winter 2022 distributed quarterly to 2800 optometric physicians
From the EDITOR For most of us, floaters are a fact of life. If we have them, we simply learn to live with the symptoms—trusting that neuro adaption will lessen the impact. This may carry over into the way we counsel our patients. But for some people, floaters can be very symptomatic and disruptive. In this issue, my colleague Salisa Williams discusses floaters and YAG laser treatment that is an option for properly screened and counseled patients.
Ami Halvorson, OD
PCLI Portland, OR
YAGLaser
Floater
Treatment
By Salisa Williams, OD | PCLI Vancouver, WA
Drops are not usually needed, and patients return for a dilated exam in one week. If additional treatments are required, they are scheduled about a month apart. Over the course of one to three treatments, floaters are usually removed or reduced to a size and number that no longer impedes vision.
EFFECTIVENESS OF TREATMENT
One study found 60% of patients had improvement after just one session. Another study found improvement in 93.7% of patients:
- 56.2% had complete improvement
- 37.5% received partial improvement
- 6.3% had no improvement with no adverse events
Until now, most studies have evaluated the efficacy of YAG laser floater treatment with floaters caused by PVD. However, a study published by Lin et. al (2021) found significant improvement in both the PVD group (72.73%) and non-PVD group (68.99%).2
COMPLICATIONS
While uncommon, complications of YAG laser floater treatment may include:
- Elevated IOP
- Damage to the lens causing cataract development or IOL pitting
- Retinal tear, holes, and detachment
- Vitreous hemorrhage, CME, and localized retinal edema
ALTERNATIVES
Observation is the safest alternative since many patients will cognitively adapt over time. Or their floaters will become peripherally displaced. Pars plana vitrectomy (PPV) or floater-only vitrectomy (FOV) are other options.
PPV is curative but invasive with more risk of adverse events. A retrospective floaters study done by the European VitreoRetinal Society found a 92% satisfaction rate with PPV but at a cost:
- Retinal breaks were reported in 5%
- Retinal detachments in 2.4% at a medium of 3 months
- Cataracts developed in 48.6%
Floaters are a common condition that impacts three-quarters of the population. As providers, we may see them as a nuisance to which patients must adapt. But for some, floaters significantly degrade their quality of vision and quality of life. Thankfully, in-office YAG laser floater treatment (also known as YAG laser vitreolysis) is a solution for appropriately selected patients.
IMPACT ON LIFE
I suffer from floaters and can empathize with those who have them. Symptomatic vitreous floaters are associated with psychological distress, including increased anxiety, stress, and depression. Interestingly, the level of distress may be disproportionate to the severity of floaters.
A quality-of-life study published by Wagle et. al. (2011) discovered that floaters can have comparable impact on one’s life as mild angina, mild stroke, colon cancer, and asymptomatic HIV infection.1 The study also found people are willing to take on some risk of death and blindness to get rid of symptoms relating to floaters.
Floaters can have a much greater impact on quality of life than one would expect. As we evaluate patients’ eyes, advising and assuring them that their floaters are free of disease, they may be frustrated if we don’t address how this condition impacts their lives.
WHAT ARE FLOATERS?
As the vitreous liquefies with age, hyaluronan and collagen molecules begin to separate. This structural change allows for the aggregation of collagen into bundles of fibers that we know as floaters. They drift about in the vitreous and cast shadows on the retina.
CAUSES OF FLOATERS
The most common cause of sudden onset floaters in older patients is PVD. As we know, a PVD rarely occurs before age 45. Other types of floaters are seen in younger, myopic patients. Retinal magnification of the images associated with myopia can make these floaters seem more pronounced.
For people who have undergone cataract surgery, floaters may be an unexpected result of improved vision. While they will see better, more light entering the eye and improved contrast may make previously masked floaters noticeable. Researchers have discovered that vitreous opacities can degrade contrast sensitivity by as much as 91%. This may be an important consideration for patients with presbyopia-correcting IOLs, as some lens designs also reduce contrast sensitivity.
HOW TREATMENT WORKS
The YAG laser fractionates and vaporizes floaters. Collagen fibers are converted to a gas that is absorbed into the eye. Although laser floater treatment has a 30-year history, it is not widely performed. But with skilled and experienced surgeons, treatment is relatively safe with minimal complications.
During treatment, a contact vitreous laser lens is used to focus the laser on the floaters. Higher power settings and more laser pulses are used than for YAG capsulotomy. A single treatment takes about 20 minutes.
YAG laser floater treatment at PCLI is performed exclusively by David Gano, MD in our Vancouver and Chehalis, WA facilities. Dave uses the Ultra Q Reflex YAG laser by Ellex. This instrument features coaxial illumination, which allows the operator to view the floater and retina simultaneously. The laser also has a unique cooling system that enables surgeons to fire hundreds or thousands of shots in a single sitting without overheating.
Questions
If you have questions, feel free to contact our optometric physicians. We’re always happy to help.
Watch Laser Floater Treatment
by Dr. Paul Singh
Weiss Ring Floater
© Paul M. Barney, OD
Ultra Q Reflex YAG Laser by Ellex
CANDIDATES FOR TREATMENT
In our experience, good candidates for YAG laser floater treatment:
- Are symptomatic for at least six months with no improvement
- Have significant impairment with a specific activity
- Dilate well (6 mm or more)
- Have a few large, well-defined, chronic floaters that can be seen in a dilated exam
- Have floaters that are not within 4 mm of the retina or the lens (if phakic)
- Do not have inflammation (uveitis or vitritis)
- Do not have vitreous hemorrhage and corneal or lens opacities that would impair the surgeon’s view
A PVD with a Weiss ring is the most successfully treated floater. One Weiss ring floater in a patient with realistic expectations is better than hundreds of diffuse floaters in patients who have anxiety about their floaters. Patients should also be counseled that there is no guarantee all floaters will be gone after treatment.
Pseudophakes are better candidates than phakic patients due to the relative risk of cataract development. Pseudophakic patients with multifocal IOLs may be challenging to treat due to multiple focal points splitting the YAG laser beam.
Poor candidates have a new onset of many tiny, mobile, nebulous peripheral floaters with limited dilation (less than 6 mm).
CONCLUSION
YAG laser floater treatment is a simple, painless procedure that can remove or reduce floaters to size and number that no longer impede vision. It can have a significant impact on people’s quality of vision and quality of life. Proper screening and good counseling set patients up for success.
References
1. Wagle A, Lim W, Yap T, Neelam K, Au Eong K. ‘Utility Values Associated With Vitreous Floaters.’ American Journal of Ophthalmology. 2011 Jul;152(1):60-65.
2. Lin T, Li T, Zhang X, Hui Y, Moutari S, Pazo EE, Dai G, Shen L. ‘The Efficacy and Safety of YAG Laser Vitreolysis for Symptomatic Vitreous Floaters of Complete PVD or Non-PVD.’ Ophthalmology and Therapy 2021; https://doi.org/10.1007/s40123-021-00422-6
ABOUT THE AUTHOR
Salisa Williams, OD
PCLI Vancouver, WA
Outgoing, warm and lively, Salisa Williams is engaging and a natural at communicating and connecting with others. Born in Fort Smith, Arkansas, Salisa grew up on her family’s cattle ranch in Eastern Oklahoma. She enjoys playing keyboard and synthesizer, traveling, attending musical and theatrical productions, fitness and going on medical mission trips. Salisa lives in Portland, Oregon.
Next
Share
Floater Treatment Guidelines
Our comanagement guidelines will help determine if patients are candidates—which may be especially important for those traveling from a distance. This service is available exclusively at our Vancouver and Chehalis, WA facilities.
Download or Request