Eyeworld

FALL 2024 | EYEWORLD | 35 C How to diagnose? Dr. Zhu said patients will complain of blurry vision that comes and goes. She said she takes this discussion a step further, describing dif- ferent symptoms that are more indicative of floaters, rather than something like a tear film disturbance. "I ask them, 'Do you notice a cloud or film that floats in front of your eye that comes and goes, especially as you move your eyes around?' Then they say, 'Yes.' They need your help in describing what they feel," she said. Objectively, floaters can be observed on a slit lamp exam. Dr. Zhu said to create a thin, high-intensity beam, hold it at an angle, and fo- cus on the anterior vitreous just behind the lens. If the floaters are deeper in the vitreous cavity, they can be viewed with a mid-vitreous lens. Sometimes they are also visible as a clump or Weiss ring floating over the retina on the dilated fundus exam with a 20 D lens. They can also be reviewed with an OCT macula en face view, represented as a gray or black shadow over the central retina. Why the wait to treat? As Dr. Charles said, patients who experience floaters after cataract surgery will notice them less over time. Why? Three reasons, he said. 1) Floaters will come further forward in the eye and out of the focal plane over time. 2) They're slightly denser than liquid vitreous, so they'll sink out of the visual axis. 3) The "magic" of 3D depth perception in the brain. As Dr. Charles put it, if something is only in one eye, there are about 15 decibels of suppression in that eye. Dr. Weng also discussed neuroadaptation as a reason to wait on treating. She said with reassurance that there are treatment options should their symptoms persist or get worse, she has found most of her patients complaining of floaters don't require further intervention. How to treat? Dr. Zhu said she only treats patients who are "immensely symptomatic," who have waited 6 months after cataract surgery, and in whom she has eliminated all other possible causes, continued on page 36 References 1. Webb BF, et al. Prevalence of vitreous floaters in a community sample of smartphone users. Int J Ophthalmol. 2013;6:402–405. 2. Wagle AM, et al. Utility values associated with vitreous floaters. Am J Ophthalmol. 2011;152:60–65. 3. Zhou I, et al. Outcomes of YAG laser vitreolysis in pseudophakic eyes with visually significant opacities following cataract surgery. Paper presented at the 2023 ASCRS Annual Meeting, May 5–8, 2023, San Diego, California. 4. Shah CP, Heier JS. YAG laser vitreolysis vs sham YAG vitreolysis for symptomatic vitreous floaters: a randomized clinical trial. JAMA Ophthalmol. 2017;135:918–923. 5. Nguyen JH, et al. Assessment of vitreous structure and visual function after neodymium: yttrium-aluminum-garnet laser vitreolysis. Ophthalmology. 2019;126:1517–1526. Relevant disclosures Charles: Alcon Weng: AbbVie, Alcon, Alimera Sciences, Apellis Pharmaceuti- cals, Boehringer Ingelheim, BVI, Carl Zeiss Meditec, EyePoint, Genentech, Iveric Bio, Novartis, Opthea, Regeneron, REGENXBIO, Springer Publishers Zhu: None identifying floaters as the main culprit. Numer- ous studies show the impact of vitreous floaters on contrast sensitivity can be significant. She tries to dissuade patients from surgical intervention at first, making sure they are truly bothered and don't see any other option to im- prove their function or quality of life. Dr. Zhu said she has been performing YAG vitreolysis in pseudophakic eyes for 3 years. She noted that there is one laser that is specifically approved for floaters (Ultra Q Reflex, Ellex), but she doesn't have this one. Dr. Zhu said you want to go up a little on your power settings (3-5 mJ) and offset it posteriorly to avoid hitting the lens. "You want to use a mid-vitreous lens so you can see exactly where you are. You don't want to hit the retina, which is very unlikely if you stay in the mid-vitreous," she said. For dense cases, she will do several hundred spots, sometimes over a few sessions. Post "floaterectomy," she puts the patient on a steroid for a week 4 times a day and might use dorzolamide/timolol in cases where the treatment is longer to mitigate any transient IOP spike. She said she has never had a retina issue with this treatment. "I presented a case series at the ASCRS Annual Meeting 3 where approximately 70% of my patients (n=77 eyes) noticed significant Weiss ring in a middle-aged man that was causing significant visual debilitation Source: Christina Y. Weng, MD, MBA

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