I have added this page as I have had some patients asking me which is the best treatment for their floaters. As there is a lot of information of very questionable quality and purpose on the internet, this section will hopefully provide some more objective information.
IF YOU ARE EXPERIENCING RECENT ONSET OF FLOATERS, PLEASE GO TO PAGE POSTERIOR VITREOUS DETACHMENT
First of all, floaters are not a disease, they are the perception of the gel (aka vitreous) moving within the eye. As the gel moves, it casts shadows on the light sensitive part of eye (the retina) and these moving shadows are perceived as floaters. Everyone has or will have floaters so how much of a problem this is depends on the person as people can have widely differing perceptions of their floaters depending on a variety of factors, such as:
1) The state of the gel, i.e attached to the posterior retina or detached, with the latter being associated with more symptoms
2) The age of the person with a higher incidence of floaters perceived by people of older age because the gel turns from being solid to liquid as we grow up
3) The size of the eye i.e the bigger (more shortsighted) the eye the more the symptoms of floaters
4) The presence of other substances within the gel, such as blood, calcium, amyloid.
The appearance or a change in quantity or quality of floaters should be reviewed by an eye doctor to exclude sight threatening problems (see PVD, DM)
For the vast majority of people, floaters range from barely perceivable to occasionally bothersome. Floaters do get worse after a posterior vitreous detachment but over time they become less bothersome as the vitreous gel moves further away from the back of the eye and collapses further on itself, which causes the floaters to move away from the centre of vision.
"So, what is the best treatment for my floaters?"
1) If they are of recent onset, get your eye checked to make sure there are no retinal tears or in the case of diabetes, there is no advanced diabetic eye disease ( I will not mention other less common causes as there are many)
2) In most cases, people function well despite the floaters. This is usually due to a combination of the floaters slowly moving away from the central vision and adaptation in higher brain function (aka getting used to them!)
3) If your floaters are really bothering you then you should see your eye doctor in case your floaters are more than just simple floaters and are associated with an eye disease
"Ok, I had my eye checked and it is fine but my floaters are really bothering me"
Surgery for floaters is very uncommon in the UK and this is for a reason. Any form of surgery is not without its risks and for what is considered to be a benign problem, surgeons are understandably cautious and advise patients against surgery.
A quick search on the internet will find all sorts of miracle cures and heated debates between sufferers as to which is the best treatment. Most of the information on the internet is at best inaccurate and often misleading.
As doctors, we should not be patronising and tell our patients what is best for them. As adults, we have the right to make an informed choice. For this reason, I have written short summaries on the three most commonly treatments encountered on the web. I hope you will find it useful . If you feel that your problem with floaters is so disabling to justify taking these risks then make sure you go to a reputable retinal surgeon (and avoid floater specialists for obvious reasons!). Removing the vitreous is the easy bit retinal surgeons do before they go on to fix the problem such as removing membranes, reattaching retinas etc. so do not feel that you are safer in the hands of a floater specialist!!
Before making a choice, you will need to be informed about the customised risk profile of your own eye, which depends on the state of the vitreous, the presence of a cataract, the size of the eye, the presence of degenerations at the edge of the retina, ...and the list goes on.
Treatment # 1: YAG Floaterectomy
Laser breaks up opacities in the gel but it does not remove them
My advice: Avoid
Reasons:
1) Uncontrolled transmission of energy from the gel to the retina with increased risk of retinal tears and retinal detachment
2) It has very modest success rate. I personally do not buy what floater specialists claim on their websites. A study by a reputable group in the UK found that 38% of patients who had YAG floaterectomy had a moderate reduction in symptoms whereas 62% had no improvement (REF). Patients report that they have gone from having a few large floaters to lots of little ones.
Treatment #2: Floaterectomy with Clear Lens/Cataract Removal.
Removal of the lens of the eye to provide access to the back of the eye where a vitrector removes the front bit of the vitreous. The natural lens of the eye is then replaced by a plastic lens implant. It requires two cuts on the eye. The surgeon uses a microscope which allows a view of the lens and the front bit of the vitreous but the retina can not be visualised in this setting.
My advice: Avoid
Reasons:
1) The removal of gel is performed with an anterior vitrector through the front of the eye and no direct view of the retina. This means that if any retinal tears occur during surgery (which can be anywhere between 5 and 15% of cases), they will not be treated at that time and may go on to cause a retinal detachment. Also, most anterior vitrectors have a low cut rate (cuts per minute), which puts more stress at the edge of the retina and increases the risk of retinal tears.
2) Removal of only part of the gel is proven to increase the risk of future retinal detachment by many fold and these detachments often occur many years after the original surgery.
3) 1 in a 1000 risk of infection and severe vision loss
4) If you do not have a cataract, why sacrifice your clear lens? Although there may be advantages in terms of reducing shortsightness, astigmatism etc, if you are young you will also loose your ability to see near without glasses. And don't let anyone convince you that the new lens implants are anywhere near as good as the lens of a younger person for near vision.
Treatment #3: Small gauge pars plana vitrectomy.
Three cuts on the eye (0.5mm wide each) are made on the white bit of the eye to allow instruments to pass to the back of the eye where the vitreous is situated. There is a vitrector, which removes gel, a light pipe to illuminate the eye inside for the surgeon to see the gel and retina and a pipe delivering a special fluid which takes up the space left by gel removal. The fluid is later quickly replaced by the production of liquid that the eye produces (aqueous). The surgeon visualises the retina with a special microscope through the pupil. Posterior vitrectors have a much higher cut rate and are therefore safer than anterior ones.
My advice: Avoid (qualified)
Reasons:
1) Pars plana vitrectomy is also associated with the occurrence of retinal tears either during or after surgery. It has a risk of retinal detachment ranging from 2% to 10% following surgery. Retinal detachments can be repaired with a success rate of 95% with a single operation but often there is some degree of permanent vision loss.
2) Clouding of the natural lens of the eye (cataract). It is not much of a problem if you are over 50 but for younger people, it is a shock when they suddenly find that they have to use reading glasses following cataract surgery (and presbyopia lens implants are nothing like a young natural lens).
3) 1 in a 1000 risk of infection and severe vision loss
If you have read the above and still feel that you are troubled by floaters enough to justify taking these risks, then read on.
There are instances where retinal surgeons remove the gel of the eye in order to manage the symptoms of floaters. In these cases, the procedure of choice is small gauge pars plana vitrectomy. This can be combined with cataract surgery if there is a significant amount of cataract, although in these cases the patient may be advised to have the cataract removed in the first instance and if the symptoms of floaters are still troublesome then they can have a pars plana vitrectomy at a later stage.
The advantages of pars plana vitrectomy over floaterectomy is that any retinal breaks created during the operation are seen and treated. Also, the entire vitreous that falls within the line of vision is removed, not just the front bit. This makes the operation very effective in removing vitreous.
YAG floaterectomy doesn't work well and it also involves a risk of retinal detachment.
Patients with better risk profile for vitrectomy for floaters
1) Older age
2) Detached posterior vitreous
3) Not moderate/high myopes
4) No history of retinal detachment (Family or personal)
5) No peripheral retinal degenerations predisposing to retinal detachment
The advice given to patients is to take their time and consider all the risks.
