12/4/2015 OPHTHALMOLOGY The author acknowledges The author acknowledges 2015 UPDATE compensation as consultant to: compensation as consultant to: San Francisco, California • • Alcon Surgical, Inc Alcon Surgical, Inc December 4-5, 2015 • • Alimera Sciences Alimera Sciences The author’s institution has received The author’s institution has received grant support from: grant support from: • • Alcon Surgical, Inc Alcon Surgical, Inc • • Allergan, Inc. Allergan, Inc. Kirk H. Packo, MD • • Genentech Genentech • • Optoview Optoview Professor & Chairman • • Regeneron Pharmaceuticals, Inc Regeneron Pharmaceuticals, Inc Rush University Medical Center Chicago, IL 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 Hyaluronic acid drops Collagen fibers aggregate • Posterior vitreous cortex & Parapillary glial tissue & Vitreous liquefies 1
12/4/2015 Similar to Cotton Candy Weiss Ring & Sugar Fibers Clumping Posterior Vitreous Cortex • Degenerative opacities composed of hydroxyapatite (calcium soaps & phospholipids) • Slight association with diabetes • Rarely noticeable to patient – only very rarely justifies vitrectomy to improve symptoms Weiss Ring & Posterior Vitreous Cortex • View in by doctor is much worse than patient’s view • Able to see fundus much better with fluorescein Sebag, J angiography 2
12/4/2015 Asteroid OCT Imaging Asteroid Ultrasound Optos Imaging Fluorescein Angiography 3
12/4/2015 • 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 Biomicroscopy • Kinetic OCT imaging of infrared view 4
12/4/2015 BMC Ophthalmol 2015:15:22-24 Patient Drawing Clinical Appearance • Case report of a large floater (vitreous cyst) Kinetic • OCT used to qualitate the Ultrasound Ultrasonography impact of the floater on the vision BMC Ophthalmol 2015:15:22-24 Kinetic OCT Large Floaters Small Floaters OCT Infrared Image 3D Reconstruction Standard OCT showing “ring” scotoma - peripheral shadowing 5
12/4/2015 • 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 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 • 266 patients with floaters (age > 21) surveyed and utility value assessed • Is the same as mild angina, mild stroke, colon cancer, and asymptomatic HIV Utility Value: • The same for acute floaters (< 1 month) or chronic floaters (> 1 year), thus do • not become less frustrating with time • Value 1.0 = “Perfect Health” • Unilateral floaters had the same UV as bilateral floaters • Value 0.0 = “Death” • Time Trade Off (TTO) of Floaters: Metric Used to Calculate Utility Value: • • Willingness to trade off 1.1 years of life out of every 10 years • Time Trade Off (TTO): Willingness to trade off #years life out of every 10 years to get rid of problem • Standard Gamble (SG) of Floaters: • Standard Gamble (SG): Willingness to risk death or blindness to rid problem • Willingness to accept an 11% risk of death and 7% risk of blindness 6
12/4/2015 ReSTOR • Absolute size of floaters Diffractive • Floaters in the visual axis • Floaters clumped anteriorly near lens Technis Refractive • Myopia – magnifies the retinal images • Multifocal Intraocular Lenses • 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 7
12/4/2015 Int. J. Environ. Res. Public Health 2015, 12, 7949-7958 • 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 or due to doctors not being sympathetic to patient’s complaint? 8
12/4/2015 YAG Vitreolysis • Should be tried first, especially with 1. Observation acute onset of floaters/PVD 2. Refer for psychologic counseling • Consider occupational needs 3. Hyaluronidase (Vitrase™) enzyme • Does it impact any activities? 4. Holistic, herbal & other “treatments” Vitrectomy • Is the patient phakic? 5. YAG laser vitreolysis • Is there other retinal pathology?’ 6. Vitrectomy • Often does not lessen with time 9
12/4/2015 • Patients can train themselves to see • Vitrase™ - Ovine hyaluronidase minimal floaters – then become fixated • FDA approved as a tissue spreading agent • Can possibly train themselves to • Off label use intraocularly disregard them? • Theoretically will decrease hyaluronidase • Anxiolytic medications? thus liquefying vitreous allowing floaters to fall inferiorly • Patients usually are very resistant to this suggestion • Study in Mexico showed 10% patients were made worse Exercises & Mystery Cure Ayurvedic Warm Palming Massage $17 Eye Bath Treatments Herbal Eye Drops The Silva Healing Method 10
12/4/2015 • 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 ophthalmologists that do treatment exclusively; promoted on internet Dr. Karickhoff’s book www.vitreousfloaters.com www. thefloaterdoctor.com www.EyeFloaters.com $225.00 11
12/4/2015 • “FOV” – Floaters Only Vitrectomy Eye (London) 2002 Jan;16(1):21-6. • Controversial among retinal surgeons • 31 patients (42 eyes) with floaters from PVD underwent • More common with small gauge surgery 54 procedures with Nd:YAG laser • Phakic eyes will develop cataract • Outcome was “subjective improvement” • Balance against other risks of typical • 38% were “moderately” improved; 61.5% had no improvement vitrectomy (RD, tears, endophthalmitis, glaucoma) • 36% underwent subsequent vitrectomy • The only true way to remove floaters • 1 patient developed a retinal detachment 12
12/4/2015 • 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 13
12/4/2015 Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382 Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382 Complications Outcomes of the Patients with Retinal Detachments • 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 Postop retina tear • 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 Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382 (2013) 251:1373–1382 Overall Patient Satisfaction after Vitrectomy Time Troubled by Floaters BEFORE Vitrectomy 14
12/4/2015 Graefes Arch Clin Exp Ophthalmol Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382 (2013) 251:1373–1382 Time Troubled by Floaters AFTER Vitrectomy Difficulty Reading Small Print Before & After Vitrectomy Graefes Arch Clin Exp Ophthalmol Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382 (2013) 251:1373–1382 Difficulty Driving at Night Before & After Vitrectomy Would You Recommend Vitrectomy to a Friend with Floaters ? 15
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