* * Aggregation of vitreous fibrils Hyaluronic acid drops - - PowerPoint PPT Presentation

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Kirk H. Packo, MD

Professor & Chairman

Rush University Medical Center Chicago, IL

2015

OPHTHALMOLOGY UPDATE

San Francisco, California December 4-5, 2015

The author acknowledges compensation as consultant to: The author acknowledges compensation as consultant to: The author’s institution has received grant support from: The author’s institution has received grant support from:

• Alcon Surgical, Inc
• Allergan, Inc.
• Genentech
• Optoview
• Regeneron Pharmaceuticals, Inc
• Alcon Surgical, Inc
• Allergan, Inc.
• Genentech
• Optoview
• Regeneron Pharmaceuticals, Inc
• Alcon Surgical, Inc
• Alimera Sciences
• Alcon Surgical, Inc
• Alimera Sciences

No conflicts relevant to this discussion No conflicts relevant to this discussion

“Exogenous” Sources:

• Hemorrhage (red cells)
• Inflammation (white cells)
• Infiltration (tumor cells, amyloidosis, RPE cells)
• Asteroid hyalosis (calcium deposits)

“Endogenous” Vitreous Sources:

• Aggregation of vitreous fibrils
• Posterior vitreous cortex & Parapillary glial tissue

* *

Hyaluronic acid drops & Vitreous liquefies Collagen fibers aggregate

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Similar to Cotton Candy Sugar Fibers Clumping Weiss Ring & Posterior Vitreous Cortex Weiss Ring & Posterior Vitreous Cortex

Sebag, J

• Degenerative opacities composed of hydroxyapatite

(calcium soaps & phospholipids)

• Slight association with diabetes
• Rarely noticeable to patient – only very rarely justifies

vitrectomy to improve symptoms

• View in by doctor is much worse than patient’s view
• Able to see fundus much better with fluorescein

angiography

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Asteroid Ultrasound Asteroid OCT Imaging Optos Imaging Fluorescein Angiography

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• Blue light (430 nm) is absorbed by RBC’s

in capillaries.

• Brain "edits out" the shadow lines of the

capillaries by dark adaptation of the photoreceptors lying beneath the capillaries.

• WBCs do not absorb blue and create gaps in

the blood column

• WBCs appear as bright dots
• Focus behind lens with slit lamp
• Have patient look up + look straight against a

red reflex

• 78D Biomicroscopy with joystick pulled back
• Kinetic ultrasonography
• OCT imaging
• Kinetic OCT imaging of infrared view

Biomicroscopy

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Kinetic Ultrasonography

BMC Ophthalmol 2015:15:22-24

• Case report of a large floater

(vitreous cyst)

• OCT used to qualitate the

impact of the floater on the vision

Clinical Appearance Ultrasound

Patient Drawing

BMC Ophthalmol 2015:15:22-24 OCT Infrared Image 3D Reconstruction Standard OCT showing “ring” scotoma

• peripheral shadowing

Kinetic OCT

Large Floaters Small Floaters

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• Floaters are always caused by a PVD
• Floaters get less noticeable with time

due to gravitational settling

• Floaters get less noticeable with time

due to neuro-psychological adaptation

• People who complain of floaters have a

psychologic problem

Am J Ophthalmol 2011:152(1):60-65

• 266 patients with floaters (age > 21) surveyed and utility value assessed
• Utility Value:
• Value 1.0 = “Perfect Health”
• Value 0.0 = “Death”
• Metric Used to Calculate Utility Value:
• Time Trade Off (TTO): Willingness to trade off #years life out of every 10 years

to get rid of problem

• Standard Gamble (SG): Willingness to risk death or blindness to rid problem

Am J Ophthalmol 2011:152(1):60-65

• Utility Value of Floaters:
• Is the same as vision loss from AMD
• Is lower than diabetic retinopathy or glaucoma
• Is the same as mild angina, mild stroke, colon cancer, and asymptomatic HIV
• The same for acute floaters (< 1 month) or chronic floaters (> 1 year), thus do

not become less frustrating with time

• Unilateral floaters had the same UV as bilateral floaters
• Time Trade Off (TTO) of Floaters:
• Willingness to trade off 1.1 years of life out of every 10 years
• Standard Gamble (SG) of Floaters:
• Willingness to accept an 11% risk of death and 7% risk of blindness

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• Absolute size of floaters
• Floaters in the visual axis
• Floaters clumped anteriorly near lens
• Myopia – magnifies the retinal images
• Multifocal Intraocular Lenses

ReSTOR

Diffractive

Technis

Refractive

• Often very distraught
• May be doctor shoppers
• Shops the internet ~ participates in blogs
• Professional surgical patient (LASIK, YAG)
• Young patients more intollerant
• Often very happy when floaters removed

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• 143 patients with floaters surveyed
• 77 (54%) were first time patients

66 (46%) had seen multiple doctors

• Women & non-myopes most likely doctor shoppers
• Is doctor shopping related to the patient’s personality
• r due to doctors not being sympathetic to patient’s

complaint?

• Int. J. Environ. Res. Public Health 2015, 12, 7949-7958

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1. Observation 2. Refer for psychologic counseling 3. Hyaluronidase (Vitrase™) enzyme 4. Holistic, herbal & other “treatments” 5. YAG laser vitreolysis 6. Vitrectomy

YAG Vitreolysis Vitrectomy

• Should be tried first, especially with

acute onset of floaters/PVD

• Consider occupational needs
• Does it impact any activities?
• Is the patient phakic?
• Is there other retinal pathology?’
• Often does not lessen with time

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• Patients can train themselves to see

minimal floaters – then become fixated

• Can possibly train themselves to

disregard them?

• Anxiolytic medications?
• Patients usually are very resistant to this

suggestion

• Vitrase™ - Ovine hyaluronidase
• FDA approved as a tissue spreading agent
• Off label use intraocularly
• Theoretically will decrease hyaluronidase

thus liquefying vitreous allowing floaters to fall inferiorly

• Study in Mexico showed 10% patients

were made worse

Herbal Eye Drops Ayurvedic Warm Eye Bath Treatments Exercises & Palming Massage Mystery Cure $17

The Silva Healing Method

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• Minimal evidence on efficacy & safety
• Not covered by insurance

($2,500 - $5,000 per eye)

• May require special Q-switched laser
• Promoted by handful of
• phthalmologists that do treatment

exclusively; promoted on internet

www.vitreousfloaters.com

• www. thefloaterdoctor.com

www.EyeFloaters.com

• Dr. Karickhoff’s book

$225.00

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• 31 patients (42 eyes) with floaters from PVD underwent

54 procedures with Nd:YAG laser

• Outcome was “subjective improvement”
• 38% were “moderately” improved; 61.5% had no improvement
• 36% underwent subsequent vitrectomy
• 1 patient developed a retinal detachment

Eye (London) 2002 Jan;16(1):21-6.

• “FOV” – Floaters Only Vitrectomy
• Controversial among retinal surgeons
• More common with small gauge surgery
• Phakic eyes will develop cataract
• Balance against other risks of typical

vitrectomy (RD, tears, endophthalmitis, glaucoma)

• The only true way to remove floaters

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• 0.44 mm diameter (cf. 20 ga = 0.95 mm)
• The smallest gauge instrumentation
• Sclerotomies easily seal without sutures
• Full complement of instruments

(probe, light, laser, forceps)

• Produced by multiple companies

Am J Ophthalmol 2011:151:995-998

• Review of 116 consecutive floaterectomies in Amsterdam, Netherlands
• Intraoperative Adverse Problems:
• 16.4% iatrogenic retinal tears
• 1 case of intraop choroidal hemorrhage (resolved)
• Postoperative Adverse Problems:
• 2.5% (n=3) retinal detachment
• 50% of phakic eyes developed cataract in 1 year
• 7.8% transient increased IOP

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Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382

• Review of 110 consecutive floaterectomies in Nijmegen, Netherlands
• 23 ga vitrectomy; assessed for satisfaction, complication, VFQ-25
• 85% were satisfied or “cured” – 9.3% were dissatisfied
• Complications:
• 10.9%

Retinal detachment (4.5% in first 3 months)

• 5.5%

Cystoid macular edema

• 3.6%

Epiretinal membrane (macula pucker)

• 0.9%

Each of: Glaucoma surgery – Macular hole - Scotoma

Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382

Complications Outcomes of the Patients with Retinal Detachments

Postop retina tear

Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382

Overall Patient Satisfaction after Vitrectomy

Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382

Time Troubled by Floaters BEFORE Vitrectomy

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Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382

Time Troubled by Floaters AFTER Vitrectomy

Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382

Difficulty Reading Small Print Before & After Vitrectomy

Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382

Difficulty Driving at Night Before & After Vitrectomy

Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382

Would You Recommend Vitrectomy to a Friend with Floaters ?

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Retina 34:1055–1061, 2014

• Review of 168 consecutive floaterectomies in Birmingham, Alabama
• 25 ga vitrectomy; assessed for satisfaction, complication, VFQ-25
• 96% were satisfied or “cured” – 4% were dissatisfied
• Complications:
• Intraop or Postop Retinal detachment
• 1 pt

Transient cystoid macular edema

• 2 pts.

Transient vitreous hemorrhage

• 7.1%

Intraoperative retinal breaks - treated

Retina 34:1062–1068, 2014

• Review of 66 consecutive 25 ga. floaterectomies in California
• Causes: 80% from PVD; 32% from myopic vitreopathy
• NO PVD was induced in the 20% not having a PVD preop
• VFQ was 28% lower in preop floater patients than age matched controls

VFQ improved by 29% after vitrectomy

• NO cases of retinal tears, RD or infection.
• Only 24% developed cataract at 15 months (zero below age 53)

Henry CR, Schwartz SG, Flynn HW Clinical Ophthalmology 2014:8 1649–1653

• 24 y/o female – 20ga floaterectomy
• Inflammation on 1st postop day
• Staphylococcus caprae endophthal.
• Recovered 20/80 vision (from 20/20)

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Simple Vitrectomies? Only happen Over the Rainbow

• Examine! – Are significant floaters there?
• Consider Surgery:
• Has the patient tried a period of observation?
• Are floaters anterior/clumped behind lens?
• Is there a multifocal lens?
• Does the patient have a convincing story/need?
• Is the patient ready to accept risks?
• Discourage Surgery:
• Is the patient phakic?
• Is there other pathology? (Lattice, High myopia)
• Already had multiple procedures? (LASIK, YAG Vitreolysis)

Thank You !

OPHTHALMOLOGY

UPDATE

San Francisco, California December 4-5, 2015

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