Eyeworld

EW RETINA 112 September 2015 EyeWorld article on YAG vitreolysis discussed on this spread. To view the original article, go to hub.eyeworld.org/h/i/136071956-sep-2015. by Timothy Olsen, MD, Ron Adelman, MD, David Brown, MD, Steve Charles, MD, William Mieler, MD, David Boyer, MD, and Keith Warren, MD, chair of the ASCRS Retina Clinical Committee 3. Benhamou N, et al. Retinal detachment following YAG laser section of vitreous strands. Apropos of 3 cases. J Fr Ophtalmol. 1998;21(7):495–500. 4. Burq MA, et al. Frequency of retinal detach- ment and other complications after neodymi- um:Yag laser capsulotomy. J Pak Med Assoc. 2008;58(10):550–2. 5. Lin JY, et al. Analysis of factors correlated with the development of pseudophakic retinal detachment—a long-term study in a single medical center. Graefes Arch Clin Exp Ophthalmol. 2013;251(2):459–65. 6. Ozyol E, et al. The role of anterior hyaloid face integrity on retinal complications during Nd: YAG laser capsulotomy. Graefes Arch Clin Exp Ophthalmol. 2014;252(1):71–5. 7. Cowan LA, et al. Refractory open-angle glaucoma after neodymium-yttrium-alumi- num-garnet laser lysis of vitreous floaters. Am J Ophthalmol. 2015;159(1):138–43. 8. Sebag J, et al. Vitrectomy for floaters: pro- spective efficacy analyses and retrospective safety profile. Retina. 2014;34(6):1062–8. 9. Delaney YM, et al. Nd:YAG vitreolysis and pars plana vitrectomy: surgical treatment for vitreous floaters. Eye (Lond). 2002;16(1):21–6. Editors' note: The authors have no financial interests related to this article. Contact information Warren: kwarren@warrenretina.com symptoms in only 31% of 42 eyes treated with YAG vitreolysis and that 68% of patients were not satisfied. 9 The role of pars plana vitrectomy remains controversial yet has been suggested to improve contrast sensi- tivity and the quality of life, 8 yet the risks of retinal tears, detachment, and cataract progression must be considered. Pharmacovitreolysis has also been suggested as an option; however, studies have not confirmed effectiveness or safety. In summary, the ASCRS Retina Clinical Committee disagrees with multiple statements that are in the article cited above. We strongly discourage this procedure for the treatment of symptomatic vitreous floaters. We are also concerned with the message that this article sends to practicing ophthalmologists. Until a properly conducted study has been carried out that truly demonstrates both efficacy and safety, this form of treatment cannot be recommended at this time. EW References 1. Mamou J, et al. Ultrasound-based quan- tification of vitreous floaters correlates with contrast sensitivity and quality of life. Invest Ophthalmol Vis Sci. 2015;56(3):1611–7. 2. Wagle AM, et al. Utility values associated with vitreous floaters. Am J Ophthalmol. 2011;152(1):60–5. laser for floaters 3 or for posterior capsulotomies. 4 While one could argue that opening an opacified posterior capsule during YAG capsu- lotomy is a different procedure, the dynamics and risks are likely similar. Based on the peer-reviewed litera- ture, there is a definite risk of retinal tears and detachment when using YAG laser treatment in the vitreous. 5 The article also states, "Don't be afraid to use higher laser ener- gies than you're used to" and also suggests that using up to 5 mJ in power and up to 1,000 spots may be needed. Studies have shown an association with increased YAG laser total energy and higher rates of reti- nal detachment and cystoid macular edema 4 in eyes treated for posterior capsulotomy, especially when the anterior hyaloid is damaged. 6 Next, the surgeons interviewed suggest "treating floaters from the periphery to the center, so that no particles float away and get lost in the vitreous." In our group's collec- tive experience, we see numerous patients with peripheral floaters even near the visual axis that are completely asymptomatic. Thus, why would one suggest treating floaters located in an asymptomatic portion of the vitreous, out of the optical axis? Given the risk associ- ated with any surgical procedure, a patient's functional impairment should be considered first. Such a recommendation not only is opti- cally inaccurate, it also likely adds more risk to this procedure. While the sources in the article claim safety, they also report com- plications such as corneal edema, pressure spikes, and inflammation. Elevated intraocular pressures, both immediate and delayed, have been reported in the literature following YAG vitreolysis. 7 Treatment with prophylactic topical agents for pres- sure spikes and inflammation adds expense, especially when the sources suggest that multiple sessions may be required. The article also implies a very high success rate in relieving patients' symptoms. Previously published peer-reviewed articles showed a moderate improvement in Members of the ASCRS Retina Clinical Committee discuss their disagreement with an article in the September 2015 issue of EyeWorld V itreous floaters represent a very common patient complaint. Clearly, floaters are bothersome, annoying, and there is evidence that symptomatic floaters affect the qual- ity of life to varying degree, depend- ing upon severity. 1,2 The September 2015 issue of EyeWorld included an article titled "Pearls for YAG vitreolysis of float- ers." We, the members of the ASCRS Retina Clinical Committee, unani- mously disagree with many of the statements and recommendations in this article. The opening statement in the article was "YAG vitreolysis is a safe, effective, and noninvasive treat- ment for floaters." Primary data was not presented, and there were no references listed to support the claim of safety. In fact, the sources report complications from the procedure. The article states that one par- ticular laser is "the only YAG laser optimized for treating floaters ... " We also recognized, as was correctly noted at the end of the article, that both experts have a financial interest with the same laser company, Ellex (Adelaide, Australia). Importantly, YAG vitreolysis has never been demonstrated to be either an accepted procedure or safe. Medical procedures and laser treatments require studies that are adequately powered, designed with proper control groups, have a study endpoint with reasonable follow-up, and have defined entry and exclusion criteria. To the best of our knowledge, such a study does not exist to definitively state that YAG vitreolysis is a safe or effective procedure. We know that there is a small but definite rate of retinal detachment when using a YAG Retina Clinical Committee responds to "Pearls for YAG vitreolysis of floaters" March 2016 Retina consultation corner

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