March 2017

 

RETINA

 

Retina consultation corner
Management of vitreous floaters and asteroid hyalosis


by Steve Charles, MD

     

Dr. Charles discusses floaters and patient satisfaction

The most challenging aspect of managing patients who complain of floaters is determining if there are also psychological issues at play. It is common to see patients with very dense floaters and no visual complaints even when questioned intensely. On the other hand, we all see patients with minimal floaters on objective clinical examination who complain bitterly. Many of this latter cohort of patients also have anxiety disorders, depression, bipolar disorders, fibromyalgia, chronic fatigue syndrome, and/or chronic pain. Their list of medications may be extensive. Surgery in such patients, especially if a retinal detachment is caused, may result in a very unhappy patient.
Cataract progression after vitrectomy is nearly uniform if any pre-vitrectomy nuclear sclerosis is present. Age is a proxy for preoperative nuclear sclerosis. Vitrectomy increases the partial pressure of oxygen by 12 mm Hg permanently as shown by Nancy Holekamp, MD, Chesterfield, Missouri. This is because the viscosity is reduced about 1000-fold, enabling greater diffusion of oxygen. I do not recommend phacoemulsification–vitrectomy because it produces suboptimal refractive outcomes if performed by vitreoretinal surgeons, and there is increased risk of retinal breaks and detachment if done by a cataract surgeon.
Optical coherence tomography (OCT) recently has been found to be an excellent way of objectively evaluating floaters, more correctly termed vitreous condensations. The infrared image displayed with the OCT B-scan on the Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, Germany) is also valuable in evaluating floaters. Use of OCT is crucial because it also discovers ophthalmoscopically invisible macular pathology; often, the actual cause of visual loss is said to be due to floaters. Asteroid hyalosis virtually never causes visual loss or requires vitrectomy.
I do not recommend performing vitrectomy if a posterior vitreous detachment (PVD) is not present. When the PVD occurs later, the patient will need another vitrectomy; creating a PVD at the time of surgery is likely to result in retinal breaks and detachment. If a decision is reached to do vitrectomy, careful peripheral retinal examination and laser prophylaxis of all retinal breaks at least 2 weeks before vitrectomy is essential.
I evaluated YAG vitreolysis for coherence when the YAG was first introduced and recommended that the indication not be pursued. I subsequently evaluated picosecond laser vitreolysis and reached the same conclusion. I have evaluated many unsatisfied post-YAG vitreolysis patients on second opinion, some of whom had lens damage. I have heard many anecdotal reports of retinal damage as well. Many vitreoretinal surgeons had evaluated YAG vitreolysis and were very negative at a town hall-style discussion at the 2016 Vit-Buckle Society meeting. In all instances, the lasers were purchased by their cataract surgery associate.

Editors’ note: Dr. Charles is chair of the ASCRS Retina Clinical Committee. He has financial interests with Alcon (Fort Worth, Texas).

Contact information

Charles: scharles@att.net

Management of vitreous floaters and asteroid hyalosis Management of vitreous floaters and asteroid hyalosis
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