CEDARS/ASPENS DebatesPublication Exclusive

YAG laser vitreolysis vs. pars plana vitrectomy for vitreous floaters

Karl G. Stonecipher, MD, and Shachar Tauber, MD, debate effective treatments for floaters.

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

Vitreous floaters remain frustrating to many patients. Not only may these be visually debilitating, but also there are few effective treatment options available. In general, patients are forced to “live with it.” This month, Karl G. Stonecipher, MD, and Shachar Tauber, MD, two of my fellow Tulane alums, discuss the options of YAG laser vitreolysis and pars plana vitrectomy for the treatment of vitreous floaters. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

YAG laser vitreolysis is safe, pain-free

Karl G. Stonecipher

For years, the “elephant in the room” has changed. Usually it takes technology to make it change. In my ophthalmic career, I have witnessed many of these changes. The initial change for me was in 1987 when surgeons were changing from extracapsular cataract surgery to phacoemulsification. Initial technology developed by Dr. Charles Kelman had made it to the mainstream in my early career, and Drs. Stephen Brint and Bruce Wallace taught me how this technology and smaller incisions made a difference. Next came my refractive surgery enlightenment. With cataract surgery, people believed that pathology existed, but why would anyone in their right mind operate on a perfectly normal myopic eye? Dr. Miles Friedlander and Dr. James Rowsey would teach me how to change peoples’ lives, which we did.

As technology progressed so did our discussions of the “elephant in the room.” First it was surface laser vision correction vs. LASIK, which then progressed to single-eye surgery to bilateral surgery. Including my mentors above, other forward thinkers such as Drs. Dan Durrie, Marguerite McDonald, Richard Lindstrom, Theo Seiler, Stephen Slade and George Waring taught me to nudge the “elephant” along with solid science, not bold bravado. Technology led the charge toward what we do today to change lives.

For years, patients who complained of symptomatic floaters were given two choices: learn to live with them or undergo vitrectomy and run the risk, albeit small, of cataract, endophthalmitis, retinal detachment, glaucoma, vitreoretinal hemorrhage and macular edema. We have always downplayed the impact of floaters on patients’ quality of life, much like with myopia, hyperopia and astigmatism possibly because a credible treatment option beyond invasive surgery such as vitrectomy has been unavailable for floaters in the past. While floaters may be a mild and short-lived inconvenience for most patients, there is nevertheless a sizeable minority for whom the problem is far more serious. One recent survey found that the deleterious impact on quality of life as a result of floaters was comparable to or worse than that of age-related macular degeneration, diabetic retinopathy or glaucoma.

The good news is that we now have another option to treat symptomatic floaters — one that does not carry the same risk profile of vitrectomy. Even though we think of YAG vitreolysis as a recent option, it has been around for quite a while. The concept, with a specially designed YAG laser used to vaporize vitreous opacities and vitreous strands, has been shown to effectively improve patient outcomes with a low rate of complications. Early studies with longer follow-ups have continued to support the effectiveness of YAG laser vitreolysis with minimal side effects. Drs. Scott Geller, James Johnson and John Karickhoff have led the way, with long-term studies showing success rates of 92% and higher and complication rates as low as 0.1%. So this concept of YAG laser vitreolysis continues to find its way into mainstream ophthalmology after more than 20 years.

In summary, laser vitreolysis has turned out to be a positive addition to our busy practice. The treatment is safe, effective and pain-free with an extremely low complication rate. We have enabled scores of patients to achieve functional improvements in their vision and greatly improved their quality of life in the process. Who knows, we may even think about bilateral cataract surgery as an option in the future.

Disclosure: Stonecipher reports he is a speaker for Ellex Laser.

Vitrectomy more likely to deliver the desired result

Shachar Tauber

For the treatment of visually disabling vitreous opacities, options include observation, YAG laser vitreolysis or pars plana vitrectomy. Because of the invasive nature of both treatment options, our group almost always recommends observation. In patients for whom observation is not an option, we prefer small-gauge pars plana vitrectomy as a definitive treatment for symptomatic floaters.

Although the idea of a clinic-based YAG laser operation is alluring for its perceived simplicity, we have the following concerns.

1. The energy delivered into the eye is not acceptable. The energy delivered to the eye in YAG vitreolysis compared with standard YAG capsulotomy is much greater. Van der Windt and colleagues state the typical required power is 2.5 mJ to 4.5 mJ, and they do not recommend exceeding 500 pulses per treatment session. They recognize multiple treatment sessions may be necessary. It is our opinion this level of energy being delivered into the eye is too great, putting the patient at unnecessarily high risk for postoperative inflammation, glaucoma and retinal tear/detachment.

2. The efficacy of YAG vitreolysis is also in question. Delaney and colleagues found that 38% of patients treated with YAG vitreolysis had a moderate reduction in symptoms while 62% had no improvement.

The alternative treatment for YAG vitreolysis, and what we recommend at Mercy in carefully selected cases, is small-gauge pars plana vitrectomy. This procedure yields much higher efficacy. In the same Delaney study, they reported 93.3% of eyes undergoing vitrectomy for floaters resulted in full resolution. By utilizing modern surgical equipment, now readily available in as small as 27 gauge and cut rates as high as 7,500 cuts/minute, very little energy is directed into the vitreous, and very little traction on the vitreous is exerted. Vitrectomy has the advantage that if a retinal tear develops intraoperatively, it should be easily identified and treated at the end of the case.

We recognize the disadvantage of going through a procedure in the operating room. This vitrectomy procedure should not be performed in phakic patients because of the inevitable progression to cataract. Some physicians advocate vitrectomy with clear lens exchange, adding another level of complexity. We do not suggest clear lens exchange. We also recognize there is a small chance of bleeding, infection, glaucoma, postoperative inflammation and retinal tear/detachment. A large amount of time is spent discussing these risks, and only if a pseudophakic patient is willing to undergo these risks will surgery be offered. A similar disclosure is undertaken when dealing with cataract, epiretinal membrane, refractive surgery or any elective surgery that is designed to produce a better quality of vision.

There are risks to either YAG vitreolysis or vitrectomy, but we choose the option that is far more likely to deliver the patient the desired result.

Disclosure: Tauber reports no relevant financial disclosures.

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

Vitreous floaters remain frustrating to many patients. Not only may these be visually debilitating, but also there are few effective treatment options available. In general, patients are forced to “live with it.” This month, Karl G. Stonecipher, MD, and Shachar Tauber, MD, two of my fellow Tulane alums, discuss the options of YAG laser vitreolysis and pars plana vitrectomy for the treatment of vitreous floaters. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

YAG laser vitreolysis is safe, pain-free

Karl G. Stonecipher

For years, the “elephant in the room” has changed. Usually it takes technology to make it change. In my ophthalmic career, I have witnessed many of these changes. The initial change for me was in 1987 when surgeons were changing from extracapsular cataract surgery to phacoemulsification. Initial technology developed by Dr. Charles Kelman had made it to the mainstream in my early career, and Drs. Stephen Brint and Bruce Wallace taught me how this technology and smaller incisions made a difference. Next came my refractive surgery enlightenment. With cataract surgery, people believed that pathology existed, but why would anyone in their right mind operate on a perfectly normal myopic eye? Dr. Miles Friedlander and Dr. James Rowsey would teach me how to change peoples’ lives, which we did.

As technology progressed so did our discussions of the “elephant in the room.” First it was surface laser vision correction vs. LASIK, which then progressed to single-eye surgery to bilateral surgery. Including my mentors above, other forward thinkers such as Drs. Dan Durrie, Marguerite McDonald, Richard Lindstrom, Theo Seiler, Stephen Slade and George Waring taught me to nudge the “elephant” along with solid science, not bold bravado. Technology led the charge toward what we do today to change lives.

For years, patients who complained of symptomatic floaters were given two choices: learn to live with them or undergo vitrectomy and run the risk, albeit small, of cataract, endophthalmitis, retinal detachment, glaucoma, vitreoretinal hemorrhage and macular edema. We have always downplayed the impact of floaters on patients’ quality of life, much like with myopia, hyperopia and astigmatism possibly because a credible treatment option beyond invasive surgery such as vitrectomy has been unavailable for floaters in the past. While floaters may be a mild and short-lived inconvenience for most patients, there is nevertheless a sizeable minority for whom the problem is far more serious. One recent survey found that the deleterious impact on quality of life as a result of floaters was comparable to or worse than that of age-related macular degeneration, diabetic retinopathy or glaucoma.

The good news is that we now have another option to treat symptomatic floaters — one that does not carry the same risk profile of vitrectomy. Even though we think of YAG vitreolysis as a recent option, it has been around for quite a while. The concept, with a specially designed YAG laser used to vaporize vitreous opacities and vitreous strands, has been shown to effectively improve patient outcomes with a low rate of complications. Early studies with longer follow-ups have continued to support the effectiveness of YAG laser vitreolysis with minimal side effects. Drs. Scott Geller, James Johnson and John Karickhoff have led the way, with long-term studies showing success rates of 92% and higher and complication rates as low as 0.1%. So this concept of YAG laser vitreolysis continues to find its way into mainstream ophthalmology after more than 20 years.

In summary, laser vitreolysis has turned out to be a positive addition to our busy practice. The treatment is safe, effective and pain-free with an extremely low complication rate. We have enabled scores of patients to achieve functional improvements in their vision and greatly improved their quality of life in the process. Who knows, we may even think about bilateral cataract surgery as an option in the future.

Disclosure: Stonecipher reports he is a speaker for Ellex Laser.

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Vitrectomy more likely to deliver the desired result

Shachar Tauber

For the treatment of visually disabling vitreous opacities, options include observation, YAG laser vitreolysis or pars plana vitrectomy. Because of the invasive nature of both treatment options, our group almost always recommends observation. In patients for whom observation is not an option, we prefer small-gauge pars plana vitrectomy as a definitive treatment for symptomatic floaters.

Although the idea of a clinic-based YAG laser operation is alluring for its perceived simplicity, we have the following concerns.

1. The energy delivered into the eye is not acceptable. The energy delivered to the eye in YAG vitreolysis compared with standard YAG capsulotomy is much greater. Van der Windt and colleagues state the typical required power is 2.5 mJ to 4.5 mJ, and they do not recommend exceeding 500 pulses per treatment session. They recognize multiple treatment sessions may be necessary. It is our opinion this level of energy being delivered into the eye is too great, putting the patient at unnecessarily high risk for postoperative inflammation, glaucoma and retinal tear/detachment.

2. The efficacy of YAG vitreolysis is also in question. Delaney and colleagues found that 38% of patients treated with YAG vitreolysis had a moderate reduction in symptoms while 62% had no improvement.

The alternative treatment for YAG vitreolysis, and what we recommend at Mercy in carefully selected cases, is small-gauge pars plana vitrectomy. This procedure yields much higher efficacy. In the same Delaney study, they reported 93.3% of eyes undergoing vitrectomy for floaters resulted in full resolution. By utilizing modern surgical equipment, now readily available in as small as 27 gauge and cut rates as high as 7,500 cuts/minute, very little energy is directed into the vitreous, and very little traction on the vitreous is exerted. Vitrectomy has the advantage that if a retinal tear develops intraoperatively, it should be easily identified and treated at the end of the case.

We recognize the disadvantage of going through a procedure in the operating room. This vitrectomy procedure should not be performed in phakic patients because of the inevitable progression to cataract. Some physicians advocate vitrectomy with clear lens exchange, adding another level of complexity. We do not suggest clear lens exchange. We also recognize there is a small chance of bleeding, infection, glaucoma, postoperative inflammation and retinal tear/detachment. A large amount of time is spent discussing these risks, and only if a pseudophakic patient is willing to undergo these risks will surgery be offered. A similar disclosure is undertaken when dealing with cataract, epiretinal membrane, refractive surgery or any elective surgery that is designed to produce a better quality of vision.

There are risks to either YAG vitreolysis or vitrectomy, but we choose the option that is far more likely to deliver the patient the desired result.

Disclosure: Tauber reports no relevant financial disclosures.