing and ultrasonography to the preop assessment of potential vitrectomy patients, doesn’t refer his patients for YAG laser vireolysis treatment. But he does use vitrecomy more aggressively than most. When deciding to operate, he says he takes careful steps to minimize risk and complications. The surgery is performed at an ambulatory surgery center under retrobulbar anesthesia. The concept of “less is more” is the guiding principle of the intervention. 

“I use a 25-ga. instrument, since I don’t see any advantage to 27-ga. instruments in this setting,” he says. “The procedure is sutureless. Two aspects of the vitrectomy are especially important. First, I don’t induce a surgical PVD in an individual who doesn’t already have one, in order to prevent an increased risk of iatrogenic retinal tears, but also to avoid increasing intravitreal pO 2 levels too much. Studies show that following PVD, pO 2 levels rise, and that’s what contributes to lens opacification and cataract formation. 11  

Second, I leave 3 or 4 mm of gel vitreous intact behind the lens. This is because vitreous contains antioxidants that mitigate the effects of reactive oxygen species that induce the cross-linking and protein aggregation in the crystalline lens that lead to cataract formation.” 11  

Studies have shown that the incidence of post-vitrectomy cataract surgery is markedly lower following a limited vitrectomy as opposed to extensive vitrectomy with PVD induction—as low as 16.9 percent with an average follow-up of 32 months, Dr. Sebag notes. 6,12

“To minimize risks, I’ve employed a limited vitrectomy,” continues Dr. Sebag. “Some would call it a core vitrectomy. Basically, I remove the central vitreous that contains the opacities. In some individuals, the posterior vitreous contains opacities. And I do go down close to the fundus, which is also very important to characterize preoperatively with ultrasound and OCT, showing me what’s going on in the preretinal posterior vitreous that may require attention. 

I have about three or four dozen patients in their 20 and 30s, myopes who have myopic vitreopathy in the posterior vitreous, which is the cause for their vision-degrading myodesopsia. They’ve all done very well without forming cataracts now, six to seven years after their procedures.” 

Minimizing Iatrogenic Breaks

When evaluating the data from some 200 of these cases, Dr. Sebag says about 22 percent underwent laser or cryoretinopexy three months preoperatively. “When I recognize lattice with erosions or holes or other lesions that I think would put the patient at too much risk for a vitrectomy, we’ll offer them preop prophylactic treatments,” he notes. “I think that has resulted in our low, 1.5-percent incidence of postop retinal tears and detachments.”

That said, Dr. Sebag offers this precaution: “Prophylactic laser isn’t necessary on every patient. Just a careful peripheral fundus exam with scleral depression is enough to identify cases that need prophylaxis.

 “I don’t use the YAG laser to treat vitreous opacities, as there are no studies to date that prove efficacy,” he adds, “although the most recent study suggests that a prospective randomized trial using objective quantitative outcome measures is warranted.” 9,17,18

New Possibilities

Ophthalmologists expect to keep pushing the envelope on vitreous floaters. Concern over quality of life and the increasing reach of therapeutic approaches will drive change. 

 “One recent experience I had with a patient demonstrates at least one example of new ways to respond to floaters,” says Dr. Shah in Boston. ( See Figures 3, 4 and 5 on page 60 .) “The patient had floaters that I tried to treat with YAG laser vitreolysis in our clinical trial. His myopic vitreopathy progressed, and he developed worse floaters.”

Next, Dr. Shah says he offered to perform a vitrectomy on the patient, which helped clear his floaters and left him completely satisfied. “I don’t think we lose much, if anything, by trying this type of step-wise approach, from observation to YAG vitreolysis to vitrectomy,” he concludes. “Managing floaters is different than it used to be.”  REVIEW

Dr. Lim is involved in grants/research for Genentech, Regeneron, Graybug, Stealth, Chengdu Kanghong and Alderya. She’s a consultant for Novartis, Ophthea, Aura Biosciences and Santen, and she receives honoraria for meetings from Alcon and Allergan. Dr. Sebag is a former consultant to ThromboGenics, Johnson & Johnson and Roche. Dr. Shah provides speaking and research services to Ellex. Dr. Singh is a consultant for Ellex, Allergan, Alcon, B+L, Aerie, Ivantis, Sun, Shire, New World Medical, Sensimed and Zeiss.

1. Stein JD, Zacks DN, Grossman D, et al. Adverse events after pars plana vitrectomy among medicare beneficiaries. Arch Ophthalmol 2009;127:12:1656-63.

2. Day S, Grossman DS, Mruthyunjaya P, et al. One-year outcomes after retinal detachment surgery among medicare beneficiaries. Am J Ophthalmol 2010;150:3:338-45.

3. Chang S. LXII Edward Jackson lecture: Open angle glaucoma after vitrectomy. Am J Ophthalmol 2006;141:6:1033-1043.

4. Sebag J. Vitreous and Vision Degrading Myodesopsia. Progr Ret Eye Res 2020; March [Epub ahead of print]  

5. Sebag J. Floaters and the quality of life. (Guest Editorial) Am J Ophthalmol 2011; 152:3-4.

6. Sebag J, Yee KMP, Nguyen JH, Nguyen-Cuu J: Long-term safety and efficacy of vitrectomy for vision degrading myodesopsia from vitreous floaters. Ophthalmology Retina 2018;2:881-7.

7. Garcia G, Khoshnevis M, Yee KM, Nguyen-Cuu J, Nguyen JH, Sebag J.  Degradation of contrast sensitivity following posterior vitreous detachment. Am J Ophthalmol 2016; 172:7-12.

8. Garcia G, Khoshnevis M, Nguyen-Cuu J, Yee KMP, Nguyen JH, Sadun AA, Sebag J. The effects of aging vitreous on contrast sensitivity function. Graefe’s Arch Clin Exp Ophthalmol 2018; 256:919-25.

9. Milston R, Madigan M, Sebag J. Vitreous floaters: Etiology, diagnostics, and management. Surv Ophthalmol 2016;61:2:211-27.

10. Mamou J, Wa C, Yee K, Silverman R, Ketterling J, Sadun A, Sebag J. Ultrasound-based quantification of vitreous floaters correlates with contrast sensitivity and quality of life. Invest Ophthalmol Vis Sci 2015;56:1611–7.

11. Ankamah E, Sebag J, Ng E, Nolan JM. Vitreous antioxidants, degeneration, and vitreo-retinopathy: Exploring the links. Antioxidants 2019;9:1.

12. Yee KM, Tan HS, Lesnick-Oberstein SY, Filas B, Nguyen, J, Nguyen-Cuu J, Sebag J. Incidence of cataract surgery after vitrectomy for vitreous opacities. Ophthalmology Retina 2017;1:154-7.

13. Lim JI. YAG laser vitreolysis-Is it as clear as It seems? Comment on YAG Laser vitreolysis vs sham YAG vitreolysis for symptomatic vitreous floaters: A randomized clinical trial. [JAMA Ophthalmol 2017] JAMA Ophthalmol 20171;135:9:924-925

14. Shah CP, Heier JS. Long-term follow-up of efficacy and safety of YAG vitreolysis for symptomatic Weiss ring floaters. Ophthalmic Surg Lasers Imaging Retina. 2020 1;51:2:85-88.

15. Kokavec J, Wu Z, Sherwin JC, et al. Nd:YAG laser vitreolysis versus pars plana vitrectomy for vitreous floaters. Cochrane Database Syst Rev 2017:1;6. 

16. Milston R, Madigan MC, Sebag J. Vitreous floaters: Etiology, diagnostics, and management. Surv Ophthalmol;61:2:211-27.

17. Sebag J. Methodological and efficacy issues in a randomized clinical trial investigating vitreous floater treatment. JAMA Ophthalmol 2018;136:4:448.

18. Nguyen JH, Nguyen-Cuu J, Yu F, Yee KM, Mamou J, Silverman RH, Ketterling J, Sebag J. Assessment of vitreous structure and visual function after Nd:YAG laser vitreolysis. Ophthalmology 2019;126:11:1517-26.

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Eye Floaters Prevalence Study

• By Team VDM

The VDM Project is currently in the process of commissioning a study on the prevalence of vitreous floaters among adults in the United States.  Project will be working with a company experienced in collecting data for social scientific studies to ensure a representative sample that allows for valid statistical inference. Although ophthalmologists (and retina specialists in particular) anecdotally report that floaters are very common, especially among older adults, these reports somewhat paradoxically seem to coexist with a widespread perception among clinicians that disability resulting from floaters is very rare, if it even occurs at all [2]. This new prevalence study will finally provide vital data that has long been lacking on the societal impact of vitreous floaters.  PROJECT to help us find a safer and better cure for Eye Floaters  HERE <<<  MASTERMIND TEAM pmc/articles/PMC3693028/ [2]  publications/EUROTIMES/11July- August/vitrectomyforfloaters. pdf (“Arguing against [the use of vitrectomy for treating floaters] was Stanley Chang MD, Edward Harkness Professor of Ophthalmology, Columbia University in New York… ‘I do believe there is disability associated with floaters, but it is relatively rare.'”) [3]  pmc/articles/PMC3996761/ (“The authors of these studies cite impairment in activities of daily living (Mason et al and Sebag et al), contrast sensitivity (Sebag et al) or well-being (Sebag et al) as the primary inclusion criteria for surgical intervention. It is somewhat surprising, however, that hundreds of patients presenting to these centers, over a short time period, would be impaired to the extent that PPV is required”) [4]  pmc/articles/PMC5812683/ [5]  pmc/articles/PMC4575027/ [6]  pmc/articles/PMC6331450/ Subscribe to the newsletter Stay up to date with latest research, goals and plans. Wee need your support. Together, we must unite for clear vision. [email protected] © 2020 All Rights Reserved | VMR RESEARCH FOUNDATION | IRS Registration EIN: 61-1888947 0800 086 1064 Book a Free Consultation 0% Finance Available – Book FREE Consultation. Optegra Leads the Way in Successful New Treatment for Floaters 3 June 2021 By Author: Alex J Shortt Medically reviewed on 17-August-2023 Specialist eye hospital group, Optegra, is leading the way in developing a new method to treat floaters , an eye condition which mainly affects young adults whom to date have been told there is little or no treatment and whose distressing symptoms are frequently dismissed. Symptoms of floaters include dots, shadows or long strands blocking everyday vision , caused by debris floating in the eye’s vitreous solution and which disturb clear sight at all times, often leading to a huge impact on confidence, attitude and outlook of the sufferer. Niall Patton, Consultant Surgeon at the Optegra Manchester Eye Hospital , utilises micro-incision sutureless surgery, called vitrectomy (which involves removing the vitreous fluid behind the lens of the eye) for patients with floaters, with remarkable results. He explains: “Floaters can torment people as these ‘clouds’ in their vision move as their eyes move, so sufferers will constantly have their vision affected. Whilst for many patients, floaters are an everyday part of life and do not bother them, in a significant percentage of individuals, this can lead to substantial detriment to a patient’s quality of life and can even result in depressive symptoms. Sufferers may become withdrawn, or seek psychiatric help. Some individuals can be concerned that they are imagining the symptoms, but they are real. “The long standing view has been that little can be done for these sufferers, but by applying the very latest modern sutureless techniques to this condition, patients can often have their lives transformed with complete alleviation of their symptoms. “We have now removed floaters on a number of patients, with excellent results. Because we largely use suture-free surgery, recovery can be very quick, often within a few days/weeks and the patients notice almost immediately that their floaters are gone. What once was a long, difficult and potentially hazardous operation is becoming as reliable and as routine as cataract surgery , usually taking less than an hour to complete. It is fantastic that we can make a dramatic impact on patients’ quality of life.” Download Information Pack Learn more about how our latest vision correction techniques could improve your vision and change your life. Or  Book Free Consultation . Read our terms & conditions. Read our privacy policy Please note – by providing these details, you agree that we can contact you via these methods Caroline Broadley, 33, from the Wirral, started suffering from floaters when she was seven months pregnant. Describing a big black mark in her eye, constantly whizzing around, Caroline felt that the latter stages of pregnancy and early months with her daughter were spoilt with anxiety and depression. She says: “This floater was not just affecting my vision, it was affecting my sanity. I felt like I was going mad as my doctor and my local hospital just told me I was hormonal, and I should go away and take some vitamin C! “I knew it was so much more than that, but people don’t realise how serious floaters can be. I got to the point I was too anxious to leave the house, and would sit in a darkened room hour after hour – as natural daylight made my vision even worse. I just wanted to sleep to escape it.” After six months, and having been put on anti-depressants, Caroline had the vitrectomy with Mr Patton. She says: “It was amazing. Having become almost agoraphobic for six months, my vision was suddenly crystal clear. I felt as though I got my life back – and could enjoy my daughter, enjoy the sunshine and start living again.” Floaters are present in the vitreous behind the lens, and move with the eye to disrupt vision. The procedure takes up to one hour, and removes this fluid, taking the floaters with it. Results can be seen within a few days, and full impact within a matter of weeks. Martin Baldwin, 56, managing director of a mobility aid company in Lancashire, suffered for three years with floaters, and became desperate to find a solution. He explains: “After previous emergency eye surgery for retinal problems, I was left with floaters and told I had to just put up with them. But it felt like a cloud over my central vision, and I would move my eyes around to shift the cloud, but it would pop straight back into the centre of my eye. It’s as though it was on a piece of elastic and would always ping back into place. “Having always had great vision, it was incredibly frustrating to have this affecting my computer work, my driving, everything I did. I was even contemplating going to America to explore treatment options, when I discovered Niall Patton at Optegra. It was a life changing operation for me – these floaters were driving me mad, I could not escape them, and now thanks to this new procedure I can see as well as I could in my twenties!” For information on this treatment, please contact us online to arrange a free consultation or call 0800 086 1064. Notes to editors: 1) Optegra is committed to the world-wide development of eye sciences and championing the latest innovations in vision correction. Optegra does this by partnering with leading UK universities in the research and development of the next generation of ophthalmic services and technologies. Optegra operates five private eye hospitals: Surrey Eye Hospital (Guildford), Birmingham Eye Hospital (Aston), Yorkshire Eye Hospital (Apperley Bridge and Laser Eye Centre in Leeds City Centre); Solent Eye Hospital (Whiteley) and Optegra Manchester Eye Hospital, (Didsbury). All are supported by over 60 consultant level ophthalmic surgeons who provide a wide range of ophthalmic procedures including: Clarivu (refractive lens exchange), laser vision correction, cataract removal, glaucoma, AMD and cosmetic procedures. 2) Floaters  are small pieces of debris that ‘float’ in the vitreous humour of the eye. They occur behind the lens (the transparent window through which light enters the eye), and in front of the retina (the light sensitive tissue that lines the back of the eye). Vitreous humour is a clear, jelly-like substance that fills the space in the middle of the eyeball. It is 99% water and 1% substances that help to maintain the shape of the vitreous. Floaters cast shadows on the retina, and it is these shadows which people can see. 3) Niall Patton MB ChB, MD, FRCOphth; Consultant Ophthalmologist, Cataract and Vitreoretinal Surgeon, Optegra Manchester Eye Hospital. Niall graduated in Medicine from the University of Manchester in 1996. He completed his ophthalmic surgical training at the Manchester Royal Eye Hospital and the Princess Alexandra Eye Pavilion, Edinburgh. In addition, he has undertaken four years of specialist Vitreoretinal surgical fellowship training at the Lions Eye Institute, Western Australia, Princess Alexandra Eye Pavilion, Edinburgh, Tennant Eye Institute, Glasgow and Moorfield’s Eye Hospital, London. In addition to his clinical expertise, Niall Patton has completed ophthalmic research in a variety of different ophthalmic fields and has been successful in procuring research grants from the Royal College of Surgeons, Edinburgh. His research culminated in the award of a Doctorate from the University of Manchester in 2006. He has spoken at national and international ophthalmology meetings, including the United States, Australia, and Europe. In addition to 49 peer-reviewed publications in ophthalmic journals, he has also co-authored a chapter of a textbook and has served as a reviewer for major international ophthalmology journals, including Investigative Ophthalmology & Visual Science, Ophthalmology, Archives of Ophthalmology & Journal of Applied Physiology. Mr Shortt is a leading ophthalmic surgeon and an expert in the fields of cornea, cataract and refractive surgery. Medically Reviewed Date: 17th August 2023 Download a free infopack Not ready for a consultation? Learn more about our range of treatments, doctors and hospitals Free Virtual Consultation Book your virtual consultation with our top rated eye hospitals Call us free We'll answer any questions you may have about treatment. 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Advanced Search Journal List Int Med Case Rep J PMC11303670 Case Reports of Severe Paediatric Sickle Cell Retinopathy: Disease Manifestations, Progression and Treatments Evdokia sourla. 1 Birmingham and Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK Peck Lin Lip Severe sickle retinopathy is commonly known in adults but not in children, hence any related treatment for sickle retinopathy in children was not well described. We reported 2 paediatric sickle patients (aged 12 and 13) presented with severe sickle retinopathy and described details of their disease progression and treatments over 2–3 years, along with the challenges faced when managing this particular group of young age sickle cell patients. Our case reports also demonstrated the benefits of laser photocoagulation treatment to early sickle proliferative disease, and how complications from advanced severe retinopathy hindered effective treatments. Introduction Sickle cell disease (SCD) is an inherited blood disorder primarily affecting African descendants. 1 The clumping of abnormal sickle-shaped hemoglobin causes vascular occlusion, reduces oxygenation and blood supply to specific body parts, leading to complications such as localized organ necrosis and commonly severe pain experienced by patients during crisis. In the case of the eyes, it may cause asymptomatic painless retinal ischemic change which could lead to retinal neovascularization (known as seafans lesion of proliferative sickle retinopathy) and vitreous hemorrhage and blindness. 1 , 2 The prevalence of proliferative sickle retinopathy is higher in sickle patients with the HbSC genotype than the HbSS genotype. 1 Published literature showed children as young as age 10 have evidence of sickle retinopathy, but severe proliferative retinopathy was reported as low as 5.6%, incidence of vitreous hemorrhage in children was even rarer. 3 Although retinal laser photocoagulation was the preferred treatment for proliferative sickle retinopathy in adult sickle cell patients, the decision for treatment is challenged by the fact that seafans lesions may undergo spontaneous auto-infarction in as high as 60% of cases. 4 , 5 Herein, paediatric patients with sickle retinopathy were often left untreated and deemed unnecessary. 5 Hence information and treatment guidance on paediatric sickle retinopathy remain lacking. We reported 2 paediatric sickle patients presented with severe sickle retinopathy, described details of their disease progression and treatments over 2–3 years, along with the challenges faced when managing this particular group of young age sickle cell patients. Our report follows the Goldberg Classifications for proliferative sickle retinopathy severity ( Table 1 ). 6 Goldberg Proliferative Sickle Retinopathy Staging (PSR) to Categorize Severity of Sickle Retinopathy PSR Stage 1 Peripheral Arteriolar Occlusion PSR Stage 2 Arteriovenous anastomosis PSR Stage 3 Peripheral Seafan neovascularization PSR Stage 4 Vitreous hemorrhage PSR Stage 5 Retinal detachment (Tractional/rhegmatogenous) Cases Presentation Patient 1 is known to have sickle genotype SC; at aged 13 was first seen by optician and referred with queried temporal retina lesions and hazy views in both eyes. First clinic attendance was 8 months later, confirmed good vision of Snellen 6/6 each eye but history of right eye frequent floaters. Initial examination confirmed existing advanced sickle retinopathy in peripheral retinae of both eyes, with main concern of large fibrosed seafan retinal neovascularization already on traction but flat retina ( Figure 1A ). There was no evidence of vitreous hemorrhage in either eye, hence no treatment was offered at this initial stage. Maculae were also normal. ( A ) Patient 1, first seen by optician at aged 13 who queried temporal retina lesions and hazy view in both eyes. First clinic attendance in 2022 August, confirmed good vision of 6/6 each eye but history of Right eye frequent floaters. Visible in these photos are large auto-infarcted seafan fibrotic scars on traction in peripheral supero-temporal retinae (white arrows) in both eyes; other smaller pre-retina fibrosis (black arrows), ghost vessels (red arrow), flat retina and no evidence of vitreous hemorrhage in either eye. No treatment was offered. ( B ) By 2023 June, patient 1 re-presented in eye casualty with Right eye vitreous hemorrhage (red arrows) with flat retina and reduced vision of 6/60. Previous supero-temporal large seafan fibrotic scar was also enveloped with hemorrhage (white arrow). Left eye status unchanged, good vision 6/6. Patient was referred to specialist sickle eye clinic for further management. ( C ) By 2023 September, Right eye vision improved to 6/7 as vitreous hemorrhage gravitated, revealing more auto-infarcted seafan scar on traction in supero-nasal peripheral retina (white arrow), previous blood-enveloped seafan site had part altered blood still masking any underlying reactivation of seafan (double white arrows). Left eye good vision, no vitreous hemorrhage but small “reactivated tips” were noted in previous auto-infarcted seafan scar (red arrow). With the clearing view, patient 1 was advised and received same day localized barrier laser to Right eye, to prevent retinal detachment with future traction bleed. Left eye was to be observed. ( D ) By 2023 December, Patient 1 maintained good vision 6/9 Right, 6/7 Left. Assessment showed no fresh/added vitreous hemorrhage in Right eye, previous barrier laser appeared inadequate (white arrow). Left eye however had worsened features of reactivation of some seafans on traction (red arrows), with evidence of gravitated vitreous hemorrhage (new). Patient was advised and received further laser top-up to Right eye, barrier laser to left eye. ( E ) By 2024 April, patient 1 reported no episodes of new floaters, vision remained good and unchanged. Assessment confirmed no clinical evidence of new added vitreous hemorrhage in either eye, previously treated seafans and traction scars (white arrows) were less aggressive and altered blood resolved. Left eye had a new sprouting seafan (not in photo view). Patient received additional sector laser to Left eye new seafan; scheduled for routine review in 6 months, earlier if experienced episode of unsettling floaters. Over the course of 1 year, patient experienced recurrence vitreous hemorrhage in his right eye from existing traction scars with no retinal detachment and no new active seafan, worse recorded vision over this period had been 6/60 ( Figure 1B and ​ andC). C ). Left eye vitreous hemorrhage happened later, bled from traction as well as from new active seafans ( Figure 1D and ​ andE). E ). Barrier laser photocoagulations were first performed to each tractional seafan fibrotic scars in supero-temporal peripheral, to reduce the risk of retinal detachment in future traction bleeds. At the last clinic review seven months following the initial laser treatment, although old vitreous hemorrhage still to resolve, but patient reported no further re-bleeds in his right eye, vision recovered well and maintained at Snellen 6/7 in each eye. Additional laser treatment was repetitively performed at each clinic visit to any observed new seafans or residual activeness of treated seafans. Patient 2 has sickle genotype SC, at aged 12 and asymptomatic, optician referred with queried right eye retinal detachment and left eye retinal lesions. Initial assessment confirmed excellent Snellen vision at 6/5 despite evidence of advanced fibrosed seafan neovascularization on traction and significant vitreous hemorrhage in his Right eye. His left eye had less severe tractional seafan neovascularization, a salmon patch but no vitreous hemorrhage ( Figure 2A ). Maculae were normal. With some obscured view from vitreous bleed, limited barrier laser treatment was nevertheless performed on the tractional seafans in Right eye. ( A ) Patient 2 first attended eye casualty in 2020 December, aged 12 having referred by optician for queried Right eye retinal detachment, left odd retinal lesion. Patient was asymptomatic. Assessment confirmed excellent vision 6/5 each eye, both eyes had auto-infarcted seafans scars on traction (white arrows). Right eye had vitreous hemorrhage (red arrows), flat retina. Left eye lesion previously queried by optician was a salmon patch in mid-temporal retina (black arrow). Patient was referred to specialist sickle eye clinic for management. ( B ) In 2021 April clinic assessment, vision remains good at 6/5. Both eyes had auto-infarcted seafans on traction as previously seen but also numerous smaller new sprouts of seafans (white arrows, better seen on slit-lamp). Right eye still limited view but clearer as old vitreous hemorrhage gravitated, flat retina, no fresh bleed. Left eye had no vitreous hemorrhage, previous salmon patch in mid-temporal had resolved, seen as a round shadowy mark (black arrow), revealing no underlying seafan. There were other smaller salmon patches in resolution (grey arrows). Patient was advised and received limited barrier laser to Right eye tractional seafan (supero-temporal) to reduce risk of retinal detachment in future traction bleeds, and additional sector laser around new sprouting seafans. Left eye was to be observed. ( C ) Patient 2 reattended 4 months later with fresh bleed in Right eye giving hazy fundus view, localized supero-temporal traction bleed was heavier (red arrow). Both eyes maintained good vision 6/6 as center macula was clear, retinae were also flat. Left eye numerous small seafans on traction, some were larger in size, but no evidence of vitreous hemorrhage. Patient was advised and received sector/barrier laser treatment to Left eye seafans but additional laser treatment to Right eye was not possible at this visit due to poor view. ( D ) Having missed a few appointments, patient was re-examined 10 months later (2022 June), maintained good vision 6/6 and improved Right eye floaters. Fundoscopy of Right eye however remained a struggle although improved; previous supero-temporal tractional seafan scar appeared more extensive and elevated (white arrow), another resolved salmon patch shadow (black arrow) was seen in nasal retina. Left eye had new active seafans, not yet elevated (white arrows) around previous resolved salmon patch; previous treated lesions appeared adequate, no evidence of vitreous hemorrhage yet in this eye. Left eye received further sector laser; Right eye was to await for further vitreous hemorrhage clearing to allow any possible effective laser top-up. ( E ) Patient re-attended clinic in 2023 September, having missed a few appointments, attended eye casualty once in 2023 June with further Right eye bleed. Vision was still good 6/7 Right, 6/5 Left. Right eye status relatively unchanged with some new bleed, old bleed slow to resolve; previous supero-temporal traction was mimicking localized retinal detachment but no subretinal fluid and not advancing. Left eye continued to have few more new seafans and residual active tip of an inadequately lasered seafan (white arrow), other adequately treated seafans resolved, no vitreous hemorrhage. Left eye received further sector laser. Plan for Right eye was to perform heavier barrier laser to supero-temporal traction as soon as view was clearer. Consideration for vitrectomy was discussed if rebleed and tractional detachment worsen. The salmon patch in left eye resolved in 4 months, with more new salmon patches developed in different parts of the retina of the same eye ( Figure 2B ). Over the period of 2.5 years, patient 2 frequently missed scheduled clinic visits (attendance rate = 45%). There were recurrent vitreous hemorrhage in Right eye with worst recorded visual level of counting fingers from his right eye when he eventually re-attended eye casualty. However, patient’s right eye vision did improve to normal at 6/6 at most clinic visits despite dense vitreous hemorrhage which was slow to clear obscuring most of peripheral retina view ( Figure 2C and ​ andD). D ). Additional laser to Right eye was hence not possible due to non-clearing peripheral hemorrhage. However, barrier laser/sector laser were performed more easily to Left eye when new sprouting seafans were found at each clinic visit, before any vitreous hemorrhage happened ( Figure 2D ). Keeping good vision of 6/7 right, 6/5 left, lacking window opportunity for effective laser treatment through the unclearing peripheral vitreous hemorrhage, patient eventually developed a localized peripheral tractional retinal detachment in his right eye, which had enough surrounding barrier laser to be secured and non-progressive at the last clinic visit ( Figure 2E ). Previous published literature confirmed that children with SCD could develop proliferative sickle retinopathy but severe blinding disease is rarely reported in children with sickle cell. 5 , 7 Our case reports confirmed that sickle cell children as young as age 12 could have severe advanced sickle retinopathy. Indeed, the severe retinopathy was already manifested in the first clinic examination, indicating that retinopathy development must have started years before. Visual level is a poor indication to reflect severity of sickle retinopathy. Majority of sickle cell patients (both adults and children) have good vision with no symptoms until retinopathy is too advanced causing symptoms of floaters or visual loss due to vitreous hemorrhage as in our case reports. This is due to sickle retinopathy disease clinical signs and features manifest predominantly in the far peripheral retina, hence often undetected by standard imagings used by optician. With the availability of advanced fundus imagings in recent years, in particular, the non-invasive wide-field fundus photography provides easy and clearer detection of peripheral sickle retinopathy disease. 8 We therefore speculate the prevalence of severe sickle retinopathy in children could be much higher than previously reported. 7 , 9 Decision to treat sickle retinopathy is perplexing for clinicians due to lack of published literature and lack of clinical intervention treatment trials. Most published studies on treatments were based on sickle adult patients but not on sickle paediatric cohort. Although laser photocoagulation was regarded as the preferred choice to treat sickle retinopathy, guidance is unclear on applying the many different types/patterns of laser photocoagulation described. 5 Although seafans could undergo auto-infarction and become inactive, their localized fibrosis often lead to tractional scars; traction bleeds contribute towards recurrent vitreous hemorrhage and the risk of retinal detachment. We described effective laser treatment to paediatric sickle retinopathy as demonstrated in our patients: “sectorial laser” is best applied when active seafan lesion is still small and not yet elevated, sector laser application is a ring of confluent laser around a seafan lesion (similar to delivering an effective “retinopexy” laser treatment for a retinal hole) ( Figure 2E ); “barrier laser” is best applied at the border of an elevated fibrosed seafan scar on traction ( Figure 1E ), to hope to reduce risk of retinal detachment with future traction bleeds. Decision on optimal effective treatment in young patients remain a challenge due to few factors. Delivering effective laser required good cooperation of patients in which case, both our 2 school boys coped very well with the out-patient slit-lamp lasering procedures at their young age of 13. Understandably, attending scheduled clinic visits would be unlikely priorities in their busy schooling activities, when they also benefited more time of good vision than period affected by bad vision as vitreous hemorrhage seem to clear faster in center than in peripheral. In addition, good vision and painless nature of sickle retinopathy often render patients unaware of seriousness of the eye disease, subsequently denying the opportunity of optimal treatment window and eventuality of disease progression. We nevertheless had clinic reviews arranged during school holiday weeks to encourage needed attendances. The other challenging factor is getting children to recognize their visual symptoms. Children are less likely to report to their parents or teachers unless the disease causes symptoms in both eyes; unilateral visual changes is often ignored. Herein, retinopathy screening at an early age could help eliminate late assessment from delayed reporting of symptoms. Published literature had suggested retinopathy screening to start as young as age 9 in children with SCD. 3 , 9 Our case reports would support this concept as our 2 patients had already presented with advanced tractional scars at age 12 and 13, hence speculating proliferative sickle retinopathy development would indeed have started at a much earlier age. In summary, children as young as age 12 can progress to develop advance sickle retinopathy if untreated. As in the adults cohort, severe sickle retinopathy in children is preventable if there is an early window of recognition and optimal treatment opportunity. Our case reports detailed management and laser treatment for paediatric sickle retinopathy which is very much lacking in available literature. Optimal management plan for this young age group remains a challenge, taking into consideration of schooling timing and cooperation of individual child for laser treatment. Our case-reports nevertheless provide some evidence of the need to start sickle retinopathy screening programme at earlier school age, perhaps inco-operating into the existing visual screening programme for childhood amblyopia/childhood squints (at around school age of 5 years old). With the easily available, non-invasive advanced investigational tool such as ultra-widefield fundus photography, sickle retinopathy screening programme at younger age could indeed be very feasible and effective. This prospect also leads us to the much needed research and studies that can better understand sickle retinopathy treatment choices and effectiveness in both adults and paediatrics. Ethics Approval and Consents for Publication This ethical approval for this retrospective case series report was granted from the Institutional Review Board (Sandwell and West Birmingham Research and Development review board) in accordance with the “Good Clinical Practice” regulations in the United Kingdom and adhered to the tenets of the Declaration of Helsinki. Informed written parental consents were obtained from all paediatric patients for investigations/treatment procedures as part of the routine and standard clinical care in our real-world clinical practice. Relevant fundus photography and angiographic images were anonymized with patients’ consents/approvals to publish. We also obtained from parents of our two paediatric patients on specific consents/approvals for this article and relevant fundus photography images to be used for publication. The authors received no funding for this work, and declared no conflicts of interest related to this work. 251 IMAGES JCM Yag Laser Vitreolysis for Vitreous Floaters Eye Floaters & Black Spots in Vision Eye Floaters (Vitreous Floaters) Posterior Vitreous Floaters vitrectomy-floaters-diagram-1 COMMENTS To Treat—or Not to Treat—Vitreous Floaters Troublesome Vitreous Floaters. Vitreous floaters may occur following a retinal tear, retinopexy, scleral buckling, or vitreous hemorrhage associated with a tear, said Gaurav K. Shah, MD, with The Retina Institute in St. Louis, Mis­souri. But most patients who experi­ence vitreous floaters fall into 2 groups: those with a posterior vitreous ... A Clearer Future For Eye Floaters Eye floaters are specks or strands that can appear in the field of vision and move around when the eyes move. These floaters are caused by the shrinking of the vitreous, a gel-like substance that ... Safer eye floater treatments come with a burst of nanobubbles Now, with the development of a safer and less invasive nanoparticle-based therapy, people with floaters may finally get their vision and quality of life back. Clumps of collagen float through the vitreous of a patient's eye, causing the appearance of floaters. Credit: Inder Paul Singh. May 01, 2022 | 10 min read. Stephanie DeMarco, PhD. Patient-reported outcomes in patients with vitreous floaters: A Seeking treatment for bothersome vitreous floaters is patient driven. 69 Therefore, PROMs are essential to measure the impact on QoL in clinical management and research of floaters. In this systematic literature review, we set out to explore the different PROMs used for patients with floaters, and to give an overview of their content and ... Management of vitreous floaters: an international survey the ... Vitreous floaters are caused by degenerative or pathologic alterations in the vitreous ultrastructure and perceived as shadows or fly-like obscurations to vision [1,2,3].While patients with ... Managing Vitreous Floaters Vitreous floaters are a common symptom, estimated in one survey to affect two out of every three individuals, with one in three reporting visual impairment. 1 When vitreous floaters measurably degrade vision, the diagnosis of vision degrading myodesopsia (VDM) can be established based on objective, quantitative criteria. 2 The psychological features of depression and perceived stress ... Study proves effectiveness of non-surgical, dietary treatment for ... References. Ankamah E, Green-Gomez M, Roche W, Ng E, Welge-Lüßen U, Kaercher Th, Barbur J, Nolan JM. Impact of symptomatic vitreous degeneration on photopic and mesopic contrast thresholds, Clinical and Experimental Optometry. 2021, DOI: 10.1080/08164622.2021.1981116 Mamou J, Wa CA, Yee KMP, et al.Ultrasound-based quantification of vitreous floaters correlates with contrast sensitivity and ... To Treat or Not to Treat: Management Options for Symptomatic Vitreous Vitreous opacities, or floaters (Figs. 1 and 2), are a common finding that may arise due to a range of different conditions, some of which may be indicative of more significant ophthalmic pathology.The most common cause, however, is the formation of a posterior vitreous detachment (PVD). This occurs when the vitreous collapses inwards, withdrawing from the retinal interface. 1 Depending on the ... Patient-reported outcomes in patients with vitreous floaters: A Seeking treatment for bothersome vitreous floaters is patient driven. To measure the impact of floaters and treatment on an individual's quality of life, patient-reported outcome measurements (PROMs) are essential. We review all studies using a PROM for patients with floaters. We evaluated content coverage against quality-of-life domains previously identified in other ophthalmic disorders ... Acute symptomatic vitreous floaters assessed with ultra-wide field Eyes with vitreous floaters were more myopic and had lower IOP than the opposite symptom free eyes. ... IBM Corp, New York, NY). A P-value less than 0.05 was considered statistically significant ... Vitreous Floaters With New Intravitreal Drugs Administered by Retina Vitreous Floaters With New Intravitreal Drugs Administered by Retina Specialists. JAMA Ophthalmol. 2023;141(11) ... Network Audio JAMA Network Video JAMA Network Conferences JAMA Summit JAMA Surgery Guide to Statistics and Methods Medical News Mpox (Monkeypox) Research Ethics Topics and Collections Visual Abstracts War and Health Women's Health ... The effectiveness of laser vitreolysis for vitreous floaters in To determine the effectiveness of laser vitreolysis in terms of contrast sensitivity function (CSF) and vision-related quality of life (VRQol) for symptomatic floaters due to posterior vitreous detachment (PVD). Materials: This is an interventional study that involved 57 eyes of 45 patients with symptomatic floaters for more than 3 months. "Eye care should be attentive to finding ways to try and reduce ... Designed to be taken daily, VitroCap®N uses ingredients including vitamin C, grapeseed extract and zinc, and has been found to decrease the prevalence of floaters in 70% of patients across a double-blind, placebo-controlled study. The six-month Floater Invention Study (FLIES) study demonstrated significant improvements in subjective visual ... Design of a Functional Eye Dressing for Treatment of the Vitreous Floater The study used color photo imaging to evaluate YAG laser vitreolysis for symptomatic vitreous floaters. A total of 32 patients were participating in the survey based on the visual function questionnaire. After 6 months of follow-ups, color imaging showed improvement in vitreous opacity over time in 93.7% of study eyes. Management of vitreous floaters: an international survey the European Vitreous floaters are caused by degenerative or pathologic alterations in the vitreous ultrastructure and perceived as shadows or fly-like obscurations to vision [1-3]. While patients with floaters often improve over time because of peripheral displacement of vitreous opacities or cognitive adaption [ 4 ], there remain a subgroup with ... Vitreous Floaters: What Can Be Done? The floaters or vitreous opacities should be correlated with the patient's symptoms on a thorough fundus examination. Symptomatic patients who are candidates for treatment report impairment in vision with a specific activity, for example with reading, watching television or driving, and this complaint should be documented in the medical record. Treating Floaters: The Pros, Cons and Techniques 1. Sebag J. Vitreous and vision degrading myodesopsia. Prog Retinal Eye Res 2020;100847. 2. Mamou J, Wa CA, Yee KM, et al. Ultrasound-based quantification of vitreous floaters correlates with contrast sensitivity and quality of life. Invest Ophthalmol Vis Sci 2015;56:1611-1617. 3. How to Handle Visually Disruptive Floaters S y mptomatic vitreous opacities (SVO) or "floaters" are a common presenting symptom to ophthalmologists and can represent a significant challenge with respect to management. In many cases, patients will neuroadapt to the opacity and won't need an intervention. In some instances, however, due to factors related to a patient's personality or daily activities, the floaters can't simply ... New study proves effectiveness of a non-surgical, dietary solution for A new study published in the Translational Vision Science and Technology (TVST), an ARVO journal, has revealed that targeted nutrition can significantly reduce 'eye floaters' as well as their associated discomforts. This study reports the outcomes of the Floater Intervention Study (FLIES), which was led by the Nutrition Research Centre ... Daring to Treat Floaters Published 9 April 2020. Daring to Treat Floaters. More experts are taking a second look at controversial approaches to resolving these visual disturbances. Call it a case of mounting evidence eating away at popular wisdom. The use of YAG laser vitreolysis and vitrectomy to treat vitreous floaters has always seemed nearly off-limits to most ... Eye Floaters Prevalence Study This new prevalence study will finally provide vital data that has long been lacking on the societal impact of vitreous floaters. Even for many other conditions that are comparatively understudied, such as tinnitus [4], fibromyalgia [5], or myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) [6], there at least exist credible estimates ... Vitreous Opacity Vitrectomy (VOV): Safest Possible Removal of "Floaters" The safest possible removal of extensive SVO as described herein was attained by an operation specifically designed for DVS treatment (vitreous opacity vitrectomy, VOV), rather than as only a means of achieving subsequent retinal surgery in the same procedure, as is usually the case. We retrospectively reviewed the outcomes of 100 consecutive ... Optegra Leads the Way in Successful New Treatment for Floaters Medically reviewed on 17-August-2023. Specialist eye hospital group, Optegra, is leading the way in developing a new method to treat floaters, an eye condition which mainly affects young adults whom to date have been told there is little or no treatment and whose distressing symptoms are frequently dismissed.. Symptoms of floaters include dots, shadows or long strands blocking everyday vision ... Case Reports of Severe Paediatric Sickle Cell Retinopathy: Disease Left eye however had worsened features of reactivation of some seafans on traction (red arrows), with evidence of gravitated vitreous hemorrhage (new). Patient was advised and received further laser top-up to Right eye, barrier laser to left eye. (E) By 2024 April, patient 1 reported no episodes of new floaters, vision remained good and ... assignment essay homework paper phd report resume review speech thesis