BLOG: Patients don’t deserve floaters
A long time ago, my kids taught me that the importance of pain depends upon whether you are the one giving it or the one receiving it.
As surgeons, and the ones who often create pain, we should be very conscious of this principle. What we describe as “a little discomfort” is enough to ruin a surgical experience. And it applies as well to other annoyances our patients endure. Floaters after cataract surgery are an example. Historically, they were something we told patients to live with, but for some, vitreous opacities are much more than an occasional distraction, and we probably need to recommend surgical intervention for floaters much more frequently.
Ann, a recent cataract patient of mine who received a trifocal lens, had nebulous visual quality complaints after surgery that occurred in both high and low lighting conditions. She loved her uncorrected vision but couldn’t tolerate this side effect. We discussed a lens exchange, and then, upon further questioning, she described subtle opacities that moved across her vision independently, suggesting floaters. Instead of a lens exchange, Ann underwent an optical vitrectomy with my retina colleague, and she now has “perfect vision.”
We need to recognize that floaters are common, especially in the cataract population. An unpublished study in our practice of patients presenting for cataract consultation showed that 75% had at least some floater symptoms before surgery, and almost 30% were bothered by them “a fair amount” or more. After surgery, this increases because the diffuse forward light scatter caused by the cataract is replaced by more discrete scatter caused by the individual vitreous opacities.
We also need to acknowledge that floaters really do impact quality of life. A 2011 study on 311 patients performed in Singapore showed patients were willing to sacrifice nearly a year of their remaining life in exchange for being rid of floaters (Wagle and colleagues). This sentiment was independent of the duration of symptoms, the presence of a posterior vitreous detachment or the presence of severity of myopia. These findings have been confirmed in a number of other studies.
How can we quantify floaters for making surgical decisions? A number of validated questionnaires (Woudstra-de Jong and colleagues) can stratify the degree of visual disability they create, and at least one B-scan ultrasound classification system (Mamou and colleagues) has been devised that correlates with patient symptoms. We need better ways to stratify risk of surgical complications in these patients. The presence of a posterior vitreous detachment certainly is one favorable prognostic factor, and there are probably others that could give us insight. Ultimately, it’s a traditional decision made by a patient, based on a fair understanding of the real-world risks alongside the potential benefits.
What’s the best way to treat these floaters? This varies by whom you ask and what tools they have available. Ellex markets a YAG laser for vitreolysis, and PulseMedica recently raised $12 million to develop hardware for floater detection and treatment. But laser tools for vitreolysis have been enthusiastically embraced by only a few anterior segment surgeons and almost none of the retina specialist community. If they offer any treatment at all, the latter tend to favor pars plana vitrectomy using small-gauge, high-frequency cutting instruments, which have greatly reduced surgical time and risk compared with legacy vitrectomy approaches.
In the longer term for cataract patients, I can foresee a time when surgeons preventively perform an optical vitrectomy at the time of cataract surgery. While it seems far-fetched by today’s standards of care, think about the benefits: While we are already in the eye, we would eliminate an important cause of visual disturbance that affects three out of four cataract patients. We could simultaneously open the poster capsule to prevent future opacification. Many anterior segment surgeons have already adopted pars plana vitrectomy for unplanned vitreous prolapse, and our skills would only improve with more frequent and planned use.
Considering the frequency of incidence, the lifestyle impact and the availability of effective treatments, we owe it to our patients like Ann to present surgical solutions for floaters when they might benefit. Let’s create a new standard of care centered on what our patients really want.
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References:
- Mamou J, et al. Invest Ophthalmol Vis Sci. 2015;doi:10.1167/iovs.14-15414.
- Wagle AM, et al. Am J Ophthalmol. 2011;doi:10.1016/j.ajo.2011.01.026.
- Woudstra-de Jong JE, et al. Surv Ophthalmol. 2023;doi:10.1016/j.survophthal.2023.06.003.
For more information:
John A. Hovanesian, MD, FACS, an ophthalmologist specializing in cataract, refractive and corneal surgery at Harvard Eye Associates in Laguna Hills, California, can be reached at drhovanesian@harvardeye.com.
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