Floaters – treatment options

Virtually all adults experience floaters to some degree.  Floaters may appear as dots,  lines, or a blurry haze in the field of vision that moves with eye movement. Floaters are more noticeable in bright settings such as a snow-covered ground or a bright sunny day.  For the most part, floaters are just a part of getting older.  What treatment options are available for floaters?

If you have not read my previous article on flashes and floaters, please start there.  Vitreous syneresis and posterior vitreous detachments are by far the most common causes of symptomatic floaters.  Other common causes are:

  • Inflammation of the eye called uveitis.

  • Vitreous hemorrhage from causes such as diabetic retinopathy, retinal tears or retinal detachment

  • Asteroid hyalosis is the build-up of calcium-lipid deposits in the vitreous cavity, causing severe floaters

  •  Intra-ocular  injections in the eye for treatment of diabetes, AMD and inflammation may cause floaters

  • Floaters may become much more noticeable after cataracts surgery.

  • Blunt trauma may cause a sudden onset of floaters.

  • Floaters may develop as a complication of some eye surgeries.

asteroid hyalosis

The first step in treating floaters is seeing a retina specialist to determine the cause of the floaters.  Patients with uveitis, vitreous hemorrhage, retinal tear, and detachment require treatment for their diseases.  Treatment of underlying causes of floaters may lessen the appearance of floaters.

Assuming there is no underlying cause of floaters that require treatment, there are two main options. Put up with it, or seek a solution such as a vitrectomy or laser treatments.  Factors that determine treatment  options are;

How bothersome are the floaters?  Floaters may cause difficulty with reading, driving, and may cause an overall decrease in vision due to decreased contrast sensitivity.  Symptom due to floaters tends to be highly subjective.  Tell your doctor how your floater affects your day to day activities.  If your symptoms are mild, treatments may not be needed.  Lightly tinted, amber-colored glasses may help with symptoms during a bright day.

A comprehensive eye is necessary.  Certain retinal pathologies such as retinal holes, retinal tears, lattice degeneration, macular pucker, the presence or absence of a posterior vitreous detachment, and other findings may determine the best treatment option.

Treatment basically boils down to two modalities:  vitrectomy and laser ablation.

A vitrectomy is a surgery that physically removes the vitreous floaters from the eye.  The procedure takes about 15 minutes to perform and is done in a surgery center as an outpatient procedure.

The vitreous is chopped into fine pieces and aspirated from the eye using the vitrectomy probe.  Clear fluid is pumped into the eye to replace the aspirated fluid and floaters.  Your doctors will go over the details of a vitrectomy in more detail.  The vitrectomy procedure has been performed for over 30 years and is covered by most insurance plans.  The results are generally overwhelmingly positive…most patients have total or very near total removal of all floaters.   However, as with any surgery, patient selection and risk assessment are important.

The ideal patient for this procedure would have troublesome floaters, an existing posterior vitreous detachment, prior cataracts surgery, and no other significant retinal pathologies.  This does not mean that patients not meeting these criteria cannot have surgery.   Your retinal specialist will discuss findings in your eye that may impact the surgical outcome.

A vitrectomy does have risks.  Cataracts may develop and existing cataracts may worsen.  Less common risks are bleeding, infection, retinal tear or detachment, and macular edema.  There are also risks from anesthesia that is required for the surgery.  Overall, the risks are low but may cause loss of vision in the worse case scenarios.

Recovery from a vitrectomy is generally rapid.  Most facilities will perform the surgery using 25 or 27 gauge instruments that require no sutures.  Eyedrops are necessary after the surgery for about 10 days.  Typically a patient can return to non-strenuous work in 1-3 days and resume full activities after about 7-14 days.

Can floaters be treated with lasers?  The answer is maybe. Ellex has introduced a line of Yag laser instruments designed to remove floaters.  Laser, and specifically YAG lasers have been in use for many years, but only recently have they been used to treat floaters.  The process of using the YAG laser to remove floaters is called YAG vitreolysis.

YAG laser works by aiming a focused beam of light onto a floater, causing a tiny explosion of energy that breaks up the floater.  The main advantage of treating floaters with a laser that it’s non-invasive.  A typical laser session involves 500-1000 applications of laser and takes 5 – 15 minutes.  Typically there is no aftercare.  A patient may return to work in hours instead of days.

YAG vitreolysis does have risks.  Glaucoma, retinal tear, retinal detachments may occur.  If the laser hits the lens, cataracts may form.  There’s a rare chance that the laser can impact the retina, which can lead to vision loss.  It’s not uncommon for patients to require multiple laser sessions.  Unlike the vitrectomy procedure that removes just about all the floaters, YAG vitreolysis only removes the larger floaters.

It’s important to understand that while YAG vitreolysis has been used to remove vitreous strands, the procedure has not been FDA approved specifically for the treatment of floaters.  What this means is that the procedure has not been adequately studied for this indication and most insurance will not cover the cost of the procedure.  You may be asked to pay out of pocket for the procedures.

My humble opinion on YAG vitreolysis is that it’s a process that needs further studies.  At this point,  I do not feel comfortable offering this treatment modality to my patients.  As always,  I recommend that you talk to your retinal specialist specifically about your conditions and needs.