The term floaters refers to the existence of dark spots in vision, which can be very annoying. Their appearance is caused by vitreous fiquidation and their treatment is controversial. Surgical interventions are available but are only rarely offered to select patients with symptomatic primary floaters. This is because many vitreoretinal surgeons consider floaterectomy unnecessary cosmetic surgery with all its associated risks.
These risks include retinal breaks, vitreous incarceration and retinal detachment, not to mention intraoperative choroidal haemorrhage and postoperative endophthalmitis. Given the elective nature of the procedure and the scarcity of objective parameters to support the indication for surgery, many vitreoretinal specialists are understandably hesitant to perform a floaterectomy.
However, there are those for whom the size and the position of the floater is a major hindrance and for them a therapeutic solution is needed.
A large study published in the American Journal of Ophthalmology1 has shown that patients are willing to trade off an average of about one out of every 10 years of their remaining life to get rid of the symptoms associated with floaters. Furthermore, the authors claim that patients are willing to take, on average, an 11% risk of death and a 7% risk of blindness to get rid of symptoms related to floaters. Whether these results reflect a realistic truth is debatable because a very important, uncountable factor which influences the desire for surgery is the patient’s personality. Some patients are clearly willing to accept the risk of an invasive procedure. Indeed, in contrast with vitrectomy for retinal detachment or macular hole, the indication for floaterectomy is primarily driven by patient demand rather than by a surgeon’s recommendation.
Patients may have a very optimistic impression of the procedure prior to the visit to the ophthalmologist but ophthalmologists tend to be more cautious. Most patients with primary floaters –those not due to ocular pathology such as uveitis- have objectively “perfect” vision. The patients’ distress does not correlate with visual acuity, since the standard clinical test of visual function does not detect the visual disability associated with vitreous floaters. However, data have been presented which show that light scattering is significantly higher in eyes with floaters.
Despite the evidence, the question for many ophthalmologists is , “Are floaters a disease or simply a nuisance”? That depends on whom you ask.
The traditional management of vitreous floaters usually includes only education and reassurance, but invasive treatments exist, including Nd:YAG laser vitreolysis, cataract surgery combined with deep anterior vitrectomy and pars plana vitrectomy. Among those, surgeons who do treat vitreous floaters most opt for pars plana vitrectomy. This procedure, primarily utilized for other indications, is routine and sophisticated, with a well-known risk profile and high rates of success. Patient satisfaction is high2.
Nd:YAG laser vitreolysis currently has a limited role. It has not yet been widely accepted , as published data are limited to a small series of highly motivated patients. In the most comprehensive study to date, postoperative patient questionnaires indicated that in no eye was laser treatment 100% successful in eliminating symptoms. Moderate improvement was noted in about one third of cases, but 7.7% experienced a worsening of symptoms3.
Vitreolytic agents might offer an alternative, although it is too early to say. More research needs to be done.
1. Wagle AM, Lim WY, Yap TP, Neelam K, Au Eong KG. Utility values associated with vitreous floaters. Am J Ophthalmol.2011 Jul;152(1):60-65.
2. Schiff WM, Ghang S, Mandava N, Barile GR. Pars plana vitrectomy for persistent, visually significant vitreous opacities. Retina. 2000;20(6):591-6.
3. Delaney YM, Oyinloye A, Benhamin L. Nd:YAG vitreolysis and pars plana vitrectomy: surgical treatment for vitreous floaters. Eye 2002;16:21-6.