‘Fun’ with Floaters: Counseling, Treatment and Managing Expectations – Retina Tips for Anterior Segment Surgeons

Although eyeballs (and even ophthalmic specialists) typically enjoy the division between the anterior and posterior segments, on occasion, overlap occurs. This crossover was explored on Day 1 of the American Society of Cataract and Refractive Surgery (ASCRS 2022) annual meeting in a session titled Retina Essentials for the Anterior Segment Surgeon, moderated by Dr. Christina Weng. Below, we cover How to Counsel Patients with Floaters as presented by Dr. Aziz A. Khanifar from the Retina Group of Washington (District of Columbia).

Those Pesky Floaters

When a patient comes in complaining of floaters, the first thing to consider is the cause, began Dr. Khanifar: “It’s very important to know what we’re dealing with and then we can decide whether or not we’re going to treat them.”

He explained that obtaining a thorough patient history is a critical first step, as well as ruling out any urgent etiologies. “We want to know how the floaters are affecting their overall visual function,” explained Dr. Khanifar. 

In regard to treatment, subjective factors like number of floaters, duration and circumstances should be considered — as well as if the patient actually wants treatment. Meanwhile, objective factors include visual acuity, contrast sensitivity, age and lens status. “If the patient does want treatment, it’s important to talk about expectations,” he shared. 

Floaters can present in different shapes — from arc-shaped, round or transparent, to shadows or clouds, as well as black dots — and their shape can also help guide recommendations to treat or not to treat. 

“When you’re looking at the patient, you want to make sure you don’t miss something much more important — you want to make sure you don’t miss a retinal tear or retinal break; you want to make sure that they don’t have uveitis and that’s not the reason they’re having floaters — because that’s an urgent thing to take care of,” continued Dr. Khanifar. “The other thing to look out for is neovascularization.”

Potential Treatment Options

There are two potential treatments for floaters: YAG vitreolysis and pars plana vitrectomy (PPV) — and both have notable advantages and disadvantages. 

Dr. Khanifar explained that although YAG is an in-office procedure with no risk of infection, it can cause an increase in IOP and/or uveitis, a retinal break or even result in more floaters. On the other hand, PPV is considered the gold standard and definitive treatment, although it does carry surgical risk including cataract development (20% incidence within the first year) and retinal detachment. He recommends observation if the floaters are not functionally significant. 

“If the patient has a single (or maybe two) relatively large focal opacities, then we can consider thinking about YAG vitreolysis — those would probably be the only patients I would refer,” he said, noting that he doesn’t personally perform YAG vitreolysis.

“If the patient has very high expectations — if it’s a patient that doesn’t want to have a single floater in their eye no matter what — that’s another thing to consider,” continued Dr. Khanifar. “If they want to avoid the operating room, you can consider YAG vitreolysis. If they don’t care about going to the operating room, then pars plana vitrectomy.”

In addition, he cautions that with YAG vitreolysis, it’s important to be aware that all the floaters might not resolve — and sometimes one floater could turn into five or 10 floaters; multiple sessions could be required as well. “If you do multiple sessions and you can’t get rid of all the floaters, then you treat with pars plana vitrectomy,” concluded Dr. Khanifar.

Following his presentation, Dr. Weng shared more insight on YAG vitreolysis for floaters: “I think it’s interesting and a reasonable option but we don’t generally support that because we don’t understand the parameters and complications, etc., But I do know some anterior segment surgeons and colleagues who are doing it.”

Editor’s Note: ASCRS 2022 is being held April 22-26, as a physical show in Washington DC, USA. Reporting for this story took place during the event.

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