Topic
Depression and anxiety are common in chronic eye diseases, and the psychological implications of symptomatic vitreous opacities (SVO) remain underexplored. This systematic review synthesized current evidence on the psychological burden of SVOs and the extent to which interventions confer psychological benefit.
Clinical Relevance
Although SVOs typically occur with normal visual acuity, many patients with vision-degrading myodesopsia report significant distress, impaired well-being, and measurable degradation of contrast sensitivity. Understanding the magnitude of this burden and the potential psychological benefits of available treatments is important for clinical decision-making and patient counseling.
Methods
In June 2025, Medline, Embase, and the Cochrane Library were searched. Eligible studies assessed outcomes related to mental health, depression, anxiety, personality, quality of life, coping, and/or patient experiences or perceptions of vitreous opacities or their treatment. The protocol was prospectively registered in PROSPERO (CRD420251243887). The primary outcome was psychological burden relative to healthy controls; secondary outcomes included psychological changes following Nd:YAG vitreolysis or pars plana vitrectomy. Given substantial heterogeneity in study design and psychological instruments, findings were synthesized descriptively.
Results
Thirteen studies met inclusion criteria, encompassing 635 patients aged 18 to 88 years across Europe, Asia, and the Americas. Across study designs, individuals with SVO reported significantly higher levels of depression, anxiety, and perceived stress than healthy controls, despite preserved visual acuity. Standardized instruments (NEI-VFQ, PHQ-9, CES-D, HADS, Zung SDS, GAD-7, STAI, PSS-10) consistently showed elevated psychological symptom scores and lower mental health-related quality-of-life scores. Personality assessments (BFI) revealed greater neuroticism and lower extraversion in patients with SVO. Interventional studies with Nd:YAG laser vitreolysis and pars plana vitrectomy demonstrated improvements in vision-related QoL and psychological well-being.
Conclusion
SVOs commonly present with a psychological overlay that affects emotional well-being. Our findings raise the possibility of a visual somatization component in psychologically vulnerable individuals, whereby vitreous changes may contribute to heightened anxiety or distress. Recognizing that traditional clinical metrics such as visual acuity may underestimate functional impairment supports the need for psychological screening, patient-centered counseling, and integration of validated floater-specific outcome measures alongside psychological endpoints.
INTRODUCTION
Vitreous opacities, commonly described as floaters, result from age-related collagen aggregation or posterior vitreous detachment. They tend to follow eye movements, which may cause distress and reduce vision quality. When floaters significantly impair visual function, this is referred to as vision-degrading myodesopsia—a clinically defined subset diagnosed on the basis of objective quantitative metrics, including contrast sensitivity testing and quantitative ultrasonography. , As some included studies use varied terminology or do not apply these diagnostic criteria, we adopt the broader term symptomatic vitreous opacities (SVOs) throughout this review. SVOs are physiologically common, with self-reported prevalence levels reaching up to 76%. Recent research has highlighted their psychological significance, demonstrating that floaters may be associated with reductions in visual function and well-being in some patients.
Senra et al conducted the first systematic review examining the psychological impact of vitreous opacities, but their preliminary conclusions were constrained by a small evidence base (five studies), heterogeneous methods, limited interventional or longitudinal data, and reliance on vision-specific QoL measures that may underestimate broader mental health effects. The review also did not assess personality traits and predated several randomized or larger-scale studies. Since then, multiple observational and interventional studies have provided more rigorous assessments of depression, anxiety, personality factors, and post-treatment changes in mental health–related quality of life. This updated systematic review synthesizes this expanded evidence to characterize the psychological implications of SVOs, evaluate interventional outcomes, and identify future research priorities. ,,
METHODS
search strategy and study selection
A systematic literature search was conducted in June 2025 using Ovid MEDLINE (2000-2025), Embase (2000-2025), and the Cochrane Library (inception to 2025). Eligible studies included those assessing mental health, depression, anxiety, personality traits, coping, or patient perceptions in individuals with SVO, with or without intervention. Randomized controlled trials (RCTs), cohort, case–control, cross-sectional, and qualitative studies were included. Exclusion criteria were non-English publications, unpublished studies, case reports, narrative reviews, editorials, and articles with duplicate data from the same patient sample. The search strategy used combinations of terms related to vitreous floaters and psychological or quality-of-life outcomes. The complete search strategy is provided in Supplemental Table 1.
Two independent reviewers (V.L. and B.P.) independently screened titles, abstracts, and full texts. Disagreements were resolved by consensus with input from a third reviewer (M.M.P.). Reference lists of included articles were also screened to identify additional studies. The review protocol was registered in PROSPERO (CRD420251243887).
data extraction
Two independent reviewers (V.L., B.P.) used standardized data collection forms to extract study identifiers (country of study, publication year, study design, study setting) and baseline information (number of patients, age, sex, psychological or QoL measures, interventions, and key outcomes). Validated mental health instruments (eg, PHQ-9, CES-D, HADS, STAI, GAD-7, PSS-10, Zung SDS) and quality-of-life metrics (eg, NEI-VFQ) were recorded. The PHQ-9, CES-D, and HADS Depression assess depressive symptoms; the HADS Anxiety and GAD-7 assess anxiety; the STAI measures state and trait anxiety; and the PSS-10 evaluates perceived stress. Vision-related quality of life was measured using the NEI-VFQ, which includes functional and mental health subscales relevant to floater-related visual disturbance.
methodological quality and risk of bias assessment
Methodological quality and risk of bias were independently assessed by two reviewers (V.L., B.P.) using validated tools appropriate to each study design. Cross-sectional studies were evaluated with the NHLBI Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, case series and case-control studies with the corresponding NHLBI tools, qualitative studies with the CASP checklist, nonrandomized interventional studies with ROBINS-I, and RCTs with Cochrane RoB 2. ,,, The assessments focused on key methodological domains, including clarity of the research question, study population definition and comparability, eligibility criteria, sample size justification, exposure and outcome measurement, masking, follow-up completeness, statistical analyses, and ethical considerations.
RESULTS
study selection
The study selection process is summarized in the PRISMA flow diagram ( Figure ). A total of 1958 records were identified through database searches. After removing 314 duplicates, 1644 records were screened by title and abstract, with 1612 excluded. Thirty-two full-text reports were assessed, of which 13 studies met the inclusion criteria. Excluded studies ( n = 19) commonly did not include patients with vitreous opacities, did not assess psychological outcomes or well-being, or did not have publicly accessible full-text versions or were not in English.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.
studies characteristics
Thirteen studies published between 2012 and 2024 were included, encompassing 635 patients aged 18 to 88 years across Europe (Belgium, Italy, Spain, Greece, UK), Asia (China, South Korea, Malaysia), and the Americas (USA, Brazil) ( Table ). The included studies comprised one observational retrospective study, one qualitative study, one nonrandomized intervention study, one prospective interventional study, two case-control studies, two cross-sectional studies, one prospective nonrandomized clinical study, two RCTs, one case series, and one prospective efficacy study. ,,,,,,,,,,,,
TABLE
Study Characteristics
| Study | Country | Design | Sample | Control Group (CG) | Setting | Visual Acuity/Any Other Objective Metrics/Floater Severity | Intervention | Outcome Measures | Main Outcome |
|---|---|---|---|---|---|---|---|---|---|
| Bamonte et al | Belgium | Observational (retrospective) | 30 patients (24 males), median age: 32.5 y, IQR 29-37 | No CG | Ophthalmology department at Brussels University Hospital | Best-corrected visual acuity ≥20/25; clinical vitreous assessment via slit-lamp indirect ophthalmoscopy; subjective floater severity (0-3 scale) | No intervention | Floaters-related quality of life questionnaire | As many as 23 out of 30 patients (76.6%) described themselves as suffering from depression and/or anxiety related to SVO. Thirteen subjects (43.3%) were currently seeking or had previously sought professional psychological support because of symptoms caused by the perception of floaters. Eleven patients (36.6%) were or had been using medication for either depression and/or anxiety caused by floaters during the previous 12 mo. |
| Cipolletta et al | Italy | Qualitative | 11 patients (6 females), age: 44-78 y | No CG | Ophthalmology department from a public hospital | N/A | No intervention | Semistructured Interviews | The following 7 categories were found: Clinical signs; perception of the disease; personal explanation; solutions presented by physicians; trust in medicine; self-construction: How the patient described him- or herself; distribution of dependency: In whom the patient usually confided for help. |
| Garcia et al | Spain | Nonrandomized intervention (pretest-post-test) | 34 patients (19 males); age: 55 ± 15.33 | No CG | Eye Clinic |
Snellen visual acuity, mean (SD) 0.74 (0.29)
Contrast sensitivity, mean (SD) 1.43 (0.23) |
Nd-YAG laser with Ultra Q-Reflex technology | National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25); NEI-VFQ-39; State-Trait Anxiety Inventory (STAI) |
Pretreatment vs post-treatment (Wilcoxon rank test):
VFQ-25: Med: 73.05, IQR:19.25 vs Med: 93.76, IQR: 8.73, P <.01 VFQ-39: Med: 74.6, IQR:19.01 vs Med: 95, IQR: 6.50; P <.001 STAI: Med: 38, IQR:11 vs Med:18, IQR 19, P <.001 |
| Goh et al | Malaysia | Prospective interventional | 45 patients (30 females); age: 60.4 ± 11.14 (33-87) | No CG | Private ophthalmology centers, health clinics, and patient self‐referral by emailing investigators | Contrast sensitivity function (CSF) and VA measured (no adverse effects on the visual acuity) | Nd:YAG laser vitreolysis with Ellex Ultra Q reflex | NEI-VFQ‐25 | The mean scores increased to 79.55 ± 9.45 from the baseline 75.06 ± 9.69 ( P ≤.001). No adverse events were recorded 1 mo after the laser treatments. Mental health score improved from 75.00 (62.50-87.50) to 81.25 (71.88-93.75) ( z = −2.219, P =.026) before and 1 mo after laser vitreolysis. |
| Gouliopoulos et al | Greece | Case control |
90 patients (52 males); age:
51 ± 11 |
57 healthy controls (26 males); age:
48 ± 16 |
Outpatient department of the 2nd Department of Ophthalmology, Medical School of National and Kapodistrian University of Athens, “Attikon” University General Hospital | No significant differences in BCVA between sample and control | No intervention | Patient Health Questionnaire-9 (PHQ-9); Zung Depression Inventory-Self-Rating Depression Scale (Zung SDS); the Hospital Anxiety and Depression Scale (HADS) | The patient group showed higher scores compared to control for PHQ-9 (9.57 ± 4.18 vs 6.57 ± 2.87, P =.040), Zung SDS (46.02 ± 9.26 vs 38.10 ± 8.34, P =.003), HADS Anxiety (8.16 ± 3.29 vs 5.81 ± 2.02, P =.027), HADS Depression (7.43 ± 3.27 vs 5.62 ± 2.52, P =.137). |
| Kim et al | Republic of Korea | Cross-sectional | 61 patients (41 females), aged 56.5 ± 10.3 | 34 healthy controls (22 females), age: 56.3 ± 10.0 | Hospital Retina Clinic | No differences in visual acuity, but patients with symptomatic floaters showed a higher rate of complete PVD identified by OCT (79% in the floater group vs 47% in the controls, P =.011) | No intervention | STAI; PSS-10; PHQ-9 |
The patient group showed higher depression (6.5 ± 6.3 vs 2.3 ± 2.3,
P
<.001,
d
= 0.89); higher perceived stress level (16.8 ± 6.7 vs 14.2 ± 4.4,
P
=.027,
d
= 0.46), and higher state anxiety (43.2 ± 12.6 vs 37.9 ± 8.0,
P
=.014,
d
= 0.5), compared to the control group (
t
test).
Depression (PHQ-9) (odds ratio 1.32, 95% CI, 1.11-1.56, P =.001), and younger age (odds ratio 0.94, 95% CI, 0.89-0.99, P =.037) were independently associated with symptomatic floaters (logistic regression). |
| Nguyen et al | US | Prospective, nonrandomized clinical study | 86 patients (18 multifocal IOL, 33 monofocal IOL, 35 phakic) with floaters and PPV—“In 12 patients with MFIOLs who underwent surgery, NEI VFQ-39 questionnaires were available for analysis” | 94 patients (37 multifocal IOL, 27 multifocal, 30 phakic) with floaters and no intervention | VMR Institute for Vitreous Macula Retina | BVCA, CSF, quantitative ultrasonography (QUS) for vitreous echodensity | Limited (25 G) vitrectomy | NEI-VFQ-39 | 12 subjects with MFIOLs and had gotten vitrectomy saw an 11% improvement in the composite score ( P =.10), and 23% improvement in mental health ( P =.07). |
| Nunes et al | Brazil | Randomized, controlled, masked, double-blind clinical trial | 8 patients (6 female); age: 60 ± 7.7 (48-72) | 11 patients (sham) | Single hospital center | CS measured | Nd:YAG laser vitreolysis | NEI-VFQ-25, 0-10 symptom scale |
The intervention group reported a significantly better general vision (75.8 vs 59.2;
P
=.037). A significant difference in mental health (
P
=.048) was observed when comparing the 6th-mo values of the intervention (84.3) and control groups (70.3). The answers given to the questionnaire from the initial time point at the 6th and 18th mo of follow-up were compared, with no statistically significant difference observed.
Subjective perception scale: pretreatment (6.2 ± 1.0), 6th mo post-treatment (2.5 ± 2.4, P =.001), 18 mo (2.4 ± 2.3). |
| Schiff et al | US | Case series | 5 patients (all males), age: 58-66 y | No CG | Eye Hospital | BCVA (all 20/40 or better) | Pars plana vitrectomy | NEI-VFQ-39 |
Improvement in VSSF after surgery: 76.4 (presurgery); 98.53 (3 mo after surgery);
P
=.059.
Improvement in VSMH after surgery: 41.67 (presurgery); 79.17 (3 mo after surgery); P =.003. |
| Sebag et al | US | Prospective efficacy study | 61 patients (35 males, 26 females); age: 59 ± 14 y; 34 phakic. Efficacy study ( n = 16) | 16 age-matched controls (efficacy study only) | VMR Institute for Vitreous Macula Retina | CSF (Freiburg Acuity Contrast Test) | Limited 25 G pars plana vitrectomy | NEI-VFQ (11 subscales including mental health) | NEI-VFQ composite score 28.3% lower in floater patients vs controls (73.2 ± 15.6 vs 93.9 ± 8.0, P <.001); improved 29.2% postvitrectomy ( P <.001). Mental health subscale: largest individual improvement at 46.1% ( P <.001). |
| Senra et al | UK | Cross-sectional |
149 patients (108 males), age: 34.8 ± 11.8 (18-76)
With current or previous diagnosis |
UK population | Manchester Royal Eye Hospital | N/A | No intervention (some had previous vitrectomy or laser) | The Big Five Inventory (BFI), PHQ-9, Generalized Anxiety Disorder 7-item scale (GAD-7) | Compared to the general population, sample had a significantly increased score in the domain of BFI-neuroticism (3.27 vs 2.97, ρ < 0.0001, d = 0.38) and reduced score in the domain of extraversion (2.97 vs 3.24, ρ < 0.0001, d = 0.33). Female patients scored significantly higher than male patients on BFI-neuroticism ( ρ = 0.01), and on BFI-agreeableness ( ρ = 0.01). Age was positively correlated with BFI-Conscientiousness ( r = 0.19, ρ = 0.02) and with BFI-Agreeableness ( r = 0.20, ρ = 0.01). Overall, 36% of the sample had moderate to severe symptoms of depression, and 43% had moderate to severe symptoms of anxiety. 55.7% had a self-reported history of depression/anxiety. The sample mean scores on PHQ-9 and GAD-7 were 8.03 (SD = 5.94) and 9.17 (SD = 6.05), respectively. |
| Those with a history of depression/anxiety had significantly higher BFI-neuroticism scores ( t = −4.87, ρ < 0.0001), and higher current symptoms of depression (PHQ-9 scores) ( t = −4.19, ρ < 0.0001) and anxiety (GAD-7 scores) ( t = −4.33, ρ < 0.0001). | |||||||||
| Shah and Heier | US | RCT (retrospective follow-up) | 27 patients (YAG vitreolysis) | 8 patients (sham) | Ophthalmic Consultants of Boston | BCVA, objective grading by masked reviewer | YAG laser vitreolysis | NEI-VFQ-25 | There was improvement in the following parameters compared to baseline: near vision activities (baseline: 78.7, final: 85.8, difference: 7.1; range: −25 to 50; median: 0; 95% CI, 1.6-12.6; P =.016), distance vision (baseline: 84.6, final: 89.0, difference: 4.4; range: −16.7 to 41.7, median: 0; 95% CI 0.3-8.5; P =.042), mental health (baseline: 71.7, final: 85.7, difference: 14.0; range: −6.3 to 56.3; median: 12.5; 95% CI 9.1-18.8; P <.001), and role difficulties (baseline: 81.3 baseline, final: 93.4 final, difference: 12.1; range −12.5 to 75; median: 12.5; 95% CI, 5.6-18.7; P <.001). |
| Wu et al | China | Case control | 28 patients (24 males), age: 31.6 ± 8.9 | 39 healthy controls (33 males), age: 29.2 ± 2.3 | Eye University Hospital | BCVA assessed, no significant differences with control or post-treatment | Pars plana vitrectomy | Center for Epidemiologic Studies Depression Scale (CES-D) |
CES-D scores were significantly higher for patients (18.3 ± 8.6) than for healthy controls (12.4 ± 6.0;
P
=.003,
d
= 0.8).
CES-D scores were negatively correlated with age ( r = −0.42, P =.025). CES-D scores were significantly lower after surgery (18.3 ± 8.6 vs 11.9 ± 5.4, P <.001, dz = 0.85). |
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