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YAG laser for treatment of floaters still in pioneer stage
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I obtained a YAG laser very early. I visited my friend Danièle Aron-Rosa, MD, in Paris after her first reports, and she allowed me to perform YAG laser capsulotomy on three of her patients. I was amazed. I had been doing phacoemulsification with posterior chamber lens implantation since 1977. I performed posterior capsulotomy with a needle knife under a Zeiss Opmi 1 operating microscope through the pars plana in my office surgery suite. It was a disruptive innovation to be able to perform a posterior capsulotomy with a painless laser procedure in a few minutes.
In the early 1980s, I convinced my chairman, Don Doughman, MD, to buy me one of the first AMO YAG lasers, and mine had serial number 4. Later, at the Phillips Eye Institute, we obtained the Swiss YAG laser designed by Franz Fankhauser, MD. It was more sophisticated and could also perform YAG laser cyclophotocoagulation. Our practice at Minnesota Eye Consultants now owns Ellex YAG lasers, which have quite exquisite focusing capability. (I have no vested interest in YAG lasers.)
Little was known about YAG laser parameters, indications or complications when I obtained my first laser. I found one could, of course, perform posterior capsulotomy safely and effectively. I also found I could fragment the anterior capsule, cut the iris and remove precipitates from IOLs. My early experience convinced me that a large number of shots and powers up to 10 mJ were well tolerated. My first experience doing YAG laser vitreolysis was cutting vitreous strands to the wound with peaked pupils. I found higher energy settings were required than when cutting posterior capsule, often 4 mJ to 6 mJ.
While many shots and careful focusing were critical, it was clear YAG laser vitreolysis was possible. We looked at our complication rates and found elevated IOP, retinal detachment and cystoid macular edema could occur. Iritis was extremely rare, and I did not find it necessary to treat my patients after surgery with steroid or NSAID drops. We managed elevated IOP with topical antihypertensive pretreatment, usually topical apraclonidine. We found delaying YAG laser capsulotomy for at least 3 months after cataract surgery reduced the incidence of CME. Retinal detachment occurred more commonly in the younger male axial myope. I learned to counsel these patients about the increased risk and follow them more closely. Other risk factors included a history of retinal detachment or a symptomatic retinal break in either eye.
As mentioned above, today I have access to an Ellex YAG laser. I continue to perform YAG laser vitreolysis and have treated some patients with vitreous floaters and vitreous opacities. I have restricted my treatments to pseudophakic eyes with anterior vitreous opacities. I am impressed that many have improvement in their symptoms, but some do not. For phakic patients with severe symptoms and pseudophakic patients with posterior vitreous floaters and opacities, I currently refer them to my vitreoretinal colleagues. To date none of them have ever recommended or performed a YAG laser vitreolysis, but every year they seem more comfortable performing vitrectomy as the procedure becomes continuously less invasive.
During a recent discussion with Steve Charles, MD, he was very negative on YAG laser vitreolysis for vitreous floaters and opacities, but quite positive on vitrectomy in select cases with meaningful symptoms. My impression is that the party line of the retinal community is definitely guarded to negative on YAG laser vitreolysis. In every procedure and treatment, there are pioneers/innovators, then early adopters followed later by the larger majority. I believe we are in the pioneer/innovator stage for YAG laser treatment of vitreous floaters and opacities, especially for those in phakic eyes and when near the retina.
I am not a pioneer/innovator in this field, but I do feel comfortable lysing vitreous strands and treating anterior floaters and opacities in pseudophakic eyes. I commonly perform these treatments at the time of YAG laser posterior capsulotomy. If there are significant vitreous opacities in the anterior vitreous, I increase the power to 4.5 mJ and treat them. My goal is to disrupt them into tiny pieces. In some cases I can cut vitreous strands on one side of a large floater or opacity and get it to move off to the side out of the visual axis.
There is an art to these treatments, and I personally have never applied more than 200 shots. It is surprising to me that a surgeon and patient could tolerate as many as 1,000 shots in a single setting, as noted in the accompanying cover story. I counsel my young male axial myopes and those with other risk factors about the possibility of a retinal detachment, although I do not have enough experience to know that they are at greater risk than they are after YAG laser capsulotomy alone. I see the patients 1 month after treatment and examine the retina. I do find that many patients are significantly affected by their vitreous floaters/opacities and today find it appropriate to discuss potential treatments with those who have significant symptoms.
I applaud the innovators working in this area with both the YAG laser and small-port vitrectomy. I encourage prospective clinical trials and honest reporting of outcomes, including patient-reported outcomes with validated surveys and, of course, complication rates. Eventually, a randomized prospective study comparing YAG laser vitreolysis with small-port vitrectomy for vitreous floaters and opacities would be desirable. Perhaps DRCR.net can get such a study funded. As in so many areas of ophthalmology, we have much to learn, but a minimally invasive, safe and effective way to treat symptomatic visually significant vitreous floaters and opacities is a major unmet need.
Disclosure: Lindstrom reports no relevant financial disclosures.