Vitrectomy for Floaters: Patient Selection and Surgical Consideration
Learn about vitrectomy for floaters, including patient selection criteria, surgical indications, pre-operative risk factors, anesthesia, operative techniques, recovery, and post-operative guidelines. Discover why and when to consider referral for this innovative procedure to improve patients' quality of life.
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Vitrectomy for Floaters-when, why, how Frank S Siringo, MD, OD Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care March 2025 Winter Ophthalmic Summit - 1 -
- 2 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Course Description Vitrectomy for Floaters-when, why, how This talk will discuss patient selection for vitrectomy for floaters. Indications for the procedure will be enumerated, such as duration of symptoms and impact on vision related quality of life. Symptoms will be categorized as either/both discrete opacities vs diffuse reduction in contrast sensitivity. Patient-centered factors predictive of recalcitrant symptoms, such as corneal and lens status, will be explored. Pre- operative risk factors for complications will be discussed. Anesthesia and operative technique will round out the talk, which will end with a question and answer period. - 3 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-when When to consider Referral Rapid referral acute PVD and unable to r/o break surgeon to f/u Elective referral Persistent symptoms >3 months Surgeon to discuss: possibility for spontaneous improvement Vitrectomy risks, benefits, recovery Surgeon recheck ~2 months after initial eval, (~6 mos after symptom onset) Book surgery if still having visually disabling symptoms - 4 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-why Why refer patients for surgical consideration? Clear visually disabling floaters in visual axis Remove gauze-like posterior hyaloid causing diffuse blur Offer hope Some patients feel this is their new lot in life Limits their visually related ADLs - 5 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-why Contrast sensitivity PVD reduces CSF Varying degree based on vitreous density Pre-existing factors reducing CSF High myopes post-RK/PRK/LASIK Multifocal IOLs EDOF IOLs Additive diminution Double or triple hit - 6 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-why Contrast sensitivity examples of normal and reduced CSF CVI Scotland - Simulated Images - Flowers - 7 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-how Surgical eval and procedure Preoperative eval Scleral depression Pre-treat tears, holes or high-risk lattice Procedure 25/27 g pars plana vitrectomy Trans-conjunctival, sutureless +/- triamcinolone staining +/- partial air fluid exchange - 8 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-how Anesthesia and recovery Anesthesia options (1 or 2) + (3 or 4) 1. Monitored anesthesia care (IV anxiolytic/analgesic) 2. sublingual anxiolytic 3. sub-tenon block 4. retrobulbar block Recovery One week no heavy lifting/bending Vision worse week one vs preop Air bubble 3-5 days Vision better vs preop by week one - 9 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-how Surgical Considerations Induce PVD if not complete? limited vs complete vitrectomy Remove anterior hyaloid? Cataract acceleration? Peel vs observe insignificant ERMs? - 10 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-how What about laser? First RCT: YAG vitreolysis vs sham symptomatic Weiss ring 54% had symptom improvement after 1 treatment Lead author no longer doing this procedure Second RCT: YAG vitreolysis vs no intervention Different from sham control Improved visual function and subjective scores in YAG group No difference in CSF YAG vs control No RCTs comparing laser to vitrectomy - 11 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-how What about laser? Laser safety No risk of infection Risk of lens/retina damage Often need multiple sessions amplifying risk Platform Expensive investment Out of pocket cost to patient PPV is routine for surgeons - 12 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-how Surgical video - 13 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline Pearls The more symptomatic pre-op, the happier post op The more CSF is affected, the more symptomatic Post-LASIK myopes MFIOLs These patients have been consumers of eye care for decades Unlikely to accept there s nothing we can do Will seek second opinion if they aren t offered hope Laser vitreolysis treats discrete opacities May not improve CSF as posterior hyaloid not removed May be helpful for those with focal symptoms - 14 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Outline-vitrectomy for floaters Questions? - 15 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
References 1. Mano F, LoBue SA, Eno A, Chang KC, Mano T. Impact of posterior vitreous detachment on contrast sensitivity in patients with multifocal intraocular lens. Graefes Arch Clin Exp Ophthalmol. 2020 Aug;258(8):1709-1716. doi: 10.1007/s00417-020-04705-9. Epub 2020 Apr 22. PMID: 32318806. 2. Nguyen JH, Yee KMP, Nguyen-Cuu J, Mamou J, Sebag J. Vitrectomy Improves Contrast Sensitivity in Multifocal Pseudophakia With Vision Degrading Myodesopsia. Am J Ophthalmol. 2022 Dec;244:196-204. doi: 10.1016/j.ajo.2022.05.003. Epub 2022 May 10. PMID: 35562070. 3. Milston R, Madigan MC, Sebag J. Vitreous floaters: Etiology, diagnostics, and management. Surv Ophthalmol. 2016 Mar-Apr;61(2):211-27. doi: 10.1016/j.survophthal.2015.11.008. Epub 2015 Dec 8. PMID: 26679984. 4. Sebag J. Vitreous and Vision Degrading Myodesopsia. Prog Retin Eye Res. 2020 Nov;79:100847. doi: 10.1016/j.preteyeres.2020.100847. Epub 2020 Mar 6. PMID: 32151758. 5. Sebag J, Yee KM, Wa CA, Huang LC, Sadun AA. Vitrectomy for floaters: prospective efficacy analyses and retrospective safety profile. Retina. 2014 Jun;34(6):1062-8. doi: 10.1097/IAE.0000000000000065. PMID: 24296397. 6. Garcia GA, Khoshnevis M, Yee KMP, Nguyen-Cuu J, Nguyen JH, Sebag J. Degradation of Contrast Sensitivity Function Following Posterior Vitreous Detachment. Am J Ophthalmol. 2016 Dec;172:7-12. doi: 10.1016/j.ajo.2016.09.005. Epub 2016 Sep 12. PMID: 27633841. 7. Nguyen JH, Nguyen-Cuu J, Mamou J, Routledge B, Yee KMP, Sebag J. Vitreous Structure and Visual Function in Myopic Vitreopathy Causing Vision-Degrading Myodesopsia. Am J Ophthalmol. 2021 Apr;224:246-253. doi: 10.1016/j.ajo.2020.09.017. Epub 2020 Sep 17. PMID: 32950508. 8. CVI Scotland - Simulated Images Flowers 9. Shah CP, Heier JS. YAG Laser Vitreolysis vs Sham YAG Vitreolysis for Symptomatic Vitreous Floaters: A Randomized Clinical Trial. JAMA Ophthalmol. 2017 Sep 1;135(9):918-923 10. Ludwig GD, Gemelli H, Nunes GM, Serracarbassa PD, Zanotele M. Efficacy and safety of Nd:YAG laser vitreolysis for symptomatic vitreous floaters: A randomized controlled trial. Eur J Ophthalmol. 2021 May;31(3):909-914 - 16 - Saving Sight and Improving the Lives of our Patients Through Innovation and the Highest Quality Care
Vitrectomy for Floaters-when, why, how Frank S Siringo MD, OD
