AN OUTPATIENT PROCEDURE ADDRESSES BOTHERSOME FLOATERS
The “Surgical Focus” department presents the perspectives of several medical professionals regarding their experiences with one procedure or product recently launched in the United States.
FOR YEARS, patients with bothersome floaters were told the only choice for treatment was observation or a vitrectomy. But because of the risk of complications, such as cataract, infection or retinal detachment, most ophthalmologists opted to do nothing. However, a small percentage of eye doctors in the U.S. now offer YAG laser vitreolysis, or vaporization of floaters, and one company, Ellex, has begun marketing its Ultra Q Reflex and Tango Reflex lasers for this treatment.1 The company launched www.TreatEyeFloaters.com as an educational resource for the procedure.
While many eye specialists are holding out for large clinical trials, those working with the procedure say it’s safe, effective and improves patients’ quality of life.
“It has made an incredible impact in our practice,” says I. Paul Singh, M.D., of Eye Center of Kenosha, Wisc., who has performed more than 3,000 laser floater procedures in four and half years.
Dr. Singh says he was turned on to the treatment when a patient, a primary care physician who was fed up with his floaters, sought treatment via laser vitreolysis from an ophthalmologist in Virginia. Dr. Singh says the patient raved about the results. A week later, Dr. Singh says his YAG laser broke just before he headed to the American Academy of Ophthalmology meeting, where he talked to a sales rep from Ellex Medical and purchased its Ultra Q Reflex laser — out of necessity.
Little by little, he says he tried using the laser on his patients who had floaters. About 15 to 20 cases in, patients were reporting improved quality of life.
“That was really what got me excited about doing the procedure and educating doctors, because there’s such a need for it,” Dr. Singh says. “Now, we do have a safer, more efficacious way to treat certain types of floaters.”
PROCEDURE
During the procedure, three nanosecond pulses of laser light are used to evaporate the collagen and hyaluronin molecules within floaters, converting them into a gas absorbed into the eye. It takes about 10 to 20 minutes, depending on the type of floater. Because the laser delivers energy to inert proteins, not living tissue, there is no induced inflammation or recovery time, other than waiting for dilation to subside. Post-treatment care includes monitoring patients for rare spikes in IOP or possible retreatment, but no anti-inflammatory medications are needed.
Dr. Singh says the Ultra Q Reflex and Tango Reflex lasers are optimized for viewing the vitreous because they allow for coaxial illumination, giving the operator the ability to view the floater and retina at the same time, providing the necessary spatial context needed for safe and efficacious treatments. The lasers also have the ability to adjust the amount of coaxial illumination to maximize contrast and visualize floaters, allowing him to fire the laser in any slit lamp position. The products also have a truncated energy beam, which ensures a more efficient dispersion of energy, even at higher levels.2
“It is important for doctors to appreciate that the increase of energy on the laser is a non-linear relationship with the amount of dispersion of energy in the eye (convergence zone),” Dr. Singh says. “For instance, at 1mJ, the convergence zone is 110µ , while increasing the laser to 10mJ increases the convergence zone to 220µ — a less than 50% increase.”
These lasers also have an air-cooled cavity that enables thousands of shots to be fired without overheating or causing the laser to reset, Dr. Singh notes.
“We use a very short pulse duration of laser, about three nanoseconds,” Dr. Singh says. “The heat is dissipated well before the next shot is fired, which is why we feel comfortable firing hundreds of shots.”
CANDIDATE SELECTION
The best candidates, says Ronald Norlund, O.D., of the Cataract & Laser Institute in Fort Wayne, Ind., are patients who have a defined floater, like a Weiss ring after a posterior vitreous detachment. The Fort Wayne practice has an ophthalmologist on staff who performs the procedure.
“Something well-defined and opacified, like a clump or a puff ball, is the easiest to treat and results in the greatest satisfaction,” Dr. Norlund says.
Large strands, clusters or small webs of floaters also can be debulked or repositioned with laser treatment, Dr. Norlund explains. Lasers may not be able to completely treat more amorphous opacifications, but they can break them up or move them out of the visual axis, he says.
Location also is key, says Stephen Pruett, O.D., who works with Dr. Singh. Floaters in the middle of the eye are most easily treated. Floaters near the back or front of the eye are more concerning because of their proximity to the retina or the lens, respectively.
Physicians using the Ellex laser for the procedure recommend taking a pre-operative OCT image to identify existing retinal conditions, such as a retinal tear, that might eliminate the patient as a candidate for laser floater removal.
The procedure, which can cost about $1,000 to $2,000 per eye, is covered by many insurers, Dr. Norlund says, provided the floater significantly disrupts daily activities, such as reading or driving, and that it has been stable for two to three months prior to laser treatment.
Laser vitreolysis has had mixed results through the years, partly due to the limitations of older technology, says Dr. Singh. Isolated case studies have reported cataract formation in four patients following laser vitreolysis, due to perforations in the posterior capsule.3-5
RECENT STUDIES
In a retrospective study of 1,272 patients, presented at the 2017 American Society of Cataract & Refractive Surgeons meeting, Dr. Singh reported a 0.8% total adverse event rate.6 One case was of a retinal hemorrhage that spontaneously resolved. Two phakic lenses were hit, one of which required cataract surgery. Seven patients developed an IOP spike, of whom two are still on topical medications.
“After seeing the improvement in quality of life with laser floater removal, I do believe the need/benefits outweighs the risks associated with the procedure,” Dr. Singh says.
James H. Johnson, M.D., who has focused his Irvine, Calif. practice solely on floater treatment for the past 10 years and treated more than 2,000 patients, says success varies on the type of floaters patients have. Weiss rings may result in 80% to 95% perception of improvement while more amorphous, diffuse floaters can result in 50% to 70% perception of improvement, he says.
But some ophthalmologists remain on the fence, awaiting randomized controlled trials comparing YAG laser vitreolysis with vitrectomy for the treatment of symptomatic floaters. An example of a recently published peer-reviewed study was in JAMA Ophthalmology, July 2017: Chirag P. Shah, M.D., M.P.H., a vitreoretinal specialist with Ophthalmic Consultants of Boston, conducted a pilot clinical trial comparing YAG laser vitreolysis to sham YAG in 52 patients who had symptomatic Weiss rings.7 Those in the YAG laser group reported greater symptomatic improvement (54%) after a single treatment compared with controls (9%), and the 10-point visual disturbance score improved by 3.2, versus 0.1 in the sham group. There were no complications. Still, Dr. Shah says he and his colleagues are not currently offering the procedure.
A poster Dr. Singh presented at the European Society of Cataract and Refractive Surgeons meeting in 2014 summarized the results of treating 296 eyes of 198 patients.8 Ninety-three percent, who had an average of 1.7 laser floater removal procedures, said they were satisfied with their post-laser improvement in daily functioning.
Jennifer Lim, M.D., of the Illinois Eye and Ear Infirmary, in an editorial calls for more research.1 In it, she says Dr. Shah’s study “does not prove that YAG vitreolysis is safe.” She also says the procedure’s influence, “on the subsequent behavior of the vitreous gel and liquefaction is unknown.”
Dr. Singh is working on additional studies using dark adaptation and pattern electroretinography, showing vitreolysis has no effect on retina function, so far.
In addition, he is a founding member of the International Ophthalmic Floater Society, launched last year, to collaborate on best practices for patients. OM
Dr. Singh is a speaker and consultant for Ellex. The other interviewees reported no relevant financial conflicts of interest.
References
- Lim JI. YAG Laser Vitreolysis – Is It as Clear as It Seems? JAMA Ophthalmol. 2017 Jul 20. doi: 10.1001/jamaophthalmol.2017.1683.
- Singh, IP. Reflex Technology: Transforming Anterior and Posterior YAG Treatments with a New Generation Laser. White paper, Ellex Medical, 2017.
- Noristani R, Schultz T, Dick HB. Cataract formation after YAG laser vitreolysis: importance of femtosecond laser anterior capsulotomies in perforated posterior capsules. Eur J Ophthalmol. 2016 Nov 4;26(6):e149-e151.
- Koo EH, Haddock LJ, Bhardwaj N, Fortun JA. Cataracts induced by neodymium-yttrium-aluminium-garnet laser lysis of vitreous floaters. Br J Ophthalmol. 2017 Jun;101(6):709-711.
- Sun IT, Lee TH, Chen CH. Rapid Cataract Progression after Nd:YAG Vitreolysis for Vitreous Floaters: A Case Report and Literature Review. Case Rep Ophthalmol. 2017 May 29;8(2):321-325.
- Singh IP. Neodymium:YAG Laser Vitreolysis: Retrospective Safety Study. ASCRS paper presentation, 2017.
- Shah CP, Heier JS. YAG Laser Vitreolysis vs Sham YAG Vitreolysis for Symptomatic Vitreous Floaters: A Randomized Clinical Trial. JAMA Ophthalmol. 2017 Jul 20. doi: 10.1001/jamaophthalmol.2017.2388.
- Singh IP. Vitreous floaters: An Under-Appreciated and Under Treated Problem: Patient Satisfaction and Complications of YAG Vitreolysis. ESCRS Annual Meeting Posters, 2014.