Like most providers, I downplayed floaters in the past because I felt there was nothing I could do. Now, after performing more than 5,000 laser-based floater treatments over the past seven years, I have come to appreciate the impact floaters can have on a patient’s daily functioning. They often return for their posttreatment visits with improvement in their daily life similar to post-cataract surgery patients; “I can drive again,” “I can read again,” “I can perform in the orchestra again.” It is clearly evident that, in symptomatic patients, the visual symptoms associated with floaters are a growing concern and warrant more than merely observation. Until I started treating floaters, I thought of floaters as just a nuisance and counseled patients to live with them. Because they are part of the normal aging process, I felt there was no need to address them. Indeed, I dismissed my floater patients as there was no safe, in-office treatment option. I’m sure many of you have also said these words to your patients, “Get used to them,” “They will eventually go away,” “They are normal and don’t harm you.” But have you stopped and thought: “Why are we so quick to dismiss these patients?”

In medicine, our decision to treat or not to treat has been based on the risk-benefit ratio involved with the treatment. Basically, the higher the risk, the more severe the symptoms must be before the surgeon is willing to perform the surgery. As technology has advanced and techniques have evolved, the risk profile of many treatments has improved. Not only does this offer obvious benefits for the patient, but it also allows treatment earlier in the disease process—and for patients who would have historically been ignored. For instance, the old paradigm of cataract surgery has changed. Today, our definition of “clinically significant” cataract has changed. A 20/40 cataract, once considered not suitable for treatment 20 years ago due to the risk and limitations of surgery, is now considered treatable. Advances in glaucoma procedures, and more specifically the advent of microinvasive surgery (MIGS), have changed the glaucoma treatment paradigm, with surgery now offered earlier in the disease process due to its enhanced safety profile. This, in turn, has redefined the patient type and the justification for surgery. Now, quality of life is a key definition of “uncontrolled glaucoma.” One would rarely consider a trabeculectomy for a patient with mild glaucoma on 1 or 2 medications, but with the advent of MIGS, the “ideal” patient for glaucoma surgery has changed. The same can be said for dry eye. Until recently, many of us ignored this
condition, minimizing its impact on daily functioning due to a lack of options to treat, or even to diagnose. Once new treatment options and diagnostic devices became available, we as a profession recognized the impact ocular surface disease has on patient quality of life, and as a result, more and more options are becoming available.

Historically, the only treatment offered for vitreous floaters was a pars plana vitrectomy (PPV). This procedure works well to eliminate the symptoms associated with floaters, but there are significant risks involved with the procedure, such as cataract formation and retinal detachment.¹ Although recent advances in technology have improved the safety profile of vitrectomy, there is still the challenge of postoperative healing time, during which patients may be off of work for a few days to weeks and on eye drops for a few weeks to months. For many surgeon’s and patients, the overall risk and cost from a PPV is greater than the issues caused by floaters. Therefore, a majority of doctors decide to observe many of the common types of floaters, such as a Weiss ring or other solitary vitreous opacities. Unfortunately, these floaters can still negatively affect patient’s quality of life.

A study by Wagle et al. addressed the impairment on functional quality associated with floaters in 311 outpatients.² The utility values of floaters were equal to age-related macular degeneration, and similar to glaucoma, mild angina, stroke, and asymptomatic human immunodeficiency virus (HIV). This demonstrates that floaters do have a significant impact on quality of life, similar to other ocular and systemic diseases. Further, a study by Webb et al. found that floaters are very common in the general population, irrespective of age, race, gender, and eye color. In a review of 603 smartphone users, 76% (n = 458) indicated that they notice floaters, with 199 of these individuals citing noticeable vision impairment as a result of their floaters. Furthermore, myopes and hyperopes were 3.5 and 4.4 times more likely, respectively, to report moderate-to-severe floaters.³ A 2016 study by Garcia et al. showed that there was a 52.5% reduction in contrast sensitivity function following posterior vitreous detachment (PVD). In a survey of approximately 600 smartphone users, 33% of respondents reported that their floaters caused noticeable visual impairment.⁴

Now, with advances in laser technology, laser lenses, and new treatment protocols, the adverse event profile associated with laser-based floater treatment is favorable. It also offers the benefit of a simplified postoperative course. As a result, the definition of clinically significant vitreous opacity (CSVO) has changed: symptomology does not have to be as severe as that for a vitrectomy. Smaller floaters, such as Weiss rings and other types of floaters (amorphous clouds and strings), that were often considered to be not clinically significant to warrant surgery, are now able to be treated. We don’t have to minimize the impact of these floaters and tell patients to “just deal with it.”

It is important to note that laser floater treatment (LFT) is not intended to replace or compete with vitrectomy. The ideal patient for LFT is very different from that of a vitrectomy patient. These patients often have been told they are not good candidates for a vitrectomy. This can be the case in a phakic patient, or in patients with a smaller type floater.

LFT for symptomatic floaters, also known as vitreolysis, is actually not new. It was first introduced in 1993, when Tsai et al. described a series of patients undergoing Nd:YAG vitreolysis. It was later popularized by Dr. Karickhoff. Despite their work, which demonstrated good efficacy and safety, other older data sets, which suggested only modest efficacy and possible safety concerns, led many doctors to be skeptical about the procedure. It is important to note these older studies were using laser technology not optimized for LFT. Further, the treatment protocol was not optimized. For instance, Delaney et al. in 2002 published a study reporting 38.3% success using a non-randomized questionnaire. The study was performed using older Nd:YAG technology with average energy settings of 1.2 mJ. This energy is too low to vaporize and sufficiently reduce the size of the floater. A fear of complications and an overall lack of understanding of Nd:YAG laser delivery of energy have also contributed to the skepticism surrounding LFT. Colleagues often fear LFT will cause retinal detachment, inflammation, and other serious complications. Recent data based on new technology, and new protocols, addresses these fears. The reason for the variable outcomes in some earlier studies was due to the limitations of traditional Nd:YAG lasers. There were three main limiting factors when performing LFT with traditional Nd:YAG lasers: (1) Lack of visualization of the entire vitreous and necessary spatial awareness between lens and retina; (2) suboptimal power usage during the procedure thus limiting vaporization of the floater (3) inability to fire sufficient number of shots due to older cooling cavities and thus the instability and inconsistency of energy delivery through the entire procedure.