- by Dr. Patrick Monahan, M.D.
Vitreous floaters can be a frustrating and even a debilitating condition for many people. However, complaints of vitreous floaters were often passed over or dismissed by practitioners. In the past, procedures to alleviate the floaters had relatively high rates of complications, and it took a significant time to recover. With the advent of new, small instrument surgery, treatment of vitreous floaters is now a more reasonable choice. Small instrument surgery allows an easier, quicker surgery as well as a more comfortable and quick recovery. Most importantly, the risk of complications is reduced.
What causes vitreous floaters?
Vitreous floaters are very common and for most people are nothing more than a nuisance. The most common cause of vitreous floaters is from a posterior vitreous detachment (PVD).
The vitreous (liquid and gel in the center of the eye) is mostly solid at age 10. It turns into liquid centrally as a person gets older. Eventually the vitreous collapses and peels away from the retina which is on the back wall of the eye. The patient may notice this as a large cobweb floater or multiple string-type floaters when it occurs. It is sometimes associated with some flashing lights. The vitreous gel usually then melts or liquefies over the next several weeks to months. The floaters often subside starting within a few days, and all but a few settle to the bottom of the eye and disappear within a 6-month period. Some residual floaters can be seen for life. The problem occurs when the floaters don't become translucent and don't settle. Sometimes the vitreous will only partially peel off the back wall of the eye (or retina), and floaters may get stuck in the visual axis or the center of the vision. These floaters can be quite bothersome because of the sharp shadows they cast on the retina. Bleeding may occur when the vitreous peels off the optic nerve or causes a retinal tear. Even if the retinal tear is repaired, the blood left in the eye can stain the translucent vitreous floaters and make them more opaque which makes them more bothersome. Of course, the main concern when new vitreous floaters develop is that it might be associated with a new retinal tear, and, hence, a possible subsequent retinal detachment.
New floaters, and/or flashing lights, should be evaluated by your eye doctor as soon as possible.
Other causes of new floaters include asteroid hyalosis, a benign condition with the development of yellow crystalline opacities in the vitreous. These develop suspended uniformly in the vitreous. They only become bothersome later in life when the vitreous jelly collapses or melts and the floaters start moving around significantly and coalesce centrally into dense clumps.
Vitreous hemorrhage can occur from several conditions including a retinal tear, diabetic retinopathy, retinal vein occlusion, severe cases of macular degeneration, trauma, and other conditions. This usually presents as a sudden onset of red or black floaters, possibly with significantly decreased vision. These symptoms warrant urgent evaluation.
Uveitis, which is an inflammation in the eye, can be caused by a number of conditions. These would include infection, parasites, autoimmune conditions, trauma, and some cancers. It usually presents with light sensitivity and blurred vision in addition to the floaters. These symptoms warrant urgent evaluation.
Myopic Floaters (associated with a near-sited eye) are often the most troublesome for patients. These often start to develop at a younger age and get worse becoming problematic as early as ones thirties or forties. These floaters are not always associated with a posterior vitreous detachment, especially in younger patients. In these cases the collagen fibers in the vitreous break down centrally and then reform in clumps creating fibrous floaters. These appear like cotton balls or sometimes shower curtain like opacities in the eye. These respond best with Floaters only Vitrectomy, (see below).
What are the treatments for vitreous floaters?
Traditionally, vitreous floaters have been considered a benign nuisance and unless associated with vision loss, no treatment was offered. The risk and inconvenience of surgery and recovery were far worse than living with the floaters. More recently that has changed with the advent of new technology and new techniques for their removal.
Options for vitreous floaters:
The first option is no treatment.
Not treating but just observing is still the most common course for most people with new floaters. Patients with a posterior vitreous detachment usually develop significant floaters initially, but these floaters quickly subside in days to a few months. Hence, it would be prudent to wait at least until 6 months after a posterior vitreous detachment before considering intervention. The initial, large cobweb floaters continue to melt away and become smaller as they fall out of the middle of the visual axis.
If the floaters don't go away, then patients need to ask themselves, how much do the floaters interfere with my life? Are they a minor nuisance and most of the time not noticeable, or do they prevent me from reading comfortably or using a computer? Are they dangerous while driving, presenting a false image in side vision? Would removing them be worth the risk of treatment?
All treatments have risk, no matter how small, to life, eye, and vision.
The second option is laser treatment.
With this treatment, a YAG laser is used, which can break up the floaters, partially disintegrate them and move them out of the visual axis, but it does not get rid of them. It works best if you have one large floater caught in the center of your visual axis. Getting the floater to break up or move out of the center of your visual field can be helpful. The risk with this procedure is very low.
The third option is surgery.
Vitrectomy surgery for vitreous floaters used to have a much higher risk and a long and sometimes uncomfortable recovery. With the advent of small instrument surgery (25 gauge and 27 gauge), that has changed significantly. Small instruments enter the eye through very small, needle-like holes in the wall of the eye and are used to clear up the vitreous floaters. With removal of the instruments from the eye, the wounds are self-sealing, requiring no sutures. This leaves the eye much more comfortable and allows it to heal quicker. The risks of this procedure are (1) that it will cause cataract progression in the eye. (2) retinal detachment and (3) infection. Hence, it is an excellent option for patients who have already had cataract surgery. It can be a reasonable procedure for younger patients with myopic floaters who have not had cataract surgery. In these cases a Floaters only Vitrectomy (Now with 27 gauge instruments), is performed. Only the central vitreous is removed leaving the outer shell to protect the lens, slowing or preventing rapid cataract progress. However, they need to fully understand the risks involved.
Small instrument surgery for vitreous floaters is done as an outpatient in a hospital or surgical center. The procedure itself takes less than 20 minutes. Following the procedure, the patient will usually wear a patch and/or a shield on the eye for about 3 days. The patient can usually drive again and return to work within 3 to 5 days. Eye drops are placed by the patient in the eye 3 times per day over the first week. These are tapered away during the first month. See Vitrectomy surgery.
A full evaluation of the patient's peripheral retina should be done prior to treatment for vitreous floaters to rule out any retinal breaks or weak areas in the retina that might cause problems following the surgery. Approximately one month after the surgery, this evaluation should be redone to make sure no complications have occurred. Below is a video of how vitrectomy for floaters is performed.
Dr. Patrick Monahan, M.D.
Copyright 2007, Updated 2016, Retinal Diagnostic Center
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