Begone Floaters!

The tide is turning for patients with vision-degrading vitreopathy.

Landmark paper: J Sebag et al., “Long-Term Safety and Efficacy of Limited Vitrectomy for Vision Degrading Vitreopathy Resulting from Vitreous Floaters”, Ophthalmology Retina, 9, 881–887 (2018). DOI: e201803011

This study, published in September 2018, looked at outcomes of patients undergoing vitrectomy for vitreous opacities, also known as vitreous floaters (1). Vitreous opacities contribute to the disease entity of vision-degrading vitreopathy, which can lower visual acuity (VA) and degrade contrast sensitivity function (CSF). Vitrectomy for floaters has remained controversial, and much debate has occurred about the appropriateness of vitreoretinal surgery for patients with good VA but bothersome floaters; however, with the widespread adoption of micro incisional vitrectomy surgery (MIVS), efficient and safe surgical approaches are available that should be considered. Prior to this study, long-term results in a large series with objective quantitative outcome measures were lacking.

This case series enrolled 145 patients reporting bothersome vitreous floaters, which were compared to 70 age-matched controls. Posterior vitreous detachment (PVD) alone was the cause in 96/195 (49.2 percent), myopic vitreopathy alone was the cause in 30/195 (15.4 percent), PVD with myopic vitreopathy was the cause in 56/195 (28.7 percent) and asteroid hyalosis was the cause in 13/195 eyes (6.7 percent).

Limited vitrectomy with 25-gauge instruments was performed without surgical PVD induction, preserving 3 to 4 mm of retrolental vitreous in phakic eyes. The study had excellent follow-up of mean 32.6 months (range 3–115 months) and defined main outcomes measures of VA, 39-item National Eye Institute Visual Function Questionnaire (VFQ) results, CSF (Weber index), and quantitative ultrasonography results.

The study found that with the surgical technique employed, vitreous echodensity decreased by 94.1 percent (P < 0.0001), VFQ results improved by 19.3 percent (P < 0.0001) and VA improved (P < 0.0001). Of particular importance, preoperative CSF was degraded by 91.3 percent compared with controls (P < 0.0001) and this normalized at 1, 3, 6, 12, 24, 36, and 48 months after surgery (P < 0.00005 for each time point).

During the study period, there were no cases of endophthalmitis. There were three retinal tears and three retinal detachments that underwent successful repair. Clinically significant vitreous hemorrhage developed in two patients, clearing spontaneously. Two epimacular membranes and four recurrent floaters from new PVD were treated by re-operation. Cataract surgery occurred in 21 of 124 patients (16.9%) at a mean age of 64 years (no patients younger than 53 years required cataract extraction); cataract surgery occured at an average of 13.1 months after vitrectomy.

Vitrectomy for vitreous floaters remains a controversial topic. But as any ophthalmologist or vitreoretinal surgeon knows, this is a common problem and patients who present for treatment options are significantly bothered by symptoms.

This case series has two major takeaways:

First, patients with vision degrading vitreopathy have clinically relevant effects on visual function, contrast sensitivity, vitreous echodensity and visual acuity compared to controls. This study helps give credence to these patients and gone are the days where the symptoms of “floaters” were trivialized. The diagnosis of vision degrading vitreopathy helps give credibility to a pathologic state with significant objective markers.

Second, the authors show that limited 25-gauge MIVS provides an effective and safe treatment approach that decreases vitreous echodensity, improves patient well-being, improves VA, and normalizes CSF.

Specifically, by having long-term follow-up in the case series, we can better counsel patients on the efficacy and safety profiles of this intervention during the informed consent process. As the authors correctly point out, these findings warrant a prospective randomized trial and highlight the evolving surgical spectrum of MIVS.

Inside perspective

First author Jerry Sebag shares the background and impact of his “landmark literature”…

Myodesopsia (Greek for floaters) is experienced by young people with myopic vitreopathy and older people with posterior vitreous detachment. When vitreous opacities also cause degradation in contrast sensitivity function, the condition is known as vision degrading myodesopsia. Patients with this ailment have long been dismissed by doctors as not having a disease because, until recently, there were no tests that could quantify severity and identify individuals deserving intervention. Once we developed quantitative ultrasound to evaluate vitreous structure (1) and began measuring contrast sensitivity function to quantify vision beyond visual acuity (2, 3), we realized that there are patients who suffer greatly with this problem. Case selection was thus enabled, and a cure could legitimately be offered. Vitrectomy was modified to minimize risks of infection, retinal detachment, and cataract. The safety profile has been very high in the short term (4) and long term (5). Quantitative outcome measures documented reduced vitreous density, improved visual acuity, and normalized contrast sensitivity function.

But above all in importance has been the exceptional degree of patient happiness (confirmed with VFQ-39 testing), making the journey greatly satisfying.