EnVision Summit 2023: Surgically addressing floaters: Choose patients carefully

Floaters are a huge and common annoyance for patients that can occur in a number of scenarios (Image courtesy stock.adobe.com)

Floaters are a huge and common annoyance for patients that can occur in a number of scenarios, such as posterior vitreous detachments, retinal tears/detachment, asteroid hyalosis, trauma, hemorrhage (diabetes, hypertension, macroaneurysms), uveitis (inflammatory, infectious, idiopathic), and lymphoma/malignancy according to Laxmi Devisetty, MD, who shared her pearls for dealing with floaters at the Envision Summit in Puerto Rico. She is in private practice in Savannah, GA.

Devisetty cited a prospective observational study¹ that reported how common subclinical floaters are, even in nonsymptomatic subjects. The number of perceived floaters also was correlated only weakly with floater-related discomfort. Visual disturbances resulting from floaters can affect quality of life despite the absence of a correlation with visual acuity.

Treatments for floaters

In addition to observation, laser-assisted vitreolysis and pars plana vitrectomy (PPV) are options, all of which deserve careful consideration, according to Devisetty.

If opting to observe the patient, the considerations are the time limit of the observation, the explanation to the patient, and when to make the decision to actively treat the floaters.

If laser-assisted vitreolysis is chosen, 1 study reported that 35.8% of patients have moderate improvement and only 2.5% have significant improvement.²

Those investigators also found that compared to sham treatment, vitreolysis resulted in improvement, but the visual acuity remained the same. No change was seen in the functional measures between the control and treated subjects despite change in echodensity on ultrasound.

However, the procedure is associated with risks such as retinal detachment, which occurred in 2% of patients and glaucoma and cataract formation with posterior capsular disruption.

If PPV is the treatment of choice, Devisetty advised the use of small-gauge instrumentation. While PPV is more effective than YAG vitreolysis,³ the associated risks include retinal detachment in 2% to 10%, cataract progression in 25% to 60%, epiretinal membrane formation and cystoid macular edema in less than 5% each, and infection or loss of vision in less than 1%.

The overriding question for these patients that remains is whether or not to treat the floaters.

“Choose your patients carefully and document their symptoms,” Devisetty explained. “Have a thorough discussion regarding the risks and benefits with the patient before actively treating floaters.

Devisetty advised waiting 3 to 6 months for patients so they are confident that treatment is the right choice for them. In her hands, small-gauge vitrectomy is her treatment of choice because it has made it possible to decrease the risks associated with vitrectomies.

“Although small-gauge vitrectomy is not benign, it is my first and only choice for treating floaters,” she concluded.

References

1. Tassignon M-J, Dhubhghaill SN, Hidalgo IR, Rozema JJ. Subjective grading of subclinical vitreous floaters. Asia Pac J Ophthalmol. 2016;5(2):104-109. doi: 10.1097/APO.0000000000000189.

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

3. Broadhead GK, Hong T, Chang AA. To treat or not treat: management options for symptomatic vitreous floater. Asia Pac J Ophthalmol. 2020; 9(2): 96-103.