Vitreous opacities, or floaters (Figs. 1 and 2), are a common finding that may arise due to a range of different conditions, some of which may be indicative of more significant ophthalmic pathology. The most common cause, however, is the formation of a posterior vitreous detachment (PVD). This occurs when the vitreous collapses inwards, withdrawing from the retinal interface.1 Depending on the adhesive forces that exist between the vitreous and the retina at the time, PVD may be associated with a retinal tear, which occurs in approximately 14% of patients with PVD.2 If untreated, these tears can progress to a rhegmatogenous retinal detachment (RRD), with potential loss of sight.
Vitreous floaters themselves, however, when not associated with other conditions such as uveitis or RRD, are generally considered to be benign in nature and do not lead to irreversible losses in visual acuity (VA). In some instances, floaters may be indicative of more sinister pathology, such as malignancies in the case of masquerade syndromes.3 Clinicians therefore need to consider alternate diagnosis in patients with persistent or unusual symptoms.
A careful clinical examination and history can differentiate between the varying pathologies, including inflammatory causes such as uveitis, acute retinal tears, and even intraocular malignancies. The presence of pain, redness, or systemic symptoms should alert the clinician to the suspicion of other conditions, and a diagnosis of vitreous floaters should be approached with caution in these patients. If there is any concern regarding a diagnosis other than persistent nonpathological vitreous opacities, the patient should be evaluated carefully by a retinal subspecialist and consideration given to further investigations and treatment, such as retinal laser for acute retinal tears.
Despite not markedly reducing VA, floaters can interfere with vision by disrupting light transmission to the retina,4 and this can be more marked when the floaters are larger and more numerous. This may produce marked visual interference with significant impact upon patients’ quality of life.5,6 Significantly disabling floaters may be more common in those with refractive error,7 potentially compounding visual impairment in these patients.
Given that vitreous floaters do not significantly impede common clinical measures of visual function such as VA4 (as discussed below), it is often difficult for the clinician to assess the degree of visual impairment they create for patients. Recent research on alternate measures of assessing visual function, notably via contrast sensitivity (CS) has assisted in this regard8,9; however, there remains no universally accepted measures of the severity of vitreous opacities and hence no clear thresholds for when to consider intervention to relieve symptoms.
There is also some evidence that patients with symptomatic floaters have higher rates of psychological stress,10 and may be more prone to seek multiple opinions (so called “doctor shopping”) than other patients.11 Patients with more severe subjective symptoms have been reported to have more significant psychological distress,10 and as such may be more likely to seek intervention for their floaters.
For patients whose floaters produce significant visual disruption, treatments are available that may produce symptomatic relief. The current mainstay of treatment is vitrectomy surgery,12 although alternate therapeutic options such as yttrium-aluminum-garnet (YAG) laser disruption of floaters exist. Vitrectomy is a major surgical intervention, and one of the key challenges in managing floaters is identifying which patients have significant enough visual disruption to warrant surgery. The issue has received particular attention given the specific demographics and the natural history of patients with this condition: a notable subset of patients are young, phakic, have high VA despite floaters, and in many cases will experience partial relief of their symptoms without intervention.13 However, for patients with significant symptoms, vitrectomy is successful in improving symptoms and is a cost-effective intervention.14 To better clarify these issues, we review the current evidence surrounding the treatment of vitreous opacities not related to other underlying pathologies such as uveitis or acute retinal tears.
A search of PubMed, EMBASE, and the Cochrane Library was undertaken between November 10 and November 13, 2019, for English language articles published after 1990 using the keywords “vitreous opacity,” “vitreous opacities,” “vitreous floater,” “vitreous floaters,” and “asteroid hyalosis.” References of relevant articles, including review articles, were also reviewed.
Vitreous floaters are often described as an acute symptom of PVD, and for many patients, do not cause significant long-term visual disturbance. A number of theories have been advanced as to why this occurs: movement of the floaters either anteriorly or peripherally away from the visual axis, and adaptation of the eye and the brain to the presence of the floaters have been suggested.14,15 A notable proportion of patients, however, will have ongoing, visually disturbing floaters for months after first presentation.
Asteroid hyalosis is a relatively uncommon condition characterized by multiple vitreous calcifications16,17 that appear as “stars in the sky” during ophthalmic examination (Fig. 3). Although the exact pathogenesis remains unknown, asteroid has been associated in some investigations with diabetes mellitus and systemic hypertension,18,19 although this has not been replicated in large population studies.17,20 Despite its impressive appearance, asteroid generally does not produce significant visual impairment, although in some cases, patients may develop notable visual disturbance,21 and this may be particularly so when asteroid is complicated by the development of a PVD, although this may relate to the anterior movement of asteroid bodies closer to the lens when a PVD occurs.22
Floaters Secondary to Other Causes
Floaters, as mentioned above, can also occur due to secondary causes, including uveitis, malignancies, or after ocular procedures, such as intravitreal injections or vitreoretinal surgery with tamponade use. These causes can potentially result in significant irreversible visual loss, and for this reason patients complaining of new-onset or worsening floaters require assessment by an ophthalmologist to exclude potentially devastating causes of their symptoms.
There are no unanimously accepted guidelines on when patients should be considered for vitrectomy for vitreous floaters. This makes selecting patients for surgery difficult, and this is further exacerbated by the fact that visual acuity does not necessarily correlate with the degree of visual impairment reported.23 In general, ophthalmologists reserve surgery for patients whose floaters are persistent and cause significant visual disturbance over a prolonged period of time,24 although assessing this is highly subjective.
More recently, there has been a better appreciation of possible means of more accurately assessing the degree of patient impairment floaters can cause. Of these, the most clinically relevant is likely to be CS, which has been shown in a number of studies to be associated with floater related patient-reported visual impairment, and to also improve after intervention.5,6 This has given rise to the terminology “vision-degrading myodesposia,” to better describe floaters that impair vision and CS, and to differentiate these from floaters that do not produce significant vision impairment.14 Other alternate methods of assessing vision (such as straylight)4 are less familiar to the ordinary clinician, although show promise in a research setting.
The size and position of floaters within the vitreous cavity can also be measured, and imaging may have a role in predicting floater severity. Although optical coherence tomography (OCT) can provide some information particularly for posterior floaters close to the vitreomacular interface, ultrasound, and in particular, quantitative ultrasound is able to provide objective, measurable data on floaters, including measures related to floater density and scatter.25 This has been shown to correlate to functional measures such as the National Eye Institute Visual Function Questionnaire (NEI-VFQ) scores and CS, suggesting that this technique may aid clinicians in assessing floater severity,25 although currently it is limited to research settings. In this regard, measurement of floater appearance on clinical examination has also been assessed, however showing only weak correlation with functional measures.26
It is also often difficult to gauge the degree of success after surgery. Preoperative VA is often very good (as mentioned above), and this also makes quantifying improvement post-procedure often difficult, as little VA change is thus possible, although some studies have reported modest acuity gains of 1-2 Snellen lines.27 Gains in other measures of vision have been reported, including improvements in CS, quality of life, and straylight.4,27–30 As mentioned above, CS is likely the most easily applicable clinical outcome in regular clinical practice, as it represents a relatively quick to perform and interpret measure with well-validated testing procedures.
Further adding to this difficulty in assessing outcomes is recent research on patient satisfaction post YAG-vitreolysis, that showed no difference in functional outcomes between treated patients and untreated controls, despite measurable differences in quantitative ultrasounds measures.31 This suggests that although ultrasound may assist in identifying patients with significant visual issues, it may be of limited benefit in identifying which patients are likely to have a clinical improvement with treatment and in measuring treatment outcomes.
Of additional concern, many patients obtain their information regarding floaters from internet sites, which in general contain poor quality data.32 Given the risk of misinformation, it is therefore important that the clinician make every effort to accurately inform patients of both the natural history of the disease and treatment options and their complications. Younger patients in particular seem more willing to endure the risk of blindness associated with surgical complications to achieve removal of floaters, and this needs to be considered when advising patients on potential therapeutic options.7
Currently, the most commonly used surgical technique in the treatment of vitreous opacities is transconjunctival sutureless pars-plana vitrectomy (PPV). Initial vitreous removal is undertaken using a standard high speed vitrectomy cutter, removing the vitreous up to the vitreous base, including any floaters within the vitreous. After clearing of the vitreous, some authors advocate induction of a PVD in cases of posterior vitreous cortex attachment, and this can be done with the aid of visualization dyes such as triamcinolone or bromophenol blue.33,34 However, PVD induction increases the risks of retinal break formation as discussed below. Finally, peripheral retinal examination is conducted and any retinal breaks can be treated with cryotherapy or laser photocoagulation retinopexy.33 In cases with a notable risk of RRD, it may be appropriate to use a form of tamponade agent including intravitreal gas.35
Due to the limited surgical steps required, floaters represent a condition whereby smaller gauge (23G or smaller) surgical incisions may be utilized effectively without significantly affecting surgical results. There is growing evidence from recent studies reporting surgical outcomes that small gauge (23 or 25G) vitrectomy is associated with lower retinal break and RRD rates as compared with larger gauge (20G) operations,36–39 although further prospective studies are needed to formally assess this. Even smaller gauge vitrectomy surgery (27G) has also been used to successfully treat vitreous floater.40 For treatment of vitreous floaters, therefore, small gauge (23G or less) surgery can be considered best practice. Interestingly, there may be a limit to the degree to which reduction in incision size improves complication rates, with some evidence suggesting that 27G or 25G vitrectomy is not any safer than 23G procedures.41–44 Modern vitrectomy techniques such as wide-angle viewing systems have also been used successfully in cases of vitreous opacities, and may enhance surgical ergonomics and reduce required endolumination.45
Complications and Safety
Adverse events are similar between vitrectomy for floaters and for other indications such as epiretinal membrane (ERM) or macular hole (MH).27,28,46 Postvitrectomy RRD rates are reported to be between 2% and 10%, cataract surgery rates in phakic eyes are 25% to 60%, and rates of other adverse events such as ERM formation or cystoid macular edema are low (≤5%).23,24,27,28,33,35,47 However, concerns have been raised that the risks of PPV remain too high given the objective level of pathology.10 One aspect considered crucial in preventing potentially visually devastating complications is careful intraoperative examination for and treatment of retinal breaks, which prevents development of future RRD.39,41 Additionally, prophylactic treatment of lesions which increases the risk of RRD, such as lattice degeneration, may reduce the risk of future retinal detachment,48,49 particularly given that these lesions have been associated with a higher rate of intraoperative retinal breaks.50 Other rarer visual complications, such as postoperative endophthalmitis, have also been reported.51
An area of procedural debate regarding the safety of vitrectomy for vitreous opacities relates to the deliberate intraoperative induction of a PVD. It has been suggested that PVD induction may prevent later PVD formation via detachment of the remaining posterior vitreous cortex. This in turn would potentially cause recurrence of floaters or RRD,48 although there is currently little evidence as to whether this in fact occurs. Two recent series investigating PPV for floaters used either core vitrectomy with either no PVD induction28 or PVD induction in a small group of patients.27 Both studies reported favorable efficacy with good safety profiles, further raising doubts regarding the necessity of inducing a PVD. PVD induction has been associated with an increased risk of RRD in surgery for vitreous floaters,33 and for other retinal disorders such as MH or ERM,52–55 although no causal relationship has been established. It has also been suggested that PVD induction may hasten cataract development, as one series found a lower rate of cataract formation when comparing limited to extensive vitrectomy.56 Given these risks, and the uncertainty regarding the benefits of PVD induction, this step in the treatment for floaters should be considered cautiously, and patients informed of the potential additional risks associated with this aspect of the procedure.
The other significant concern regarding vitrectomy for floaters relates to the long-term safety of the procedure. This is particularly important given the relatively young age and generally good baseline vision of many patients who are considering surgery. Two series have reported a significant long-term rate of complications, including RRD (5.5%–6.4%) and cystoid macular edema, with irreversible visual loss occurring in some cases.23,47 Many of these complications, including RRD, were seen up to 3.5 years after surgery,23 suggesting long-term follow-up is often indicated in what may seem to be an asymptomatic population without overt evidence of significant intraocular pathology.
Given the often younger age of many patients undergoing vitrectomy for floaters, cataract formation and progression are a concern. Most studies report between a 25% and 60% cataract surgery rate within 1 to 4 years of PPV.23,27,28,47,56 Interestingly, the lower rates of cataract surgery (approximately 25%) have been reported in 2 recent studies of small gauge surgery conducting 25G vitrectomy, although these studies also had a shorter follow-up (mean follow-up 18 months) than other studies.27,28 Other series investigating the rate of cataract progression after small gauge vitrectomy have reported conflicting results.57,58 In some cases, preservation of the anterior vitreous has also been advocated as a means of delaying cataract onset by preserving the natural vitreous environment in the vicinity of the lens.28 Recent longer-term follow-up of a series of patients undergoing small gauge, limited vitrectomy with preservation of the anterior vitreous and not inducing a PVD reported reduced cataract rates (16.9% at an average of 13 months post-vitrectomy).29 This series also showed a relatively lower rate of retinal tear and detachment (2%). Comparison of limited versus extensive vitrectomy has also been shown to result in a reduced rate of cataract formation in another recent study.56 Taken together, these studies suggest that these technical modifications are likely to improve the safety of vitrectomy for floaters.
Combined Cataract Extraction/Anterior Vitrectomy
One small series has been published regarding the use of combined cataract extraction/phacoemulsification and deep anterior vitrectomy via a posterior capsulorexhexis followed by intraocular lens implantation (IOL).59 Although successful in resolving floaters in 8 of the 10 eyes operated on, the study has not been repeated, and it has been suggested that in myopic eyes such procedures may increase the risk of RRD.60 Other studies investigating combined lens extraction/vitrectomy have generally focused on patients with more permanently vision-threatening pathologies than floaters, such as maculopathy or RRD.61,62
Multifocal Intraocular Lens Insertion
Vitreous opacities have often been considered a relative contraindication to the use of multifocal IOLs due to the potential effect of floaters in exacerbating the reduction in contrast sensitivity that may occur.63 As a result, the impact of vitreous floaters on vision with the use of multifocal intraocular lenses has been assessed in a few small series. One previous study showed that for patients unhappy with multifocal lens insertion who also suffered from symptomatic PVD, vitrectomy was effective in improving both visual acuity and visual function as measured by the NEI-VFQ, without any significant safety events during the 6 months of the study.64 One recent small series (5 eyes) has also evaluated combined phacoemulsification/multifocal intraocular lens insertion and vitrectomy symptomatic vitreous floaters with improvements in visual acuity and floater-based symptoms amongst all participants, although one patient did require subsequent refractive surgery to achieve optimum uncorrected vision.65 These two small studies suggest that patients with vitreous opacities may still be suitable for multifocal IOL insertion, although further research is needed to fully clarify this.
Although vitrectomy is currently the most commonly used treatment for vitreous opacities, other therapies have also been explored. Vitreolysis via the use of a YAG laser is one such option, and aims to disrupt large floaters into smaller, less visually disturbing pieces. This therapy is generally considered most suitable for Weiss rings (a type of floater that results from a PVD where the attachment of the vitreous at the optic disc separates), as these are discrete lesions positioned over the central visual axis.66 Larger numbers of floaters (>3) or more peripheral lesions have been considered less amenable to laser vitreolysis.67
Although able to improve vision in some patients, one retrospective comparative study showed that YAG vitreolysis produced moderate improvement in 35.8% of recipients, with significant improvement noted in only 2.5% of cases. In contrast, vitrectomy produced symptom resolution in 93.3% of cases.68 A recent randomized controlled trial comparing YAG laser disruption with sham laser showed that laser was more effective in reducing symptoms than sham therapy, although it did not result in improved visual acuity.69 However, it has been suggested that a more appropriate comparison would have been with vitrectomy which remains the mainstay of therapy, and unfortunately at present there are no prospective trials comparing these 2 treatment modalities.66,70 Additionally, one recent study showed that in a subset of patients treated with vitreolysis, there was no difference in functional measures between those who had received treatment and control patients despite measurable reductions in echodensity on ultrasound, suggesting that vitreolysis may not necessarily achieve symptomatic improvement for a notable subset of patients.31
There have also been a selection of adverse events reported related to YAG vitreolysis, with significant complications such as RRD and treatment-resistant glaucoma noted in the literature.67,71–73 It is difficult to quantify the incidence of such adverse events, given that most published series on vitreolysis are small, with at best 50 to 55 participants, and as such larger studies are needed in this area to better quantify the safety of this procedure. A number of recent case series have also reported rapid cataract formation with posterior capsular disruption after laser vitreolysis,74–77 suggesting that this therapy should be considered with caution in phakic patients.
TREATMENT FOR ASTEROID HYALOSIS
Few studies have investigated treatment of asteroid hyalosis as a separate entity from vitreous floaters, likely because of the uncommon nature of the condition and the even greater rarity of visual impairment caused by asteroid. The limited evidence available supports the efficacy of vitrectomy in improving vision in patients with visually disabling asteroid,78,79 or in cases where asteroid impairs the ability of the ophthalmologist to accurately assess or treat other potentially more serious pathologies, such as proliferative diabetic retinopathy or vitreous hemorrhage.80 Successful YAG Laser photodisruption of asteroid has also been reported in one case, although no other reports are available to support the use of YAG laser in this condition.81 A recent comprehensive review of asteroid hyalosis also noted few instances of reported visual impairment from asteroid, although it should be noted that it can markedly impair fundal examination and lens selection in cataract surgery.82
Vitreous floaters may produce visual disturbance in the absence of retinal pathology such as retinal tears or inflammation. For a significant proportion of patients, symptoms will not be severe enough to warrant intervention. However, a subset of patients has persistent visual impairment that may adversely affect a patient's quality of life and work. Currently, no clear objective guidelines exist in selecting which patients will benefit most from treatment, although contrast sensitivity and quantitative ultrasound are promising means of assessment, and contrast sensitivity is likely the most easily applicable of these to regular clinical practice. There are similarly difficulties in assessing the degree of postoperative success, and anatomic outcomes may not necessarily match with improvement in functional outcomes.
Treatment seems to be more effective with the use of vitrectomy to remove floaters as compared with YAG vitreolysis, although currently there are no prospective trials comparing and assessing these treatments. When indicated, vitrectomy for floaters is an effective means of treating what may be a visually distressing phenomenon, although patients should be fully counseled regarding possible surgical complications. Should surgery therefore be undertaken, there are aspects of operative issues that require consideration, which can affect the safety of the procedure. These are:
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