John A. Hovanesian, MD, FACS, focuses his blog on real-world comanagement cases with valuable take-home messages. Dr. Hovanesian is a specialist in cornea, external ocular disease and refractive and cataract surgery with Harvard Eye Associates in Laguna Hills, Calif., a clinical instructor at UCLA Jules Stein Eye Institute and a member of the Primary Care Optometry News Editorial Board.

BLOG: Evidence supports use of YAG for floaters

Much controversy has surrounded the subject of the use of YAG lasers to treat vitreous floaters.

The dogma in our specialty has been that floaters are a mere annoyance that most patients will adapt to and that they don’t cause visual disability. It’s been believed that vitrectomy is too extreme and risky a procedure to treat such a minor condition, and lasers have undue risk.

Indeed, anecdotal reports of retinal tears and detachments caused by older YAG laser vitreous floater treatments have raised justified concern.

But new data and technologies are challenging all of these beliefs and raising the possibility that treatment of symptomatic vitreous floaters may soon be in the mainstream of procedures for ophthalmologists. I believe this will happen for three reasons:

1. Floaters are a big deal for patients. The intermittent nature of blur from floaters makes their impact difficult to pick up on our usual visual acuity measurements. If you want to know the impact of a condition, though, ask the person who is suffering with it, not the doctor who is treating it. A 2013 study by Blake Webb asked patients with floaters how much lifestyle was impacted by this condition, and roughly one-third of patients across all age groups reported significant visual disability and interference with activities of daily living (ADL). We all know patients in our practices who complain bitterly about floaters causing disability. Why have we ignored them until now? Impact on ADLs is the reason we do cataract surgery. Why wouldn’t the same criterion prompt us to treat vitreous floaters? The Webb study alone suggests that there has been an unmet need.

2. YAG laser treatment of floaters works. Newer generation lasers like the Ultra Q Reflex by Ellex are designed specifically to address floaters. Their aim is to break up larger symptomatic floaters into smaller pieces that are less visually disabling. While this doesn’t eliminate the problem, in many cases it can significantly reduce its disabling nature. The average patient in a recent study (Shah et al.) saw a 53% improvement in symptoms. Naturally, some patients fare better than others. As many as 22% saw no improvement. Still, that’s an acceptable failure rate for patients who previously had no options.

3. YAG laser for floaters has now been proven relatively safe. Growing experience in evolving technology has helped avoid most of the serious side effects of vitreous surgery with these instruments. Staying 3 mm away from the retina and targeting localized floaters with low energy makes clinical sense and is now proven to avoid complications. Inder Paul Singh, MD, reported a series of 1,200 of his own patients in whom there were zero retinal tears. Three hundred of these have been followed out to 4 years. Dr. Singh reported a few cases of temporary spikes in IOP — a small compromise for a lifetime of better vision.

As physicians, we claim a commitment to our patients above all else. We regularly put aside our ego and conventional teaching to come up with what is right for patients. The American Society of Cataract and Refractive Surgery itself (now the world’s leading organization for cataract surgeons) was originally formed in 1974 as a society that allowed opened discussion of a radical, new concept — the intraocular lens implant — at a time when the American Academy of Ophthalmology was too conservative to permit talks and symposia that discussed this topic. While the early days of IOLs, like the early days of vitreous YAG procedures, were not all pretty, ultimately technology proved that the idea was worthy, and today it would be malpractice to deliberately leave a patient without an IOL.

Today, the pioneers of vitreous laser surgery have founded the International Society of Vitreous Laser Surgery for open discussion of this topic. I only hope that traditional physicians and societies will be receptive to credible evidence supporting these new laser procedures.

Reference:

Shah CP, Heier JS. JAMA Ophthalmol. 2017;doi:10.1001/jamaophthalmol.2017.2388.

Webb BF, et al. Int J Ophthalmol. 2013;doi:10.3980/j.issn.2222-3959.2013.03.27.

Disclosure: Hovanesian reports no relevant financial disclosures in laser vitreous surgery.