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12/4/2015
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Kirk H. Packo, MDProfessor & ChairmanRush University Medical CenterChicago, IL
2015OPHTHALMOLOGYUPDATESan Francisco, CaliforniaDecember 4-5, 2015
The author acknowledges compensation as consultant to:The author acknowledges compensation as consultant to:
The author’s institution has received grant supportfrom: The author’s institution has received grant supportfrom:
• Alcon Surgical, Inc• Allergan, Inc.• Genentech• Optoview• Regeneron Pharmaceuticals, Inc
• Alcon Surgical, Inc• Allergan, Inc.• Genentech• Optoview• Regeneron Pharmaceuticals, Inc
• Alcon Surgical, Inc• Alimera Sciences• Alcon Surgical, Inc• Alimera Sciences
No conflicts relevant to this discussionNo conflicts relevant to this discussion
“Exogenous” Sources:• Hemorrhage (red cells)
• Inflammation (white cells)
• Infiltration (tumor cells, amyloidosis, RPE cells)
• Asteroid hyalosis(calcium deposits)
“Endogenous” Vitreous Sources:• Aggregation of vitreous fibrils
• Posterior vitreous cortex & Parapillary glial tissue* * Hyaluronic acid drops
& Vitreous liquefiesCollagen fibers aggregate
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Similar to Cotton Candy Sugar Fibers Clumping
Weiss Ring &Posterior Vitreous Cortex
Weiss Ring &Posterior Vitreous Cortex
Sebag, J
• Degenerative opacities composed of hydroxyapatite (calcium soaps & phospholipids)
• Slight association with diabetes
• Rarely noticeable to patient – only very rarely justifies vitrectomy to improve symptoms
• View in by doctor is much worse than patient’s view
• Able to see fundus much better with fluorescein angiography
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Asteroid Ultrasound
AsteroidOCT Imaging
Optos Imaging Fluorescein Angiography
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• Blue light (430 nm) is absorbed by RBC’s in capillaries.
• Brain "edits out" the shadow lines of the capillaries by dark adaptation of the photoreceptors lying beneath the capillaries.
• WBCs do not absorb blue and create gaps in the blood column
• WBCs appear as bright dots
• Focus behind lens with slit lamp
• Have patient look up + look straight against a red reflex
• 78D Biomicroscopy with joystick pulled back
• Kinetic ultrasonography
• OCT imaging
• Kinetic OCT imaging of infrared view Biomicroscopy
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Kinetic Ultrasonography
BMC Ophthalmol 2015:15:22-24
• Case report of a large floater (vitreous cyst)
• OCT used to qualitate the impact of the floater on the vision
Clinical Appearance
Ultrasound
Patient Drawing
BMC Ophthalmol 2015:15:22-24
OCT Infrared Image 3D Reconstruction Standard OCT showing “ring” scotoma - peripheral shadowing
Kinetic OCTLarge Floaters Small Floaters
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• Floaters are always caused by a PVD
• Floaters get less noticeable with time due to gravitational settling
• Floaters get less noticeable with time due to neuro-psychological adaptation
• People who complain of floaters have a psychologic problem
Am J Ophthalmol 2011:152(1):60-65
• 266 patients with floaters (age > 21) surveyed and utility value assessed
• Utility Value:• Value 1.0 = “Perfect Health”• Value 0.0 = “Death”
• Metric Used to Calculate Utility Value:• Time Trade Off (TTO): Willingness to trade off #years life out of every 10 years
to get rid of problem• Standard Gamble (SG): Willingness to risk death or blindness to rid problem
Am J Ophthalmol 2011:152(1):60-65
• Utility Value of Floaters:• Is the same as vision loss from AMD• Is lower than diabetic retinopathy or glaucoma• Is the same as mild angina, mild stroke, colon cancer, and asymptomatic HIV• The same for acute floaters (< 1 month) or chronic floaters (> 1 year), thus do
not become less frustrating with time• Unilateral floaters had the same UV as bilateral floaters
• Time Trade Off (TTO) of Floaters:• Willingness to trade off 1.1 years of life out of every 10 years
• Standard Gamble (SG) of Floaters:• Willingness to accept an 11% risk of death and 7% risk of blindness
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• Absolute size of floaters
• Floaters in the visual axis
• Floaters clumped anteriorly near lens
• Myopia – magnifies the retinal images
• Multifocal Intraocular Lenses
ReSTORDiffractive
TechnisRefractive
• Often verydistraught
• May be doctor shoppers
• Shops the internet ~ participates in blogs
• Professional surgical patient (LASIK, YAG)
• Young patients more intollerant
• Often very happy when floaters removed
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• 143 patients with floaters surveyed• 77 (54%) were first time patients
66 (46%) had seen multiple doctors• Women & non-myopes most likely doctor shoppers
• Is doctor shopping related to the patient’s personality or due to doctors not being sympathetic to patient’s complaint?
Int. J. Environ. Res. Public Health 2015, 12, 7949-7958
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1. Observation
2. Refer for psychologic counseling
3. Hyaluronidase (Vitrase™) enzyme
4. Holistic, herbal & other “treatments”
5. YAG laser vitreolysis
6. Vitrectomy
YAG Vitreolysis
Vitrectomy
• Should be tried first, especially with acute onset of floaters/PVD
• Consider occupational needs
• Does it impact any activities?
• Is the patient phakic?
• Is there other retinal pathology?’
• Often does not lessen with time
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• Patients can train themselvesto see minimal floaters – then become fixated
• Can possibly train themselves to disregard them?
• Anxiolytic medications?
• Patients usually are very resistant to this suggestion
• Vitrase™ - Ovine hyaluronidase
• FDA approved as a tissue spreading agent
• Off label use intraocularly
• Theoretically will decrease hyaluronidase thus liquefying vitreous allowing floaters to fall inferiorly
• Study in Mexico showed 10% patients were made worse
Herbal Eye Drops
Ayurvedic WarmEye Bath Treatments
Exercises &Palming Massage
Mystery Cure$17
The Silva Healing Method
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• Minimal evidence on efficacy & safety
• Not covered by insurance ($2,500 - $5,000 per eye)
• May require special Q-switched laser
• Promoted by handful of ophthalmologists that do treatment exclusively; promoted on internet
www.vitreousfloaters.com www. thefloaterdoctor.com www.EyeFloaters.com Dr. Karickhoff ’s book$225.00
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• 31 patients (42 eyes) with floaters from PVD underwent 54 procedures with Nd:YAG laser
• Outcome was “subjective improvement”
• 38%were “moderately” improved; 61.5%had no improvement
• 36%underwent subsequent vitrectomy
• 1 patient developed a retinal detachment
Eye (London)2002 Jan;16(1):21-6.
• “FOV” – Floaters Only Vitrectomy
• Controversialamong retinal surgeons
• More common with small gaugesurgery
• Phakic eyes will develop cataract
• Balance against other risksof typical vitrectomy (RD, tears, endophthalmitis, glaucoma)
• The only true way to remove floaters
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• 0.44 mm diameter(cf. 20 ga = 0.95 mm)
• The smallest gauge instrumentation
• Sclerotomies easily seal without sutures
• Full complement of instruments (probe, light, laser, forceps)
• Produced by multiple companies
Am J Ophthalmol 2011:151:995-998
• Review of 116 consecutive floaterectomiesin Amsterdam, Netherlands
• Intraoperative Adverse Problems:• 16.4% iatrogenic retinal tears• 1 case of intraop choroidal hemorrhage (resolved)
• Postoperative Adverse Problems:• 2.5% (n=3) retinal detachment• 50% of phakic eyes developed cataract in 1 year• 7.8% transient increased IOP
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Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382
• Review of 110 consecutive floaterectomiesin Nijmegen, Netherlands
• 23 ga vitrectomy; assessed for satisfaction, complication, VFQ-25
• 85% were satisfied or “cured” – 9.3% were dissatisfied
• Complications:
• 10.9% Retinal detachment (4.5% in first 3 months)• 5.5% Cystoid macular edema• 3.6% Epiretinal membrane (macula pucker)• 0.9% Each of: Glaucoma surgery – Macular hole - Scotoma
Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382
Complications Outcomes of the Patients with Retinal Detachments
Postop retina tear
Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382
Overall Patient Satisfaction after Vitrectomy
Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382
Time Troubled by Floaters BEFORE Vitrectomy
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Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382
Time Troubled by Floaters AFTER Vitrectomy
Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382
Difficulty Reading Small Print Before & After Vitrectomy
Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382
Difficulty Driving at Night Before & After Vitrectomy
Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382
Would You Recommend Vitrectomy to a Friend with Floaters ?
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Retina 34:1055–1061, 2014
• Review of 168 consecutive floaterectomiesin Birmingham, Alabama
• 25 ga vitrectomy; assessed for satisfaction, complication, VFQ-25
• 96% were satisfied or “cured” – 4% were dissatisfied
• Complications:
• 0 Intraop or Postop Retinal detachment • 1 pt Transient cystoid macular edema• 2 pts. Transient vitreous hemorrhage• 7.1% Intraoperative retinal breaks - treated
Retina 34:1062–1068, 2014
• Review of 66 consecutive 25 ga. floaterectomiesin California
• Causes: 80% from PVD; 32% from myopic vitreopathy
• NO PVD was induced in the 20% not having a PVD preop
• VFQ was 28% lower in preop floater patients than age matched controls VFQ improved by 29% after vitrectomy
• NO cases of retinal tears, RD or infection.
• Only 24% developed cataract at 15 months (zero below age 53)
Henry CR, Schwartz SG, Flynn HW Clinical Ophthalmology 2014:8 1649–1653
• 24 y/o female – 20ga floaterectomy
• Inflammation on 1st postop day
• Staphylococcus capraeendophthal.
• Recovered 20/80 vision (from 20/20)
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Simple Vitrectomies?
Only happen Over the Rainbow
• Examine! – Are significant floaters there?
• Consider Surgery:• Has the patient tried a period of observation?• Are floaters anterior/clumped behind lens?• Is there a multifocal lens?• Does the patient have a convincing story/need?• Is the patient ready to accept risks?
• Discourage Surgery:• Is the patient phakic?• Is there other pathology? (Lattice, High myopia)
• Already had multiple procedures? (LASIK, YAG Vitreolysis)
Thank You !
OPHTHALMOLOGYUPDATESan Francisco, CaliforniaDecember 4-5, 2015
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