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How to Address Vitreous Floaters

For years, Dr. White listened to patients in his office describe how vitreous floaters affected their quality of vision, but without a treatment he believed in, there didn’t seem much he could do. Adopting laser vitreolysis, though, changed his mindset—making him more attuned to just how severely floaters affected not only vision, but quality of life more generally.

“It doesn’t matter how big or how small we think [the floaters are],” said Dr. White, “the impact on them is the only thing that matters.” Dr. Singh agreed, adding that too often the definition of “clinically significant” is tied to the availability of treatment options, rather than accurately reflecting a patient’s daily experience.

Before integrating Nd:YAG laser treatments for floaters, Dr. White says that he would base his determination of treatment necessity on the size and location of the floaters. Now, he lets the patient drive the conversation. “I’m not voting so much on the size of the floater,” he explains. “I’m listening very hard to the patient as they tell me the size of them. And it totally changes the conversation.”

Dr. Singh pointed to a 2022 single-center study by García et al1 in which the authors examined the quality-of-life aspect of patients’ outcomes after they underwent laser vitreolysis for floaters. The results of this study showed a significant reduction in the subjects’ anxiety and marked improvement in the answers on the VFQ-25 and VFQ-39 Visual Function Questionnaires that preceded treatment. Dr. White said while he was not particularly surprised by the overall findings, those pertaining to anxiety were interesting. “We don’t think about something like this being an anxiety trigger,” he said.

Dr. White described his three criteria for treating vitreous floaters with the Nd:YAG laser: (1) they must cause enough interference in the patient’s day-to-day life to warrant intervention; (2) they should be visible enough to determine if it will absorb the laser’s energy; and (3) they have to be located far enough in front of the retina and behind the lens to be lasered safely, although in pseudophakic eyes, the margin of safety is a little wider. He generally performs the procedure at some point after having done a capsulotomy, and he tells patients to expect it to last between 4 and 8 minutes. Often, he can eliminate the floater in a single session.

Dr. Singh concluded the conversation by stressing how important it is not to ignore patients’ complaints about perceived floaters now that vitreolysis is available. Dr. White agreed and pointed out that the procedure’s learning curve is minimal. “Anybody who can do a YAG [laser capsulotomy] can do a YAG vitreolysis. If nobody in your area does it, there’s no reason why you couldn’t, or shouldn’t.” He acknowledged that the treatment has enabled him to improve patients’ lives to a degree he did not anticipate. “It’s much more impactful than I expected.”

1. García BG, Orduna Magán C, Alvarez-Peregrina C, et al. Nd:YAG laser vitreolysis and health-related quality of life in patients with symptomatic vitreous floaters. Eur J Ophthalmol. 2021:11206721211008036.

Darrell E. White, MD