Degradation of Contrast Sensitivity Function Following Posterior Vitreous Detachment

The association of symptomatic vitreous floaters with depression and anxiety

PURPOSE

To evaluate the levels of anxiety and depression in patients with symptomatic vitreous floaters and to determine the possible correlations of psychological implications with the symptoms duration and possible improvement, the degree of posterior vitreous detachment, and the discomfort severity.

METHODS

Ninety patients complaining for floaters and fifty-seven age- and gender-matched healthy-control subjects were recruited. Every participant underwent a complete ophthalmological examination, including funduscopy and optical coherence tomography scans, while clinical and demographic data were also gathered. The Patient Health Questionnaire-9 (PHQ-9), the Zung Depression Inventory-Self-Rating Depression Scale (Zung SDS), and the Hospital Anxiety and Depression Scale (HADS) were completed by everyone.

RESULTS

Between the studied groups, no significant differences were detected regarding the clinical and demographic data (p > 0.05). The patients with floaters had significantly higher scores of PHQ-9, Zung SDS, HADS Anxiety, and HADS Depression (p < 0.001). After adjustment for several confounders, PHQ-9 (p = 0.041), Zung SDS (p = 0.003), and HADS Anxiety (p = 0.036) values remained significantly impaired. Among the patients, PHQ-9 and Zung SDS scores were significantly elevated in the patients with floaters duration less than 4 weeks (p < 0.05). Finally, anxiety and depression were significantly correlated with the symptoms duration and intensity, with the floater-associated discomfort, and with the stage of posterior vitreous detachment.

CONCLUSION

Vitreous floaters have a negative impact on patients' psychological status, by the terms of enhanced depressive and anxiety levels. To the best of our knowledge, our study is the first in the literature to elaborate the aforementioned association, by assessing three different questionnaires simultaneously.

Degradation of Photopic and Mesopic Contrast Sensitivity Function in High Myopes With Partial Posterior Vitreous Detachment

Purpose

The purpose of this study was to evaluate the effects of posterior vitreous detachment (PVD) on visual quality in patients with high myopia, as well as investigate the associated factors of photopic and mesopic contrast sensitivity function (CSF) in high myopia.

Methods

Visual quality was comprehensively assessed in patients with high myopia. Visual acuity, contrast sensitivity (CS) at four spatial frequencies (3, 6, 12, and 18 cycles per degree [c.p.d.]) under photopic and mesopic conditions, as well as the modulation transfer function cutoff value (MTFcutoff), the objective scatter index (OSI), the Strehl ratio (SR), and internal aberrations, were measured in this cross-sectional study.

Results

This study included 94 eyes from 47 subjects with bilateral high myopia, including 23 eyes with complete PVD (cPVD), 21 eyes with partial PVD (pPVD), and 50 eyes without PVD (nPVD). There was no significant difference in visual quality between the cPVD group and the nPVD group. Whereas in eyes with pPVD, there was a degradation of overall photopic CSF (versus nPVD, P = 0.048), photopic CS at 3 c.p.d. (versus cPVD, P = 0.009 and versus nPVD, P = 0.032), photopic CS at 18 c.p.d. (versus nPVD, P = 0.033), overall mesopic CSF (versus nPVD, P = 0.033), and secondary astigmatism (versus cPVD, P = 0.044). Under photopic conditions, the factors affecting CSF were pPVD and SR, whereas the factors affecting mesopic CSF were pPVD, OSI, and ganglion cell-inner plexiform layer thickness.

Conclusions

The pPVD impaired visual quality in patients with high myopia compared to nPVD or cPVD, and pPVD could be a factor explaining CSF at both photopic and mesopic illumination.

Translational Relevance

Clinicians need to closely monitor patients with high myopia with pPVD due to the potential decline in visual quality and the development of vitreoretinal disorders.

Impact of posterior vitreous detachment on visual acuity after the implantation of a diffractive multifocal intraocular lens

PURPOSE

To investigate the effect of posterior vitreous detachment (PVD) on visual acuity (VA) after implantation of a diffractive multifocal intraocular lens (mIOL).

SETTING

Eye Clinic, Okayama, Japan.

DESIGN

Retrospective case series.

METHODS

This study evaluated 475 eyes of 475 patients who underwent cataract surgery with a TECNIS Multifocal ZLB00 lens implant between November 2017 and October 2019. Patient eyes were classified into the complete PVD group (PVD group) or the control group with no PVD/partial PVD (non-PVD group) and divided into 3 age categories: 65 to 69, 70 to 74, and 75 to 79 years. The postoperative VA of the PVD and non-PVD groups was compared between and within groups by age.

RESULTS

Distance-corrected near VA (DCNVA) was significantly worse in the PVD group than in the non-PVD group in all age categories ( P ≤ .029). In the PVD group, both corrected distance VA (CDVA) and DCNVA were significantly worse in the 75 to 79 years age group than in the 65 to 69 and 70 to 74 years age groups ( P ≤ .034). CDVA and DCNVA in the non-PVD group did not differ significantly between age categories.

CONCLUSIONS

The results of this study suggest that complete PVD worsens near VA in eyes with a diffractive mIOL. Furthermore, eyes with complete PVD may show an age-related decline in both CDVA and DCNVA. In particular, eyes ≥75 years of age with complete PVD have a poor visual prognosis and should be given careful consideration when deciding whether to implant a diffractive mIOL.

Quantitative Contrast Sensitivity Function and the Effect of Aging in Healthy Adult Eyes: A Normative Database

BACKGROUND AND OBJECTIVE

We sought to establish normative quantitative contrast sensitivity function (qCSF) values in healthy adult eyes and investigate the effect of age on qCSF.

PATIENTS AND METHODS

Healthy eyes underwent qCSF testing (adaptive sensory technology) and Snellen's visual acuity (VA). Descriptive statistics and mixed-effects multivariable linear regressions were evaluated.

RESULTS

A total of 334 eyes (290 patients) with median age 61 years (range 21 to 88) had qCSF values as follows: area under the log contrast sensitivity function curve: 1.18; contrast acuity: 1.32; contrast sensitivity (CS) at 1 cycle per degree (cpd): 1.32; CS at 1.5 cpd: 1.37; CS at 3 cpd: 1.38; CS at 6 cpd: 1.20; CS at 12 cpd: 0.69; CS at 18 cpd: 0.22. Linear reductions in qCSF values per decade of age ranged from -0.02 to -0.07 vs 0.01 for visual acuity (VA). Age had a greater effect on the majority of qCSF values than VA (beta standardized regression coefficient ranged from -0.309 to -0.141 for qCSF values vs 0.177 for VA).

CONCLUSIONS

We herein establish a normative database for qCSF and quantify the effect of age on qCSF values, adding evidence towards the validation of qCSF as a clinical endpoint. [Ophthalmic Surg Lasers Imaging Retina 2024;55:212-219.].

Practical applications of vitreous imaging for the treatment of vitreous opacities with YAG vitreolysis

PURPOSE

To demonstrate the methodology and efficacy of using scanning laser ophthalmoscopy (SLO) and dynamic optical coherence tomography (OCT) to identify and treat symptomatic vitreous floaters using yttrium-aluminum garnet laser vitreolysis (YLV).

METHODS

This is a case series highlighted from a cross sectional retrospective study conducted at the Vitreous Retina Macula Specialists of Toronto. Forty eyes from thirty-five patients were treated with YLV between November 2018 and December 2020 for symptomatic floaters and imaged with SLO and dynamic OCT. Patients were re-treated with YLV if they reported ongoing significant vision symptoms during follow-up which correlated to visible opacities on exam and or imaging. Three cases will be highlighted to present the practical applications of SLO and dynamic OCT imaging for YLV treatment.

RESULTS

Forty treated eyes were enrolled in this study, with twenty-six eyes (65%) requiring at least one repeat YLV treatment following the first treatment due to ongoing symptomatic floaters. Following the first YLV, there was a significant improvement in overall mean best corrected visual acuity compared to before treatment (0.11 ± 0.20 LogMAR units vs. 0.14 ± 0.20 LogMAR units, p = 0.02 (paired t test)). Case 1 demonstrates a dense, solitary vitreous opacity that has been localized with dynamic OCT imaging to track its movements and retinal shadowing with the patient's eye movements. Case 2 shows the utility of adjusting the fixation target to monitor the movement of vitreous opacities in real-time. Case 3 exhibits an association between decreased symptom burden and vitreous opacity density after YLV.

CONCLUSION

Image-guided YLV facilitates the localization and confirmation of vitreous opacities. SLO and dynamic OCT of the vitreous can provide a real-time evaluation of floater size, movement, and morphology, to help clinicians target treatment and monitoring of symptomatic floaters.

THE WAY PATIENTS SEE FLOATERS: Widefield Dynamic Scanning Laser Ophthalmoscopy Imaging of Vitreous Abnormalities

PURPOSE

To investigate the use of dynamic widefield scanning laser ophthalmoscopy (SLO) and B-scan ultrasonography in imaging vitreous abnormalities in patients with complaints of floaters.

METHODS

Twenty-one patients underwent both dynamic SLO and B-scan ultrasonography to image their vitreous abnormalities. After reviewing these videos, patients graded each imaging technique on a scale of 1 to 10, based on how closely it represented their visual perception of floaters.

RESULTS

The mean age of the patients (12 women and nine men) was 47.7 ± 18.5 years. The patients graded a median score of nine for SLO imaging (mean = 8.43) compared with a median score of 5 (mean = 4.95) for ultrasound ( P = 0.001). Widefield SLO imaging demonstrated three-dimensional interconnectivity within the condensations of the formed vitreous that exhibited translational and rotational movements with eye saccades.

CONCLUSION

Floaters are a common complaint, but it is difficult to know whether imaging findings of the vitreous correlate to what patients perceive. Widefield SLO seems to image vitreous abnormalities related to how patients perceive their own floaters better than B-scan ultrasonography. Despite the term "floaters", the vitreous abnormalities in the videos seemed to be manifestations of a complex three-dimensional degeneration of the vitreous framework.

RECURRENT FLOATERS AFTER LIMITED VITRECTOMY FOR VISION DEGRADING MYODESOPSIA

PURPOSE

Limited vitrectomy improves vision degrading myodesopsia, but the incidence of recurrent floaters postoperatively is not known. We studied patients with recurrent central floaters using ultrasonography and contrast sensitivity (CS) testing to characterize this subgroup and identify the clinical profile of patients at risk of recurrent floaters.

METHODS

A total of 286 eyes (203 patients, 60.6 ± 12.9 years) undergoing limited vitrectomy for vision degrading myodesopsia were studied retrospectively. Sutureless 25G vitrectomy was performed without intentional surgical posterior vitreous detachment (PVD) induction. CS (Freiburg Acuity Contrast test: Weber index, %W) and vitreous echodensity (quantitative ultrasonography) were assessed prospectively.

RESULTS

No eyes (0/179) with preoperative PVD experienced new floaters. Recurrent central floaters occurred in 14/99 eyes (14.1%) without complete preoperative PVD (mean follow-up = 39 months vs. 31 months in 85 eyes without recurrent floaters). Ultrasonography identified new-onset PVD in all 14 (100%) recurrent cases. Young (younger than 52 years; 71.4%), myopic (≥-3D; 85.7%), phakic (100%) men (92.9%) predominated. Reoperation was elected by 11 patients, who had partial PVD preoperatively in 5/11 (45.5%). At study entry, CS was degraded (3.55 ± 1.79 %W) but improved postoperatively by 45.6% (1.93 ± 0.86 %W, P = 0.033), while vitreous echodensity reduced by 86.6% ( P = 0.016). New-onset PVD postoperatively degraded CS anew, by 49.4% (3.28 ± 0.96 %W; P = 0.009) in patients electing reoperation. Repeat vitrectomy normalized CS to 2.00 ± 0.74%W ( P = 0.018).

CONCLUSION

Recurrent floaters after limited vitrectomy for vision degrading myodesopsia are caused by new-onset PVD, with younger age, male sex, myopia, and phakic status as risk factors. Inducing surgical PVD at the primary operation should be considered in these select patients to mitigate recurrent floaters.

New Terminology and Methodology for the Assessment of the Vitreous, Its Floaters and Opacities, and Their Effect on Vision: Standardized and Kinetic Anatomical and Functional Testing of Vitreous Floaters and Opacities (SK VFO Test)

OBJECTIVE

To introduce VFO and SK VFO Test: new, more representative terminology for symptoms of vitreous floaters/opacities (VFO) and new standardized kinetic (SK) anatomical-functional assessment.

MATERIALS AND METHODS

Eight eyes underwent before-after limited vitrectomy (LV): best-corrected visual acuity, low-luminance visual acuity, Minnesota Low Vision Reading Chart near visual acuity in logMAR, contrast sensitivity function (CV1000E), and straylight measurements (SM) (HDA/LDA/C-Quant). SK infrared confocal scanning laser ophthalmoscopy (SK IRcSLO) and swept-source widefield optical coherence tomography (SS-WF-OCT) identified VFO and posterior vitreous detachment (PVD). SK IRcSLO was performed with gaze directed towards the extreme superior, inferior, and lateral directions.

RESULTS

Anatomical-functional results after LV improved in 7 eyes (87.5%): objective scatter index (27.34%), disturbance index (47.97%) and C-Quant Log units (2.26%). Pre-LV SK IRcSLO and SS-WFOCT imaging identified dynamic well-defined VFO and PVD status (100%). A residual asymptomatic anterior cortical vitreous-induced shadowing ripple effect was detected post-LV.

CONCLUSIONS

This is the first objective-standardized test accounting for VFO kinesis and intermittent effect. There is potential for personalizing treatment and establishing best candidates for laser or surgery. [Ophthalmic Surg Lasers Imaging Retina 2023;54:306-315.].

Vitrectomy Improves Contrast Sensitivity in Multifocal Pseudophakia With Vision Degrading Myodesopsia

PURPOSE

Multifocal intraocular lenses (MFIOL) are associated with degradation in contrast sensitivity function (CSF); yet the contribution of vitreous is not known, nor is the benefit of vitrectomy.

DESIGN

Prospective, nonrandomized clinical study.

METHODS

A total of 180 eyes of 180 patients (55 MFIOL, 60 monofocal intraocular lenses [MIOL], 65 phakic) with symptomatic vitreous opacities were enrolled. Vitreous structure was assessed with quantitative ultrasonography (QUS). Vision was evaluated with visual acuity and CSF measurements.

RESULTS

Vitreous echodensity was the same in all lens cohorts, yet CSF was worse in MFIOL eyes (P < .001). In 86 patients who elected vitrectomy, there was 68% greater vitreous echodensity and 31% worse CSF than in observation controls (P < .0001 for each). Preoperatively, CSF was 25% worse in MFIOL than in MIOL (P = .014). Postoperatively, vitreous echodensity decreased by 55%, 51%, and 52%, whereas CSF improved by 37% 48% in and 43% in MFIOL, MIOL, and phakic eyes, respectively (P < .0001 for each). NEI Visual Function Questionnaire analyses showed improved visual well-being.

CONCLUSIONS

Patients with vision degrading myodesopsia who elected vitrectomy had greater vitreous echodensity and worse CSF than controls, but no other differences in age, sex, or myopia. MFIOL eyes had worse CSF than MIOL and phakic eyes, very possibly due to combined effects of the MFIOL and vitreous opacification. Limited vitrectomy reduced vitreous echodensity and improved CSF in all eyes. All patients with CSF-degrading vitreous opacities benefited from limited vitrectomy, including those with MFIOL. As MFIOL eyes had 37% improvement in CSF, patients with MFIOL and vision degrading myodesopsia merit consideration of vitrectomy.

Visualization and Grading of Vitreous Floaters Using Dynamic Ultra-Widefield Infrared Confocal Scanning Laser Ophthalmoscopy: A Pilot Study

Purpose: To describe the appearance of vitreous opacities using dynamic ultra-widefield infrared confocal scanning laser ophthalmoscopy (IRcSLO). Design: Retrospective case series. Methods: Eyes of patients complaining of myodesopsia were analyzed using dynamic ultra-widefield IRcSLO imaging (Nidek Mirante, Nidek Co., Ltd., Gamagori, Japan), and classified according to a vitreous opacity severity scale. Results: Thirty eyes of 21 patients were included in this study. The average age was 56 years. Symptom duration ranged from 1 to more than 365 days. The most common cause of vitreous floaters was posterior vitreous detachment (63.3%), followed by vitreous syneresis (23.3%), asteroid hyalosis (10%) and vitreous hemorrhage (3.3%). Opacities were classified as Grade 1 in three eyes (10%), Grade 2 in 10 eyes (33.3%), Grade 3 in 11 eyes (36.6%), Grade 4 in two eyes (6.6%) and Grade 5 in four eyes (13.3%). Patients with Grade 1 opacities were younger than patients with opacities Grade 2 or greater. A visible Weiss ring could be identified in 0% of eyes with Grade 1 opacities, 40% of eyes with Grade 2 opacities, 100% of eyes with Grade 3 opacities, and 100% of eyes with Grade 4 opacities. In patients with Grade 5 opacities, a Weiss ring could not be identified. Conclusion: Dynamic ultra-widefield IRcSLO imaging is a useful tool to evaluate patients with vitreous floaters. It allows for accurate visualization of the number, density, and behavior of the shadows that vitreous opacities project over a very wide area of the retina, which has a positive correlation with patient perception of floaters.

The effectiveness of laser vitreolysis for vitreous floaters in posterior vitreous detachment

Purpose

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. Patients underwent one to three sessions of vitreolysis via Neodymiun-doped Yttrium Aluminum Garnet (Nd:YAG) laser. We examined the CSF using the computer programs Freiburg Acuity and Contrast Test (FrACT) and VRQoL survey using the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) before, and 1 month after, vitreolysis.

Results

Twelve patients had both eyes lasered and 33 patients had one eye lasered. The mean CSF improved from 3.20 ± 0.85%W to 2.64 ± 0.63%W 1 month after vitreolysis. Each use of the laser showed a significant mean difference in CSF (%W) as analyzed by paired t-test before and after the first laser (0.29 ± 0.49%W [P ≤ 0.001]); after the first and second laser (0.35 ± 0.53%W [P = 0.01]); and after second and third laser (0.21 ± 0.31%W [P = 0.02]). There was improvement in the median of four subscales in NEI VFQ-25 scores post treatment: general vision (z = -3.30, P = 0.001), near activity (z = 3.396, P = 0.001, distance activity (z = -2.788, P = 0.005), and mental health (z = -2.219, P = 0.026). The mean scores increased to 79.55 ± 9.45 from the baseline 75.06 ± 9.69 (P ≤ 0.001). No adverse events were recorded 1 month after the laser treatments.

Conclusion

Vitreolysis by Nd:YAG laser improved the CFS and VRQoL in symptomatic PVD patients.

Vitreous Opacity Vitrectomy (VOV): Safest Possible Removal of “Floaters”

Purpose

Primary opacities that develop in the aging vitreous, commonly termed “floaters,” were once considered merely a nuisance, not justifying any risk of surgical removal. However, vitreoretinal specialists are increasingly recognizing that extensive symptomatic vitreous opacities (SVO) that substantially interfere with activities that critically depend on vision (daily visual activities, DVA), constituting degenerative vitreous syndrome (DVS, see http://floaterstories.com), warrant removal albeit with minimal risk - but no description of how to reduce vitrectomy risks to least possible has been forthcoming. We here describe such a method.

Patients and Methods

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 VOV operations (in 81 patients, average age 66) performed with ultra-high speed, 27-gauge vitrectomy probes.

Results

All eyes rapidly achieved continuously clear vision, and no eye developed a clinically significant complication during a year of follow-up. Three small, existent retinal breaks were discovered prior to peripheral vitrectomy and one apparently iatrogenic retinal tear was found at VOV completion, when each was treated. In the eyes that were not pseudophakic, postoperative nuclear sclerosis progression was successfully managed by subsequent cataract extraction.

Conclusion

The goals of VOV for DVS are to safely restore continuously clear vision by performing tractionless vitreous removal with respect to the retina and to reduce the lifetime risk of retinal detachment, both by such vitreous removal and by microscopic examination of the peripheral retina under anesthesia (MEPRUA), guiding appropriate prophylactic retinopexy. The otherwise healthy DVS eyes so treated warrant this specific form of vitrectomy, continually focused on achieving least possible risk, to maintain an acceptable risk/benefit ratio.

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Optical Scattering from Vitreous Floaters

Vitreous “floaters” are a common entoptic phenomenon that can result in significant reduction in quality of life in a proportion of sufferers. The authors use a computational mathematical model based on Fourier optics and reflection and transmission coefficients calculated for a planar type II collagen opacity suspended in aqueous to show that floaters are perceived by the patient through interference effects that result in significant variations in intensity on the retina when viewing a constant brightness surface. The model also predicts that backscattered intensity from floaters is ten thousand to one million times lower than the variations in intensity produced on the retina, which demonstrates that the visible effects of floaters for the patient can be highly significant, whereas clinical observation of the vitreous may be entirely unremarkable. Importantly, the results also demonstrate that floaters do not need to be opaque to cause symptoms, with only small differences in refractive index between the floater material and the surrounding vitreous needed to produce significant optical effects. The model predicts that pupil size is an important factor in determining the severity of symptoms from floaters, with constricted pupils giving much greater effect than dilated pupils. Finally, the authors’ model predicts that floaters degrade contrast sensitivity function, with greatest degradation occurring in the 5–40 cycles per degree spatial frequency range and that the effects of shadowing caused by floaters are very strongly correlated to the predicted degradation of contrast sensitivity function. Bioelectromagnetics. 43:90–105, 2022. © 2021 The Authors. Bioelectromagnetics published by Wiley Periodicals LLC on behalf of Bioelectromagnetics Society.

The Efficacy and Safety of YAG Laser Vitreolysis for Symptomatic Vitreous Floaters of Complete PVD or Non-PVD

INTRODUCTION

To evaluate and compare the efficacy and safety of YAG laser vitreolysis in treating symptomatic vitreous floaters of complete posterior vitreous detachment (PVD) and non-PVD.

METHODS

In this prospective cohort study, 51 eyes with symptomatic floaters were treated with YAG laser vitreolysis. Participants were divided into complete PVD and non-PVD groups. Objective visual quality measures including the Strehl ratio (SR), internal spherical aberration (SA), internal comatic aberration (CA), internal high-order aberration (HOA), area ratio of modulation transfer function (MTFa) and Vitreous Floaters Symptom Questionnaire (VFSQ-13) scores were used to compare the efficacy of YAG laser vitreolysis treatment between two groups.

RESULTS

The mean age of all patients was 56.80 ± 10.82 years old. In total, 36 of 51 (70.59%; 95% CI 58.10-83.10) patients reported their symptoms as significant or complete improvement after YAG laser vitreolysis treatment. Post-treatment MTFa, internal SA and internal HOA were significantly better compared to baseline (26.19 ± 14.73 vs. 29.19 ± 17.98, p = 0.013; 0.05 ± 0.05 vs. 0.04 ± 0.04, p = 0.031 and 0.23 ± 0.22 vs. 0.16 ± 0.07, p = 0.044; respectively) in all eyes. Twenty-nine of 51 (56.86%) eyes had floaters of non-PVD type. Significant or complete subjective improvements in the PVD group and non-PVD group were 72.73% and 68.97% (p = 0.344), respectively.

CONCLUSIONS

Improved subjective and objective visual quality in participants with symptomatic floaters following YAG laser vitreolysis was found in both groups. The efficacy of YAG laser vitreolysis was comparable in floaters of complete PVD and non-PVD types.

Impact of symptomatic vitreous degeneration on photopic and mesopic contrast thresholds

CLINICAL RELEVANCE

Contrast thresholds under photopic and mesopic luminance conditions are compromised in subjects with vitreous degeneration. A plausible explanation is needed for the visual discomfort expressed by patients suffering from symptomatic vitreous degeneration.

BACKGROUND

The current study investigates the effect of symptomatic vitreous degeneration on photopic and mesopic contrast at high spatial frequencies.

METHODS

An age-matched sample of 115 subjects, comprising 30 subjects with symptomatic vitreous floaters (cases) and 85 healthy subjects (controls), was included in this study. Visual acuity and flicker thresholds were measured for all participants. Photopic and mesopic functional contrast thresholds at 10 cycles per degree were measured for all participants to assess the effect of floaters on contrast. Further, to determine the effect of posterior vitreous detachment on contrast, the sample was divided into three groups: cases with posterior vitreous detachment (n = 12); cases without posterior vitreous detachment (n = 18); and controls (n = 85), and their contrast thresholds were compared.

RESULTS

Photopic and mesopic contrast thresholds were lower by 37.4% and 27.5%, respectively, when the cases were compared with the controls (p = 0.028 and p < 0.001 for photopic and mesopic contrast thresholds, respectively). Photopic contrast was lower by 64.0% in cases with posterior vitreous detachment compared with controls (p = 0.001). Compared with controls, mesopic contrast was lower in cases with posterior vitreous detachment and in cases without posterior vitreous detachment by 30.3% and 25.6%, respectively (p = 0.014 and p = 0.017 for cases with and without posterior vitreous detachment, respectively).

CONCLUSION

: Subjects with vitreous degeneration have diminished photopic and mesopic contrast thresholds compared with controls. This finding highlights the negative impact of vitreous degeneration on the quality of vision.

Dietary Intervention With a Targeted Micronutrient Formulation Reduces the Visual Discomfort Associated With Vitreous Degeneration

Purpose

To investigate the impact of supplementation with a targeted micronutrient formulation on the visual discomfort associated with vitreous degeneration.

Methods

In this clinical trial, 61 patients with symptomatic vitreous floaters were randomized to consume daily, the active supplement consisting of 125 mg L-lysine, 40 mg vitamin C, 26.3 mg Vitis vinifera extract, 5 mg zinc, and 100 mg Citrus aurantium or placebo for 6 months. Change in visual discomfort from floaters, assessed with the Floater Disturbance Questionnaire, was the primary outcome measure. Secondary outcome measures included best-corrected visual acuity, letter contrast sensitivity, photopic functional contrast sensitivity with positive and negative contrast polarity, and quantitative vitreous opacity areas.

Results

After supplementation, the active group reported a significant decrease in their visual discomfort from floaters (P < 0.001), whereas the placebo group had no significant change in their visual discomfort (P = 0.416). At 6 months, there was a significant decrease in vitreous opacity areas in the active group (P < 0.001) and an insignificant increase in vitreous opacity areas in the placebo group (P = 0.081). Also, there was a significant improvement in photopic functional contrast sensitivity with positive contrast polarity in the active group after supplementation (P = 0.047).

Conclusions

The findings of this study indicate improvements in vision-related quality of life and visual function of patients suffering from vitreous floaters after supplementation with a formulation of antioxidative and antiglycation micronutrients. Notably, these improvements were confirmed by the decrease in vitreous opacity areas in the active group.

Translational Relevance

This targeted dietary intervention should be considered to support patients with symptomatic vitreous degeneration.

Vitreous Structure and Visual Function in Myopic Vitreopathy Causing Vision-Degrading Myodesopsia

PURPOSE

Myopic vitreopathy features precocious fibrous vitreous liquefaction and early posterior vitreous detachment (PVD). It is unclear whether visual function is affected by myopic vitreopathy and PVD. This study assessed the relationships among axial length, structural vitreous density, PVD, and visual function.

DESIGN

Retrospective case-control study.

METHODS

Ultrasonography measurements were made of axial length, logMAR VA, contrast sensitivity function (CSF [Freiburg acuity contrast test]), and quantitative B-scan ultrasonography.

RESULTS

Seventy-nine subjects (45 men and 34 women; mean age: 49 ± 14 years) were analyzed. Axial lengths ranged from 22 to 29.2 mm (mean: 24.9 ± 1.8 mm; myopic eyes: 26.35 ± 1.35 mm; and nonmyopic eyes: 23.45 ± 0.75 mm; P < .001). With increasing axial length there was greater vitreous echodensity (R: 0.573; P < .01) and degradation in CSF (R: 0.611; P < .01). Subgroup analyses found that myopic eyes (>- 3 diopters) had 37% more vitreous echodensity than nonmyopic eyes (762 ± 198 arbitrary units [AU] vs. 557 ± 171 AU, respectively; P < .001) and that CSF was 53% worse in myopic eyes (3.30 ± 1.24 Weber index [%W]) than in nonmyopic eyes (2.16 ± .59 %W; P < .001). Myopic eyes with PVD had 33% greater vitreous echodensity (815 ± 217 AU; P < .001) and 62% degradation in CSF (3.63 ± 2.99 %W) compared to nonmyopic eyes with PVD (613 ± 159 AU; 2.24 ± 0.69 %W; P < .001, each). Limited vitrectomy was performed in 11 of 40 cases (27.5%), normalizing vitreous echodensity and CSF in each case.

CONCLUSIONS

Axial myopia is associated with increased fibrous vitreous liquefaction and echodensity, as well as profound degradation of CSF. PVD in myopic eyes is associated with even more structural and functional abnormalities, normalized by limited vitrectomy. These findings may explain some common complaints of myopic patients with respect to vision and quality of life.

Volumetric Optical Imaging and Quantitative Analysis of Age-Related Changes in Anterior Human Vitreous

Purpose

The purpose of this study was to characterize age-related changes in anterior human vitreous with 3-D swept source optical coherence tomography (SS-OCT) and evaluate associations with axial length (AL) and contrast sensitivity function (CSF).

Methods

There were 49 phakic eyes in 49 patients (40.0 ± 19.3 years) had 3-D volumetric scanning of the lens and retrolental vitreous with SS-OCT at 1050 nm. OCT-derived indices of vitreous optical density (VOD), vitreous opacification ratio (VOR), and lens optical density (LOD) were correlated with AL and double-pass assessment of retinal point spread function (Objective Scatter Index [OSI]). CSF was measured using an adaptive-optics visual simulator (area under log-log contrast sensitivity function [AULCSF]).

Results

Vitreous SS-OCT detected gel vitreous, liquefied lacunae, Berger's space, retrolental laminae, and fibrous opacifications. VOD, VOR, and LOD showed high reproducibility (intraclass correlation coefficients 0.968, 0.975, and 0.998, respectively). VOD was highly correlated with VOR (Pearson's R = 0.96, P < 0.000001). VOD, VOR, and LOD correlated with age (R = 0.48, 0.58, and 0.85, P < 0.001 for each). VOR and LOD correlated with OSI (R = 0.36, P = 0.0094, and R = 0.36, P = 0.0096, respectively). VOR correlated negatively with AULCSF (R = −0.53, P < 0.00009), which was related to OSI. Myopic eyes had higher OSI than nonmyopic eyes (P = 0.0121), consistent with correlation between OSI and AL (R = 0.37, P = 0.0091). Multivariable regression confirmed these findings.

Conclusions

SS-OCT visualized microstructural features of anterior human vitreous, where opacification is associated with increased light scattering and CSF degradation. SS-OCT enables high-resolution optical evaluation of vitreous opacities.

Visual function deficits in eyes with resolved endophthalmitis

To evaluate the changes in functional vision in patients with resolved endophthalmitis. This was a cross-sectional study. The study included 20 patients with resolved endophthalmitis and best-corrected visual acuity of 20/100 or better. Visual acuity (VA), contrast threshold (CT), red/green (RG) and yellow/blue (YB) colour vision and 15 Hz flicker modulation threshold (FMT) were assessed using standard psychophysical techniques. The median age was 54 years. The median visual acuity was 0.27 (~ 20/40-Snellen Equivalent) ((interquartile range [IQR]), 0.30) logMAR). The median log contrast threshold (CT) was - 1.13 (IQR, 0.36) log units (normative value for age-matched CT: - 1.61 log units). The median red/green (RG) and yellow/blue (YB) thresholds were 11.52 (IQR, 26.19) and 9.45 (IQR, 16.20) CAD units respectively, which were at least 5 times higher than age-matched normative RG and YB thresholds. The median central cone- mediated FMT was 17.64% (IQR, 23.40%), which was much higher compared to age-matched FMT (5.48% [IQR, 3.47]). Linear regression revealed significant relationship between contrast thresholds and foveal thickness (y = 0.001x-1.47, R2 = 0.20, p = 0.048). Though endophthalmitis may resolve with a good visual acuity, deficits in visual functions like chromatic discrimination, cone-mediated flicker and contrast sensitivity persist.

STRUCTURAL AND FUNCTIONAL CHARACTERISTICS OF LAMELLAR MACULAR HOLES

PURPOSE

Lamellar macular holes (LMHs) can been subdivided into tractional and degenerative subtypes. This cross-sectional cohort study compared structural and functional characteristics in these subtypes hypothesizing that tractional LMH has a higher prevalence of vitreopapillary adhesion and tangential traction (macular pucker), whereas degenerative LMH has more ellipsoid zone disruption and worse vision, measured three different ways.

METHODS

Tractional LMH (n = 22) and degenerative LMH (n = 15) were distinguished by optical coherence tomography criteria. Separate spectral domain optical coherence tomography scanning of the macula and optic disk was performed. Visual acuity, contrast sensitivity function (Weber Index, %W), and the degree of visual distortions (3-dimensional threshold Amsler grid; % volume lost [%VL]) were quantified.

RESULTS

Vitreopapillary adhesion was present in 14/22 (64%) tractional, but in only 3/15 (20%) degenerative LMH (P = 0.006). Macular pucker was present in 19/22 (86%) tractional, but in only 8/15 (53%) degenerative LMH (P = 0.011). Ellipsoid zone disruption was present in 13/15 (87%) degenerative, but in only 2/22 (9%) tractional LMH (P = 0.0001). Visual acuity was better in tractional than degenerative LMH (P = 0.006), as was contrast sensitivity function (tractional = 3.44 ± 1.07 %W, degenerative = 4.66 ± 1.73 %W; P = 0.015). Visual distortions were less in tractional (0.33 ± 0.61 %VL) than in degenerative (0.85 ± 0.68 %VL) LMH (P = 0.014).

CONCLUSION

Structure and visual function differ significantly in subtypes of LMH. Tractional LMH has 3-fold higher prevalence of vitreopapillary adhesion and 2-fold higher prevalence of macular pucker. Degenerative LMH has 9-fold more ellipsoid zone disruption, worse visual acuity and contrast sensitivity function, and 3-fold more distortions. Thus, outer retinal integrity seems more closely correlated with vision than anterior structural abnormalities in LMH.

Impact of posterior vitreous detachment on contrast sensitivity in patients with multifocal intraocular lens

PURPOSE

To investigate posterior vitreous detachment (PVD) and pars plana vitrectomy (PPV) effects on contrast sensitivity function (CSF) in patients with a multifocal intraocular lens (MfIOL).

METHODS

This single-center prospective case-control study analyzed 27 patients with 43 consecutive eyes. Twenty patients with 36 consecutive eyes received MfIOL implantation with either ZLB00 or ZMB00. CSF was measured as the area under the log contrast sensitivity function (AULCSF) in the presence and absence of PVD (PVD+ group and PVD- group, respectively). Seven eyes associated with a symptomatic PVD and severe visual dissatisfaction after MfIOL implantation underwent PPV (symptomatic PVD+ group). CSF was measured prior to and after PPV.

RESULTS

The mean AULCSF was significantly lower in the PVD+ group (1.5 ± 0.1) versus the PVD- group (1.7 ± 0.1, p < 0.0001). Major complaints in the symptomatic PVD+ group included floaters (n = 2) and blurry vision (n = 5). The preoperative AULCSF (1.4 ± 0.1) was significantly lower in the symptomatic PVD+ group versus the PVD- group (p < 0.0001) and PVD+ group (p = 0.02). The preoperative AULCSF in the symptomatic PVD+ group was significantly improved after PPV (1.4 vs. 1.7, respectively, p = 0.002).

CONCLUSIONS

PVD significantly decreased CSF in patients with MfIOL. Patients with symptomatic PVD exhibited the greatest decrease in CSF, which was significantly improved after PPV. Measurement of CSF and careful assessment of PVD may be useful in determining the appropriateness of surgical intervention for improving visual performance and satisfaction in MfIOL patients with symptomatic PVD.

Safety and Efficacy of YAG Laser Vitreolysis for the Treatment of Vitreous Floaters: An Overview

Emerging evidence has suggested that the entoptic phenomena associated with vitreous opacities (i.e. vitreous floaters) are more bothersome than previously believed. In addition, the prevalence of vitreous floaters is likely increasing due to the evolving global pandemic of myopia. The use of YAG laser vitreolysis for the treatment of annoying vitreous floaters has attracted significant attention in recent years as the technique offers a number of potential advantages. Unfortunately, the currently available evidence that is needed to guide clinical practice is both very limited and contradictory. As a consequence, the technique remains highly controversial. A review of the existing literature sheds light on patient- and treatment-related factors that may significantly affect both the effectiveness and the safety of the procedure. The current article discusses important aspects of key publications on the topic, offers suggestions for clinical practice, and highlights unmet needs that should be addressed by future research.

Vitreous and Vision Degrading Myodesopsia

Macromolecules comprise only 2% of vitreous, yet are responsible for its gel state, transparency, and physiologic function(s) within the eye. Myopia and aging alter collagen and hyaluronan association causing concurrent gel liquefaction and fibrous degeneration. The resulting vitreous opacities and collapse of the vitreous body during posterior vitreous detachment are the most common causes for the visual phenomenon of vitreous floaters. Previously considered innocuous, the vitreous opacities that cause floaters sometimes impact vision by profoundly degrading contrast sensitivity function and impairing quality-of-life. While many people adapt to vitreous floaters, clinically significant cases can be diagnosed with Vision Degrading Myodesopsia based upon echographic assessment of vitreous structure and by measuring contrast sensitivity function. Perhaps due to the ubiquity of floaters, the medical profession has to date largely ignored the plight of those with Vision Degrading Myodesopsia. Improved diagnostics will enable better disease staging and more accurate identification of severe cases that merit therapy. YAG laser treatments may occasionally be slightly effective, but vitrectomy is currently the definitive cure. Future developments will usher in more informative diagnostic approaches as well as safer and more effective therapeutic strategies. Improved laser treatments, new pharmacotherapies, and possibly non-invasive optical corrections are exciting new approaches to pursue. Ultimately, enhanced understanding of the underlying pathogenesis of Vision Degrading Myodesopsia should result in prevention, the ultimate goal of modern Medicine.

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

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.

Objective assessment of YAG laser vitreolysis in patients with symptomatic vitreous floaters

Background

To objectively evaluate YAG laser vitreolysis for symptomatic vitreous floaters using color photo imaging.

Methods

In this interventional and prospective study, 32 eyes of 32 patients with symptomatic vitreous floaters secondary to posterior vitreous detachment (PVD) were treated with a single session of yttrium aluminum garnet (YAG) laser. Primary outcomes were objective and subjective changes measured by masked grading of color fundus photographs and National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25), respectively. Secondary outcomes included Early Treatment Diabetic Retinopathy Study (ETDRS), best-corrected visual acuity (BCVA) and adverse events. Wilcoxon signed-rank test was used to analyze the results of the objective and subjective assessments at each time point. P < 0.05 was considered statistically significant.

Results

Thirty-two patients (32 eyes; 13 men and 19 women) with symptomatic vitreous floaters were enrolled in this study (mean age: 59.4 years). All study patients were followed up for 6 months. Following the laser vitreolysis, there was a statistically significant improvement in both the near visual function (z = - 2.97; p = 0.003; r = 0.633) and visual disturbance rate (z = - 3.97; p < 0.001; r = 0.84). Distance visual function did not show statistically significant difference after the laser procedure (p = 1.00). Color fundus photograph did reveal vitreous opacity improvement over time in 93.7% of study eyes (partial improvement in 37.5% and total improvement in 56.2% of study eyes). During the follow-up period, recurrence of vitreous floaters, BCVA deterioration and adverse events were not observed.

Conclusions

YAG laser vitreolysis decreased the amount of vitreous floaters opacities seen on color fundus imaging and improved related symptoms according to the NEI VFQ-25 responses.

Cost-Effectiveness of Limited Vitrectomy for Vision-Degrading Myodesopsia

PURPOSE

Patients afflicted with clinically significant vitreous floaters suffer from vision-degrading myodesopsia, characterized by impairment in contrast sensitivity function (CSF) and decreased quality of life. This study determined the cost-effectiveness of limited vitrectomy for this condition.

DESIGN

Retrospective, interventional case series and third-party insurer cost-utility analysis.

METHODS

Sixty-seven patients suffering from unilateral vitreous floaters (20 non-myopic patients with posterior vitreous detachment [PVD]; 17 myopic patients [>-2 diopters] without PVD; 30 myopic patients with PVD) completed the National Eye Institute Visual Function Questionnaire (VFQ-39) and were tested with best-corrected visual acuity (BCVA) and CSF measurements before and after limited vitrectomy. A reference case cost-utility analysis was performed.

RESULTS

The mean VFQ-39 increased 19% (P < 0.00001) after surgery, with general vision improving 27% for the entire group and 37% for non-myopic PVD (P < 0.00001 for each). VFQ-39 correlations with time tradeoff utilities indicated a 14.4% improvement in quality of life. Mean BCVA improved 13.5% postoperatively (P < 0.00001) and CSF improved 53% (P < 0.00001). The incremental patient value gain conferred by limited vitrectomy was 2.38 quality-adjusted life-years (QALYs), and the average cost-utility ratio in 2018 U.S. real dollars was $1,574/QALY.

CONCLUSIONS

Limited vitrectomy for vision-degrading myodesopsia is clinically effective, in that it improves BCVA, CSF, and patient well-being. It is also highly cost-effective ($1,574/QALY), with an average cost-utility ratio vs. no therapy that is superior to cataract surgery ($2,262/QALY), amblyopia therapy ($2,710/QALY), and retinal detachment repair ($45,304/QALY). Myopic patients without PVD had the lowest cost-utility ratio of all ($1,338/QALY).

Assessment of Vitreous Structure and Visual Function after Neodymium:Yttrium-Aluminum-Garnet Laser Vitreolysis

PURPOSE

Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser treatment is performed on vitreous floaters, but studies of structural and functional effects with objective outcome measures are lacking. This study evaluated Nd:YAG laser effects by comparing participants with vitreous floaters who previously underwent laser treatment with untreated control participants and healthy persons without vitreous floaters using quantitative ultrasonography to evaluate vitreous structure and by measuring visual acuity and contrast sensitivity function to assess vision.

DESIGN

Retrospective, comparative study.

PARTICIPANTS

One eye was enrolled for each of 132 participants: 35 control participants without vitreous floaters, 59 participants with untreated vitreous floaters, and 38 participants with vitreous floaters previously Nd:YAG-treated. Of these, 25 were dissatisfied and sought vitrectomy; 13 were satisfied with observation.

METHODS

The 39-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-39) to assess participant visual well-being, quantitative ultrasonography (QUS) to measure vitreous echodensity, and best-corrected visual acuity (BCVA) and contrast sensitivity function (CSF) to evaluate vision.

MAIN OUTCOME MEASURES

Results of NEI-VFQ-39, QUS, BCVA, and CSF.

RESULTS

Compared with control participants without vitreous floaters, participants with untreated vitreous floaters showed worse NEI-VFQ-39 results, 57% greater vitreous echodensity, and significant (130%) CSF degradation (P < 0.001 for each). Compared with untreated eyes with vitreous floaters, Nd:YAG-treated eyes had 23% less vitreous echodensity (P < 0.001), but no differences in NEI-VFQ-39 (P = 0.51), BCVA (P = 0.42), and CSF (P = 0.17) results. Of 38 participants with vitreous floaters who previously were treated with Nd:YAG, 25 were dissatisfied and seeking vitrectomy, whereas 13 were satisfied with observation. Participants seeking vitrectomy showed 24% greater vitreous echodensity (P = 0.018) and 52% worse CSF (P = 0.006). Multivariate linear regression models confirmed these findings.

CONCLUSIONS

As a group, participants previously treated with Nd:YAG laser for bothersome vitreous floaters showed less dense vitreous, but similar visual function as untreated control participants with vitreous floaters. Because some treated eyes showed less dense vitreous and better visual function than those of untreated control participants, a prospective randomized study of Nd:YAG laser treatment of vitreous is warranted, using uniform laser treatment parameters and objective quantitative outcome measures.

Asteroid hyalosis-a comprehensive review

Asteroid hyalosis is a relatively common cause of vitreous opacities, which is possibly associated with diabetes mellitus and hereditary pigmentary retinopathies. We review the history, epidemiology, and biochemistry of asteroid hyalosis, as well as its relationship with ocular and systemic conditions. We describe imaging modalities used for diagnostic evaluations in cases of severe asteroid hyalosis and propose hypotheses regarding its lack of significant effects on vision. We discuss cataract surgery in patients with asteroid hyalosis and the selection of intraocular lenses for implantation.

Nd:YAG Laser Vitreolysis for Symptomatic Vitreous Floaters: Application of Infrared Fundus Photography in Assessing the Treatment Efficacy

Background

Vitreous floater is a physically common phenomenon with aging and is related to visual impairment and decrease of quality of life. Nd:YAG vitreolysis is supposed to be an option for resolving floaters, but its clinical efficacy is undefined. We aimed to evaluate the efficacy of Nd:YAG vitreolysis in treating floater semiquantifiably by determining changes of floater areas on infrared fundus photography (IR).

Methods

Patients with floaters and those who underwent Nd:YAG vitreolysis were retrospectively summarized from June 2015 to Nov 2017. Intraocular pressure, visual acuity, visual function questionnaire (VFQ-25) scores, and floater areas calculated using Image J software were recorded preoperatively and 6 months after YAG lasers.

Results

50 patients (25 female/25 male, with an average age of 60.34 years) with 55 eyes (29 OD and 26 OS) presenting floaters and underwent YAG vitreolysis treatment were included. Severe symptoms were reported in 17 eyes, moderate in 21 and mild in 17 eyes. No severe Nd:YAG vitreolysis procedure-related complications occurred in all patients except one mild retinal injury. There were no significant changes in intraocular pressure and visual acuity after the laser treatment. 43 eyes had improved symptoms; in 8, floaters had disappeared; and 4 had no changes according to VFQ-25 scores. The median of shadow areas of floaters before operation was 1.41 (0.29–12.85) cm², which decreased to 0.12 (0–2.77) cm² after the operations (t=5.849, P=0.001). The mean VFQ-25 scores increased to 88.54 ± 12.74 from the baseline 71.44 ± 12.77 (t=11.82, P=0.001). Pearson correlation analysis showed that the shadow areas of floaters were negatively correlated to VFQ-25 scores before (r=−0.73, P=0.001) and after (r=−0.72, P=0.001) treatments.

Conclusion

Nd:YAG vitreolysis was effective and safe in alleviating the visual symptoms induced by floaters. Quantification of floater shadow areas on infrared fundus photography could serve as an objective index for assessing treatment efficacy of Nd:YAG vitreolysis.

A Novel Vision-Enhancing Technology for Low-Vision Impairments

Ocular disorders such as vitreoretinal pathologies are widespread, especially in older adults. In particular, degenerative diseases of the retina such as macular senile degenerations are on the rise and affect millions of people with hundreds of thousands of new cases each year. These diseases can cause profoundly disabling visual impairments, in some cases severely compromising the central and/or the peripheral vision in one or both eyes. In this paper, we present a novel vision aids technology that allows for correcting or attenuating the perception of visual field defects due to ocular pathologies of diverse origins or traumas by using techniques of 3D visualisation, eye tracking, and image processing. The presented technology is mainly conceived for providing vision aids that can significantly improve the quality of life of people with this kind of visual disorders. As well, it could be employed for supporting the diagnosis of ocular dysfunctions and for monitoring the progression of diseases. The technology shown in this work is protected by an International Application in Patent Cooperation Treaty (PCT).

Long-Term Safety and Efficacy of Limited Vitrectomy for Vision Degrading Vitreopathy Resulting from Vitreous Floaters

PURPOSE

Vitreous floaters can lower visual acuity (VA) and degrade contrast sensitivity function (CSF). Limited vitrectomy improves VA and normalizes CSF, but long-term results in a large series with objective quantitative outcome measures are lacking.

DESIGN

Case series.

PARTICIPANTS

One hundred ninety-five eyes of 145 patients (87 men, age = 57.6 ± 4.3 years; 58 women, age = 61.5 ± 12.0 years) reporting bothersome vitreous floaters were compared to 70 age-matched controls. Posterior vitreous detachment (PVD) alone was the cause in 96/195 (49.2%), myopic vitreopathy alone was the cause in 30/195 (15.4%), PVD with myopic vitreopathy was the cause in 56/195 (28.7%), and asteroid hyalosis was the cause in 13/195 eyes (6.7%).

METHODS

Limited vitrectomy with 25-gauge instruments was performed without surgical PVD induction, preserving 3 to 4 mm of retrolental vitreous in phakic eyes. Follow-up averaged 32.6 ± 23.5 months (range, 3-115 months), with 2 years or more in 144 eyes, 3 years or more in 69 eyes, 4 years or more in 51 eyes, and 5 years or more in 24 eyes.

MAIN OUTCOME MEASURES

Visual acuity, 39-item National Eye Institute Visual Function Questionnaire (VFQ) results, CSF (Weber index), and quantitative ultrasonography results.

RESULTS

After surgery, vitreous echodensity decreased by 94.1% (P < 0.0001) and VFQ results improved by 19.3% (P < 0.0001). Preoperative VA was 0.68 ± 0.21, improving to 0.77 ± 0.19 after surgery (P < 0.0001). Preoperative CSF was degraded by 91.3% compared with controls (P < 0.0001), normalizing at 1, 3, 6, 12, 24, 36, and 48 months after surgery (P < 0.00005 for each). There were no cases of endophthalmitis. There were 3 retinal tears and 3 retinal detachments that underwent successful repair. Clinically significant vitreous hemorrhage developed in 2 patients, clearing spontaneously. Two macular puckers and 4 recurrent floaters from new PVD were cured by re-operation. Cataract surgery occurred in 21 of 124 patients (16.9%; mean age, 64 ± 7 years; none younger than 53 years), an average of 13.1 ± 6.8 months after vitrectomy.

CONCLUSIONS

Limited vitrectomy for Vision Degrading Vitreopathy decreases vitreous echodensity, improves patient well-being, improves VA, and normalizes CSF. The long-term efficacy and safety profiles suggest this may be a safe and effective treatment for clinically significant vitreous floaters, warranting a prospective randomized trial.

The effects of aging vitreous on contrast sensitivity function

PURPOSE

Contrast sensitivity function (CSF) declines with age. When unassociated with cataracts, this is hypothesized to be due to macular ganglion cell complex (GCC) thinning. However, other studies found associations with increased vitreous echodensity and posterior vitreous detachment (PVD). We investigate the relationship between CSF, vitreous echodensity, PVD, and GCC thickness as related to age in the same subjects.

METHODS

Age, CSF (Weber index: %W), vitreous echodensity (quantitative ultrasonography [QUS]), lens status (phakia or pseudophakia), best-corrected visual acuity (BCVA), and GCC thickness (SD-OCT) were evaluated in 57 eyes of 57 subjects with (n = 32, mean age = 62 years) and without (n = 25, mean age = 44 years) PVD (P < 0.001). A multivariate linear regression analysis was performed to assess the effects of independent variables on CSF.

RESULTS

CSF was 51.2% worse in eyes with PVD (2.98 ± 0.31 %W) compared to no PVD (1.97 ± 0.24 %W; P < 0.001). QUS was 55.8% greater in eyes with PVD than those without (P < 0.001). Among all subjects, PVD status, vitreous echodensity, and age were the only independent variables demonstrating significant effects on CSF. Lens status, BCVA, and GCC thickness did not demonstrate association with CSF.

CONCLUSIONS

PVD, vitreous echodensity, and age are determinants of CSF. PVD and increased vitreous echodensity are each associated with diminished CSF, independent of age. Thus, in the absence of GCC thinning and cataracts, vitreous changes may be a cause of decreased CSF with age.

Psychological Distress in Patients with Symptomatic Vitreous Floaters

Purpose

To evaluate the degree of psychological distress in symptomatic vitreous floater patients and to evaluate whether these psychological factors are associated with the severity of discomfort associated with vitreous floaters.

Methods

We recruited 61 patients with symptomatic vitreous floaters and 34 controls. The degree of posterior vitreous detachment (PVD) was evaluated using optical coherence tomography. We measured the level of depression, perceived stress, state, and trait anxiety and the degree of floater-associated discomfort with self-administered questionnaire. We compared psychological parameters between floater patients and control. We also compared clinical and psychological characteristics among different floater-associated discomfort severity groups.

Results

Symptomatic vitreous floater patients showed higher rate of complete PVD and higher psychological distress compared to the control. On multiple logistic regression analysis, complete PVD (p = 0.001), depression (p = 0.001), and younger age (p = 0.037) were significantly associated with symptomatic floaters. There were no significant differences in complete PVD rate among different discomfort groups, while severe discomfort group showed higher depression, perceived stress, and state and trait anxiety compared to the other two milder symptom groups.

Conclusions

Symptomatic vitreous floater patients showed substantial level of psychological distress, and the severity of floater symptoms was significantly associated with psychological distress.

YAG Laser Vitreolysis vs Sham YAG Vitreolysis for Symptomatic Vitreous Floaters: A Randomized Clinical Trial

Importance

Vitreous floaters are common and can worsen visual quality. YAG vitreolysis is an untested treatment for floaters.

Objective

To evaluate YAG laser vitreolysis vs sham vitreolysis for symptomatic Weiss ring floaters from posterior vitreous detachment.

Design, Setting, and Participants

This single-center, masked, sham-controlled randomized clinical trial was performed from March 25, 2015, to August 3, 2016, in 52 eyes of 52 patients (36 cases and 16 controls) treated at a private ophthalmology practice.

Interventions

Patients were randomly assigned to YAG laser vitreolysis or sham YAG (control).

Main Outcomes and Measures

Primary 6-month outcomes were subjective change measured from 0% to 100% using a 10-point visual disturbance score, a 5-level qualitative scale, and National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25). Secondary outcomes included objective change assessed by masked grading of color fundus photography and Early Treatment Diabetic Retinopathy Study best-corrected visual acuity.

Results

Fifty-two patients (52 eyes; 17 men and 35 women; 51 white and 1 Asian) with symptomatic Weiss rings were enrolled in the study (mean [SD] age, 61.4 [8.0] years for the YAG laser group and 61.1 [6.6] years for the sham group). The YAG laser group reported greater symptomatic improvement (54%) than controls (9%) (difference, 45%; 95% CI, 25%-64%; P < .001). In the YAG laser group, the 10-point visual disturbance score improved by 3.2 vs 0.1 in the sham group (difference, -3.0; 95% CI, -4.3 to -1.7; P < .001). A total of 19 patients (53%) in the YAG laser group reported significantly or completely improved symptoms vs 0 individuals in the sham group (difference, 53%; 95% CI, 36%-69%, P < .001). Compared with sham, NEI VFQ-25 revealed improved general vision (difference, 16.3; 95% CI, 0.9-31.7; P = .04), peripheral vision (difference, 11.6; 95% CI, 0.8-22.4; P = .04), role difficulties (difference, 17.3; 95% CI, 8.0-26.6; P < .001), and dependency (difference, 5.6; 95% CI, 0.5-10.8; P = .03) among the YAG laser group. Best-corrected visual acuity changed by -0.2 letters in the YAG laser group and by -0.6 letters in sham group (difference, 0.4; 95% CI, -6.5 to 5.3; P = .94). No differences in adverse events between groups were identified.

Conclusions and Relevance

YAG laser vitreolysis subjectively improved Weiss ring-related symptoms and objectively improved Weiss ring appearance. Greater confidence in these outcomes may result from larger confirmatory studies of longer duration.

Trial Registration

clinicaltrials.gov NCT02897583.

Paradigm Shifts in Ophthalmic Diagnostics

PURPOSE

Future advances in ophthalmology will see a paradigm shift in diagnostics from a focus on dysfunction and disease to better measures of psychophysical function and health. Practical methods to define genotypes will be increasingly important and non-invasive nanotechnologies are needed to detect molecular changes that predate histopathology.

METHODS

This is not a review nor meant to be comprehensive. Specific topics have been selected to illustrate the principles of important paradigm shifts that will influence the future of ophthalmic diagnostics. It is our impression that future evaluation of vision will go beyond visual acuity to assess ocular health in terms of psychophysical function. The definition of disease will incorporate genotype into what has historically been a phenotype-centric discipline. Non-invasive nanotechnologies will enable a paradigm shift from disease detection on a cellular level to a sub-cellular molecular level.

RESULTS

Vision can be evaluated beyond visual acuity by measuring contrast sensitivity, color vision, and macular function, as these provide better insights into the impact of aging and disease. Distortions can be quantified and the psychophysical basis of vision can be better evaluated than in the past by designing tests that assess particular macular cell function(s). Advances in our understanding of the genetic basis of eye diseases will enable better characterization of ocular health and disease. Non-invasive nanotechnologies can assess molecular changes in the lens, vitreous, and macula that predate visible pathology. Oxygen metabolism and circulatory physiology are measurable indices of ocular health that can detect variations of physiology and early disease.

CONCLUSIONS

This overview of paradigm shifts in ophthalmology suggests that the future will see significant improvements in ophthalmic diagnostics. The selected topics illustrate the principles of these paradigm shifts and should serve as a guide to further research and development. Indeed, successful implementation of these paradigm shifts in ophthalmology may provide useful guidance for similar developments in all of healthcare.