In the article by Tan and associates describing the safety of vitrectomy for floaters, the authors analyzed a retrospective case series of vitrectomy in 116 eyes with vitreous floaters to determine the complications and risk profile. In 25.9% of cases, the posterior vitreous cortex was still attached and a posterior vitreous detachment (PVD) was induced during surgery. In these cases, retinal breaks were found in 9 (30%) of 30 cases, whereas in the eyes that did not undergo PVD induction, retinal breaks were found in only 10 (11.6%) of 86 cases. This statistically significant difference brings into question the advisability of PVD induction. Indeed, in a study of retinal breaks after the induction of PVD, Chung and associates found that in vitrectomy for macular pucker, PVD induction was associated with retinal breaks in 9 (32%) of 28 eyes, as compared with 3 (2.1%) of 146 eyes without PVD induction ( P = .006). In macular hole surgery, PVD induction was associated with retinal breaks in 19 (12.7%) of 105 cases versus 1 (3.1%) of 32 cases without PVD induction ( P = .008). Thus, PVD induction is a significant risk factor for iatrogenic retinal breaks in vitrectomy surgery.
PVD also is known to be a significant risk factor for rhegmatogenous retinal detachment (RRD), as most recently confirmed (again) in the Scottish Retinal Detachment Study, where 85% of cases were the result of PVD. Indeed, in the series reported by Tan and associates, RRD occurred only in cases that had undergone PVD induction. Because Tan and associates noted that one of the most feared complications of vitrectomy for floaters is postoperative RRD, it is not clear why they chose to induce PVD in all cases with an attached vitreous.
In view of the fact that floaters are perceived by patients as a significant health problem, it is incumbent on the medical profession to develop effective and safe methods to cure this disease. Despite claims on the Internet and in the lay literature, eye drops have no effect on floaters. Neodymium:yttrium–aluminum–garnet laser treatments also are not effective. Vitrectomy is effective and needs to be safe. An important consideration in this regard is the recent finding that in a study of 695 vitrectomy cases, the risk of RRD was reduced from 4.9% to 1.1% ( P = .04) by using small-gauge vitrectomy instrumentation. Thus, until pharmacologic vitreolysis is able to meet the demands of patients with floaters, minimally invasive, sutureless vitrectomy using small-gauge instruments without PVD induction seems to be an effective and safe approach.