Eyeworld

EW SECONDARY FEATURE 88 September 2015 by Lauren Lipuma EyeWorld Staff Writer Experts share tips for getting started with the procedure Y AG vitreolysis is a safe, effective, and noninvasive treatment for floaters. Although it is a simple point-and-shoot proce- dure, it does have a learning curve, and many factors contribute to achieving good visual outcomes. With little instruction avail- able on the technique, it falls to individual surgeons to share their wisdom with their colleagues. Here, experienced surgeons Karl Brasse, MD, Vreden, Germany, and I. Paul Singh, MD, in private practice, The Eye Centers of Racine & Kenosha, Wis., share their pearls for getting started with vitreolysis and tips for avoiding potential complications. Assemble the needed equipment The first step toward incorporating YAG vitreolysis into practice is to procure the needed equipment—an appropriate Nd:YAG laser and sur- gical contact lenses. The only YAG laser optimized for treating floaters is the Ultra Q Reflex multimodality laser (Ellex, Adelaide, Australia). The right contact lenses are crucial to success with YAG vitreolysis. Appropriate contact lenses are available from Volk Optical (Mentor, Ohio) and Ocular Instruments (Bellevue, Wash.). Keep in mind that you'll likely need more than one lens; highly myopic eyes need a lens with a longer focal length, and you'll need an off-axis lens to treat floaters that are not perfectly centered in the vitreous. Things to know beforehand Before getting started, read the rele- vant reference material and familiar- ize yourself with the procedure. Dr. Brasse recommends purchasing Laser Treatment of Eye Floaters, by John Karickhoff, MD, the only vitreolysis textbook available. Dr. Karickhoff's book covers everything from laser plasma physics to how to avoid potential complications. Pearls for YAG vitreolysis of floaters Only treat floaters in the safe zone (blue), at least 3 mm from both the lens and the retina. Contact lenses are crucial to success when visualizing and treating floaters. Use a lens with a longer focal length (center) to treat highly myopic eyes and an off-axis lens (right) to treat floaters that are not centered in the vitreous. Similar to gonioscopy-assisted surgery, it's important to practice visualization with the contact lenses before getting started, Dr. Singh said. After purchasing the lenses, practice visualizing floaters preoperatively to get used to the view through the lens. Don't be afraid to use higher laser energies than you're used to. The more matter the laser must trav- el through, the higher the energy required to break down tissue. For that reason, surgeons will need to use higher energy levels to vaporize floaters than to do a YAG capsuloto- my. Dr. Brasse recommends starting with a low energy level (around 2.0–2.5 mJ) and titrating upward until it is high enough to break down the floater material. Be aware that energy levels as high as 4.0–5.0 mJ and even up to 8 mJ may be required to vaporize floaters in the posterior part of the vitreous. Be aware that a high number of laser shots—potentially up to 1,000—may be needed to com- pletely vaporize the floater. Some physicians may be hesitant to fire more than a few hundred shots for fear of causing a retinal detachment, but fewer shots may not complete- ly break down the floater material. Ellex recommends limiting the num- ber of shots fired in one laser session to 400 and repeating treatment several weeks later if needed. Start with the easiest cases Because there is a learning curve associated with this procedure, Drs. Brasse and Singh agreed that choosing the right patient and the right floater are crucial to success when starting out. "The key for me is picking the right patient, picking the right floater, and then practicing beforehand with the visualization," Dr. Singh said. To avoid causing a traumatic cataract by accidentally hitting the lens or posterior capsule, start with pseudophakic patients. Avoid patients with multifocal lenses, however, because the lens' multiple focal points will divide the YAG laser beam. A divided laser beam makes visualization more difficult. It could also cause the laser to hit other ocular structures and may not achieve enough energy to vaporize the floater. Start with large, fibrous floaters such as Weiss rings that are easy to visualize and vaporize with the laser. Avoid treating the diffuse, cloud-like floaters caused by vitreous syneresis; treat these floaters only after gaining sufficient experience with the laser. Remember that the larger and more amorphous the floater, the more laser shots and treatment sessions will be needed. It is important to set expecta- tions ahead of time. If the floaters are larger, denser, and more amor- phous, patients need to be aware that they might need multiple sessions. If the floaters are too far posterior, near the retina, or ante- rior near the lens, patients must be aware that the surgeon may not be

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