Eyeworld

89 EW SECONDARY FEATURE September 2015 A small percentage of patients do experience pressure spikes after treatment, so Dr. Brasse applies dorzolamide/timolol twice imme- diately after laser treatment to keep the IOP low. He also prescribes prednisolone 1% eye drops every 30 minutes for the rest of the day, followed by 6 times daily for 1 week. Be sure to examine patients the next day to check visual acuity and IOP. Dr. Singh does not routinely give anti-hypertensive or anti-inflamma- tory drops postoperatively, but does stress the importance of checking pressures within a couple of weeks. Patients at higher risk for an IOP spike are those patients who are pseudophakic/post-YAG capsuloto- my and who have anterior floaters. He thinks the gas bubbles may travel into the anterior chamber and can potentially disrupt the outflow system. Finding the right patients Dr. Singh routinely asks patients during the eye exam if they have any issues with floaters. "I don't go out looking for patients," Dr. Singh said. "These patients are in your of- fice already. We've conditioned our patients to realize that nothing can be done, so patients stop complain- ing about them. So when you start asking patients, you'll find them." Remember that you don't have to get rid of every floater for the patient to be visually satisfied, he added. The goal is to achieve a functional improvement in vision so that patients can easily perform their routine day-to-day activities. For more information, visit Dr. Karickhoff's website at www. eyefloaters.com or Dr. Brasse's web- site at www.floater-vitreolysis.net for presentations he has given on the topic. Visit the Ellex website at www. ellex.com for videos from Dr. Singh and information about the laser and further treatment guidelines. EW Editors' note: Drs. Singh and Brasse have financial interests with Ellex. Contact information Brasse: brasse@augenarzt-vreden.de Singh: ipsingh@amazingeye.com able to remove the entire floater due to its proximity to the retina or lens. Surgical technique Before starting, make sure that the patient has no active inflammation, retinal pathology, or signs of acute posterior vitreous detachment. To avoid causing damage to any ocular structures, only treat floaters in the "safe zone"—at least 3 mm from both the retina and the lens. Dr. Singh's rule of thumb is that when he can visualize the floater (when it's in focus), if the retina is also in focus, the floater is too close to the retina to treat. "If the retina is not in focus, and the floater is in the middle of the vitreous, you're not going to hit any other structures," he said. Make sure that the floater is vis- ible preoperatively at the slit lamp so that you don't have to search for it after the patient sits down at the laser. If you have trouble finding the floater initially, one of Dr. Singh's tricks is to ask patients where they've seen the floater lately. "The key in this procedure is visualization," he said. "If you can't visualize it, do not do it." Often times, Dr. Singh needs to increase the magnification compared to what he normaly uses for a YAG capsulotomy. It takes some time to find the right magnification for each surgeon. Avoid treating in the direction of the macula, optic nerve or blood vessels, and stop treatment if you see corneal edema. Dr. Brasse recommends treat- ing floater strands in the anterior vitreous first and working posterior- ly. In this manner, you can vaporize floaters that may block your view of the posterior structures. Dr. Brasse warns, however, to avoid combining YAG capsulotomy and floater vitre- olysis in the same session. Because the cavitation gas bub- bles travel upward, they can block the field of view, so Dr. Brasse rec- ommends starting from the top of the floater and working downward. He also recommends treating float- ers from the periphery to the center, so that no particles float away and get lost in the vitreous. Multifocal IOLs can divide the YAG laser beam, so avoid treating floaters in multifocal IOL patients. Make sure that the retina is not in focus when visualizing the floater. Start with large, well-defined floaters like the one pictured here. Avoid treating floaters directly in front of the macula, optic nerve, or major blood vessels (circled in white). Source (all): Karl Brasse, MD

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