Vitrectomy for vitreous floaters: analysis of the benefits and risks

Management of vitreous floaters: a review

PURPOSE OF REVIEW

Vitreous floaters, characterized by the perception of spots or shadows in the visual field, commonly result from posterior vitreous detachment and can cause chronic symptoms in affected patients. The diagnosis of posterior vitreous detachment is typically determined clinically and can sometimes be confirmed with optical coherence topography (OCT) [1 ▪▪ ] . The objective of this review is to review management options for symptomatic vitreous floaters.

RECENT FINDINGS

Symptoms of vitreous floaters may be mild or may significantly affect patient quality of life. Observation is the most common management strategy. Procedural management options include pars plana vitrectomy (PPV) and neodymium-doped yttrium aluminium garnet (Nd:YAG) vitreolysis. PPV is considered the most definitive management option for vitreous floaters. PPV, however, carries inherent risks, notably infection, cataract formation, and retinal detachment [2] . Nd:YAG laser vitreolysis is a less invasive alternative with studies demonstrating varied success [1 ▪▪ ,3,4] .

SUMMARY

This review provides insights into the current state of knowledge regarding the management of vitreous floaters and can guide clinical decision-making.

Efficacy and safety of early YAG laser vitreolysis for symptomatic vitreous floaters: the study protocol for a randomized clinical trial

BACKGROUND

Vitreous floaters are a common ocular condition that affects individuals of all ages. Although vitreous floaters are typically benign, they can significantly impair visual acuity and quality of life. Laser vitreolysis, which uses an Nd: YAG laser to vaporize collagenous vitreous opacities, is increasingly being used as a treatment option. However, there is currently a lack of evidence regarding its efficacy and the appropriate timing of its application. This study aims to evaluate the efficacy and safety of early intervention with YAG laser vitreolysis in treating symptomatic vitreous floaters.

METHODS

The present study is a randomized, controlled, double-blind clinical trial. A total of 70 participants with symptomatic floaters for 1 month were prospectively recruited. These participants will be randomly assigned to two groups, with 35 individuals in each group: the early treatment group and the delayed treatment group. Participants assigned to the early treatment group will undergo YAG laser vitreolysis immediately, followed by a sham laser treatment 3 months later. On the other hand, participants assigned to the delayed treatment group will receive a sham laser treatment and then undergo YAG laser vitreolysis 3 months later. The follow-up time points will be 1, 3, 6, and 12 months from randomization. Primary outcomes will be participants' self-reported improvement in visual disturbance on a scale of 1 to 10 and their scores on the National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25). Secondary outcomes will be an objective evaluation of the effectiveness of the treatment in reducing vitreous floaters through OCT and fundus photography and tracking any adverse events related to the eyes or overall health.

DISCUSSION

This clinical trial aims to evaluate the effectiveness of YAG laser vitreolysis in treating symptomatic vitreous floaters and assess the safety of performing early intervention with YAG laser vitreolysis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05800353 . Registered on 10 March 2023.

Forward Light Scattering of First to Third Generation Vitreous Body Replacement Hydrogels after Surgical Application Compared to Conventional Silicone Oils and Vitreous Body

To treat certain vitreoretinal diseases, the vitreous body, a hydrogel composed of mostly collagen and hyaluronic acid, must be removed. After vitrectomy surgery, the vitreous cavity is filled with an endotamponade. Previously, pre-clinical hydrogel-based vitreous body substitutes either made from uncrosslinked monomers (1st generation), preformed crosslinked polymers (2nd generation), or in situ gelating polymers (3rd generation) have been developed. Forward light scattering is a measure of Stray light induced by optical media, when increased, causing visual disturbance and glare. During pinhole surgery, the hydrogels are injected into the vitreous cavity through a small 23G-cannula. The aim of this study was to assess if and to what extent forward light scattering is induced by vitreous body replacement hydrogels and if Stray light differs between different generations of vitreous body hydrogel replacements due to the different gelation mechanisms and fragmentation during injection. A modified C-Quant setup was used to objectively determine forward light scattering. In this study, we found that the 1st and 3rd generation vitreous body replacements show very low stray light levels even after injection (2.8 +/- 0.4 deg2/sr and 0.2 +/- 0.2 deg2/sr, respectively) as gel fragmentation and generation of interfaces is circumvented. The 2nd generation preformed hydrogels showed a permanent increase in stray light after injection that will most likely lead to symptoms such as glare when used in patients (11.9 +/- 0.9 deg2/sr). Stray light of the 2nd generation hydrogels was 3- and 2-fold increased compared to juvenile and aged vitreous bodies, respectively. In conclusion, this significant downside in the forward light scattering of the 2nd generation hydrogels should be kept in mind when developing vitreous body replacement strategies, as any source of stray light should be minimized in patients with retinal comorbidities.

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.

Patient-reported outcomes in patients with vitreous floaters: A systematic literature review

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, and against a qualitative study investigating quality-of-life issues in patients with floaters. We assessed measurement properties of PROMs using an extensive range of psychometric quality criteria. We identified 59 studies using 28 different PROMs. Many PROMs were not specifically developed for patients with floaters. Floater-specific PROMs were mostly based on content validation from an ophthalmologist or researcher perspective; two included a patient perspective. Using the outcomes of the qualitative study, we found that the floater-specific PROMs were narrow in their content coverage, with most items relating to visual symptoms and activity limitations. Testing the psychometric quality of PROMs was rare, and when employed mostly limited to responsiveness and known group validity. The remarkable high number of floater-specific PROMs reveals a need for such measurements in ophthalmology. Unfortunately, reporting on psychometric quality is limited, and content development is most often done without patient involvement.

Spontaneous remission of vision degrading myodesopsia of posterior vitreous detachment type

PURPOSE

The study aims to observe the spontaneous remission of posterior vitreous detachment (PVD)-type vision degrading myodesopsia (VDM) during long-term follow-up.

METHODS

We retrospectively reviewed VDM patients with PVD type that refused any treatment. The ratio and time of significant spontaneous remission of floater symptoms occurring were described. The associated factors with significant remission of floater symptoms were analyzed in the univariate and multivariate logistic regression analyses.

RESULTS

In total, 179 patients with VDM were assessed. The mean age of all patients was 60.56 ± 0.47 years old, and the mean duration of follow-up was 23.89 ± 6.63 months. Of the patients, 40.78% have significant improvement in their floater symptoms after mean 16.55 ± 10.63-month follow-up. Myopia (OR = 0.280, 95% CI = 0.084-0.932, P = 0.038), the number of floaters > 3 (OR = 0.343, 95% CI = 0.172-0.683, P = 0.002), and floaters with string-like pattern (OR = 0.370, 95% CI = 0.166-0.824, P = 0.015) and blocky pattern (OR = 0.299, 95% CI = 0.090-0.993, P = 0.049) were negatively correlated with the significant spontaneous remission of VDM symptoms in the multiple binary logistic regression analysis.

CONCLUSIONS

Approximately 40% of VDM patients with PVD may experience significant spontaneous remission during long-term follow-up. Patients that are non-myopic and with fewer floaters are more likely to feel relief from VDM symptoms. Floaters with string-like or blocky patterns are less likely to undergo spontaneous remission.

Early vitrectomy in eyes with non-diabetic vitreous hemorrhage

Background

Optimal management of non-diabetic vitreous hemorrhage (NDVH) is controversial, and reliability of B-scan ultrasonography in detecting retinal tears (RTs) has been reported to be highly variable by previous literature.

Objectives

To report outcomes of conservative versus surgical management of NDVH and reliability of B-scan ultrasonography in detecting RTs and rhegmatogenous retinal detachment (RRD).

Design

Retrospective observational single-center cohort study.

Methods

Ninety-six consecutive NDVH from 96 eyes (96 patients) with minimum follow-up duration of 12 months were included.

Results

Seventy-two eyes (75%) underwent early pars plana vitrectomy (PPV), 19 (20%) were managed conservatively and 5 (5%) underwent late PPV. Initial mean best corrected visual acuities (BCVAs) were 1.95 ± 1.19, 1.19 ± 1.38, and 1.14 ± 1.04 logMAR respectively, the difference was statistically significant (p = 0.039). Mean final BCVAs were 0.92 ± 1.19, 0.59 ± 0.87, and 1.25 ± 1.89 logMAR, respectively, the difference was not significant (p = 0.447). When comparing initial and final BCVAs, the difference was significant only in the early PPV group (p = 0.00001) and was not significant in the conservative group (p = 0.066) and in the late PPV group (p = 0.46). Complications included RRD (n = 2) and re-bleed in vitrectomized cavity (n = 1) in the early surgical group, need for additional laser or cryoretinopexy to RTs (n = 2), retinal detachment (n = 1), neovascular glaucoma (n = 1), persistent vitreous hemorrhage (n = 2) in the conservative group. B-scan ultrasound showed preoperative 11.53% sensitivity and a 60.0% positive predictive value for diagnosing retinal tears (RTs) in NDVH.

Conclusion

The benefit of early PPV in NDVH seems to outweigh the risks of surgery, especially in the context of low sensitivity of B-scan in identifying RTs, and significant improvement in final BCVA following surgery may occur. NDVH should be promptly referred to vitreoretinal services, as surgery may be a safer and more advisable option.

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.

Visual Snow Syndrome as a Network Disorder: A Systematic Review

Aim: By reviewing the existing clinical studies about visual snow (VS) as a symptom or as part of visual snow syndrome (VSS), we aim at improving our understanding of VSS being a network disorder. Background: Patients with VSS suffer from a continuous visual disturbance resembling the view of a badly tuned analog television (i.e., VS) and other visual, as well as non-visual symptoms. These symptoms can persist over years and often strongly impact the quality of life. The exact prevalence is still unknown, but up to 2.2% of the population could be affected. Presently, there is no established treatment, and the underlying pathophysiology is unknown. In recent years, there have been several approaches to identify the brain areas involved and their interplay to explain the complex presentation. Methods: We collected the clinical and paraclinical evidence from the currently published original studies on VS and its syndrome by searching PubMed and Google Scholar for the term visual snow. We included original studies in English or German and excluded all reviews, case reports that did not add new information to the topic of this review, and articles that were not retrievable in PubMed or Google Scholar. We grouped the studies according to the methods that were used. Results: Fifty-three studies were found for this review. In VSS, the clinical spectrum includes additional visual disturbances such as excessive floaters, palinopsia, nyctalopia, photophobia, and entoptic phenomena. There is also an association with other perceptual and affective disorders as well as cognitive symptoms. The studies that have been included in this review demonstrate structural, functional, and metabolic alterations in the primary and/or secondary visual areas of the brain. Beyond that, results indicate a disruption in the pre-cortical visual pathways and large-scale networks including the default mode network and the salience network. Discussion: The combination of the clinical picture and widespread functional and structural alterations in visual and extra-visual areas indicates that the VSS is a network disorder. The involvement of pre-cortical visual structures and attentional networks might result in an impairment of "filtering" and prioritizing stimuli as top-down process with subsequent excessive activation of the visual cortices when exposed to irrelevant external and internal stimuli. Limitations of the existing literature are that not all authors used the ICHD-3 definition of the VSS. Some were referring to the symptom VS, and in many cases, the control groups were not matched for migraine or migraine aura.

Nd:YAG laser vitreolysis and health-related quality of life in patients with symptomatic vitreous floaters

BACKGROUND

The treatment of floaters has consisted primarily of monitoring. The therapeutic approach is based on surgical removal or Nd:YAG laser treatment. The objective of this study was the assessment of the quality of life in patients treated with Nd:YAG laser for floaters.

METHODS

Single-center pretest-posttest design in a cohort of subjects treated with Nd-YAG laser with Ultra Q-Reflex technology. Health-related quality of life of the patients was measured before and after the intervention with the Visual Function Questionnaires VFQ-25 and VFQ-39. Anxiety level was measured with the State-Trait Anxiety Inventory. Visual acuity, contrast sensitivity, and safety parameters were also considered.

RESULTS

Thirty-four patients were included in the study. For the VFQ-25 baseline, the median was 73.05, interquartile range (19.25) versus a final median value of 93.76 (8.73) with p < 0.01. The baseline median for the extended version VFQ-39 was 74.60 (19.01) versus the final median of 95.01 (6.50) with p < 0.001. Regarding the anxiety, according to the STAI questionnaire, there were statistically significant differences between the baseline and the final conditions, with a baseline median of 38 (11) versus a final median of 18 (19); p < 0.001. When the analyses differentiated between patients with and without myopia, there were statistically significant differences for VFQ-25 and VFQ-39.

CONCLUSIONS

This study shows an improvement in the health-related quality of life and a significant decrease in anxiety for patients that have undergone Nd: YAG Ultra-Q Reflex laser vitreolysis for floaters vaporization. The effect found is higher in myopic patients.

The effectiveness of ocriplasmin versus surgery for the treatment of macular holes: A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review looking at the effects of ocriplasmin compared to pars plana vitrectomy on macular holes to assess the effectiveness of the treatment options.

METHODS

Literature was searched through MEDLINE, EMBASE, CINAHL, Clinical Trials.gov, and ProQuest Dissertations and Theses until June 12, 2018. Conferences held through Association for Research in Vision and Ophthalmology, Canadian Society of Ophthalmology, and American Academy of Ophthalmology were searched until June 18, 2018. A total of 208 records were screened leaving 26. One author independently reviewed them for quality and extracted data. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were followed. The adverse events, MH closure rate, change in MH size, and the extent to which the patients' visual acuity is restored by each treatment option; ocriplasmin and vitrectomy.

RESULTS

Twenty-six articles were included for qualitative and quantitative analysis. Meta-analysis results showed a 34% closure of macular holes after ocriplasmin treatment compared to 92% after vitrectomy. A significant improvement in visual acuity was seen after vitrectomy (SMD = -1.42; CI: [-1.98, -0.86]) as well as the ocriplasmin treatment (SMD = -0.73; CI: [-0.98, -0.48]).

CONCLUSIONS

Results suggested 92% macular hole closure after vitrectomy compared to 34% after ocriplasmin. A significant improvement in visual acuity of patients was seen after both treatments. More good quality randomized controlled trials are required to make strong conclusions.

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.

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.

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.

Outcomes of transconjunctival sutureless 27-gauge vitrectomy for vitreoretinal diseases

AIM

To evaluate the safety and efficacy profile of 27-gauge (27G) pars plana vitrectomy (PPV) for the treatment of various vitreoretinal diseases.

METHODS

The clinical outcomes of 61 eyes (58 patients) with various vitreoretinal diseases following 27G PPV were retrospectively reviewed.

RESULTS

Surgical indications included rhegmatogenous retinal detachment (n=24), full-thickness macular hole (n=12), diabetic retinopathy (n=11), vitreous hemorrhage (n=6), Eales disease (n=4), pathological myopia-related vitreous floater (n=2), and macular epiretinal membrane (n=2). The mean follow-up was 166.4±61.3d (range 98-339d). The mean logMAR best-corrected visual acuity (BCVA) improved from 1.7±1.1 [0.02 decimal visual acuity (VA) equivalent] preoperatively to 1.2±1.0 (0.06 decimal VA equivalent) at the last postoperative visit (P<0.001). The mean operative time was 49.9min. With the exception of complicated cataract in one eye, no intraoperative complications were encountered. No case required conversion to conventional 20-, 23- or 25G instrumentation in all surgical maneuvers except for silicone oil infusion, which required a 25G oil injection syringe. Postoperative complications included transient ocular hypertension, vitreous hemorrhage, persistent intraocular pressure elevation, subconjunctival oil leakage, and recurrent retinal detachment. No cases of hypotony, endophthalmitis, and sclerotomy-related tears were observed.

CONCLUSION

The current results suggest that 27G PPV system is a safe and effective treatment for various vitreoretinal diseases. When learning to perform 27G PPV, surgeons may encounter a learning curve and should gradually expand surgical indications from easy to pathologically complicated cases.

Surgical Outcomes of 27-Gauge Pars PLana Vitrectomy for Symptomatic Vitreous Floaters

Purpose

To report the surgical outcomes of 27-gauge pars plana vitrectomy (PPV) for symptomatic vitreous floaters.

Methods

47 eyes of 47 patients (39 males, 83.0%) with symptomatic vitreous floaters who underwent 27-gauge PPV and followed up for more than 6 months were included. The mean age was 34.7 ± 13.5 years.

Results

No operative complication occurred. At first day postoperatively, the intraocular pressure (IOP) was significantly lower than that at other time points (8.6 ± 2.7 mmHg, p < 0.001). 28 (59.6%) eyes had transient hypotony (IOP < 8 mmHg). All were recovered within 1 week postoperatively. The BCVA of 41 eyes (41/47, 87.2%) remained unchanged or improved. Postoperative complications occurred in two eyes: one (2.1%) had endophthalmitis and one (2.1%) had retinal detachment. No clinical significant cataract was observed in the 42 postoperative phakic eyes. 91.5% of the patients were satisfied with the surgery outcome. Besides, 91.3% of the patients felt that the floaters were removed completely or only had an acceptable residual.

Conclusion

Visual acuity of most patients remained unchanged or improved following 27-gague pars plana vitrectomy for symptomatic vitreous floaters, resulting in high patient satisfaction. However, this treatment should be performed with great caution since severe postoperative complications may still occur. This trial is registered with NCT03049163.

27-Gauge Vitrectomy for Symptomatic Vitreous Floaters with Topical Anesthesia

Purpose

Traditionally acceptable methods of anesthesia for vitrectomy surgery are quite varied. However, each of these methods has its own potential for complications that can range from minor to severe. The surgery procedure of vitrectomy for symptomatic vitreous floaters is much simpler, mainly reflecting in the nonuse of sclera indentation, photocoagulation, and the apparently short surgery duration. The use of 27-gauge cannulae makes the puncture of the sclera minimally invasive. Hence, retrobulbar anesthesia, due to its rare but severe complications, seemed excessive for this kind of surgery.

Method

Three cases of 27-gauge, sutureless pars plana vitrectomy for symptomatic vitreous floaters with topical anesthesia are reported.

Results

The vitrectomy surgeries were successfully performed with topical anesthesia (proparacaine, 0.5%) without operative or postoperative complications. Furthermore, none of the patients experienced apparent pain during or after the surgery.

Conclusion

Topical anesthesia can be considered for 27-guage vitrectomy in patients with symptomatic vitreous floaters.

Degradation of Contrast Sensitivity Function Following Posterior Vitreous Detachment

PURPOSE

To evaluate the effect of posterior vitreous detachment (PVD) on contrast sensitivity function (CSF) in previously normal eyes, with the hypothesis that PVD reduces CSF.

DESIGN

Prospective observational case series.

METHODS

At a single clinical practice 28 eyes were evaluated: 8 eyes of 8 adults (mean age 54.4 ± 10.1 years; range 39-68 years) with normal CSF documented by Freiburg Acuity Contrast Testing (Weber index: %W) who subsequently experienced PVD, as confirmed by ultrasonography and optical coherence tomography; 8 fellow eyes without PVD; and 12 control eyes: 9 eyes with PVD in patients who chose observation and 3 fellow eyes without PVD.

RESULTS

At study entry there was no significant difference in CSF of fellow eye controls (mean 1.44 ± 0.27 %W; range 1.06-2.00 %W) and eyes that subsequently developed PVD (1.81 ± 0.61 %W; P = .146; range 1.01-2.69 %W). Following PVD there was a 52.5% reduction in CSF (2.76 ± 0.30 %W; P = .001; range 2.25-3.14 %W). CSF in the patients who chose limited vitrectomy (2.51 ± 0.46 %W; range 2.03-3.06 %W) was 41.8% worse than in the eyes with PVD of patients who chose observation (1.46 ± 0.21 %W; P = .001; range 1.08-1.87 %W). After vitrectomy, CSF improved by an average of 43.2%, normalizing in each case at 1 month (CSF 1.51 ± 0.28 %W; P = .001; range 1.14-2.00 %W), 3 months (1.38 ± 0.10 %W; P = .0002; range 1.28-1.51 %W), and 12 months (1.34 ± 0.34 %W; P = .0001; range 1.01-1.89 %W, n = 5) postoperatively, attaining the same CSF as the control fellow eyes (1.34 ± 0.20 %W; range 1.06-1.56 %W).

CONCLUSION

PVD is associated with significant reduction in CSF of previously normal eyes. This quantifiable negative impact on visual function can distinguish patients who are not significantly bothered by vitreous floaters from those with clinically significant symptoms.