Question for Dr. Stacy Regarding Floaters

Dr. Stacy,

In a recent discussion regarding floaters (which I unfortunately deleted), I
believe you stated that floaters would have to be VERY bad before a
vitrectomy might be justified.

I have what I consider to be very bad floaters for the past 7 years, and
have been wrestling with that question over that time.

What criteria does one use to determine whether to seek a vitrectomy? In my
case, I have large globs of "mud" that obscure a large portion of my vision.
Reading is very difficult, for example, not only because so much of a line
of print is obscured, but because the contrast between the print and
background is poor. It is also not an exaggeration to say that the globs
torment me almost all of the time and seem to cause persistent eye strain
and tearing. Yet I have something close to 20/20 on an eye chart and no eye
disease according to recent dilated eye exams. What are your thoughts as to
what criteria justify vitrectomy?

Thank you for your comments.

I would also be interested in any additional opinions from other readers.

Charles

 

Google is your friend.

20/20 on the eye chart is a first cut. It isn't the final answer.

What does your doctor advise?

ObOT: I had a vitrectomy about a year ago. My doctor said that as a
side effect, I would lose the floaters.

 

Charles, if I were in your situation, I'd be setting up a pre-surgery
consultation with my retinal surgeon rather than seeking opinions on
the internet. I had a vitrectomy about a year ago to remove a macular
pucker. The worst consequence of the surgery was the development of a
cataract in the surgical eye. (I've read that it's the result of the
lens' exposure to oxygen.) Unless you are at high risk for retinal
detachment, I believe that the a vitrectomy is quite safe if done by a
competent retinal surgeon. And with the new 25-gauge "sutureless"
equipment, recovery is very rapid. One surgeon wrote that the day
after the vitrectomy, it's frequently difficult to tell which of the
patient's eyes had the surgery.

Best of luck!

 

Good advice, but since he's asking, I'll venture that he might be a
candidate for it, especially if he is over age 50, since the subsequent
cataract surgery that is certain to follow if he hasn't yet had it is
sort of a blessing in disguise. I'll bet he's 20/20 only part of the
time, and when the goop is in the way he may drop to worse than 20/100
or so in the affected eye.

w.stacy, o.d.

 

Mine went quite well. However, I was on restriction for two weeks (no
lifting or bending over). Since I had already given notice at work, and
had planned to spend the next week cleaning out my office, this was a
problem. I talked to my boss and extended my leaving another two weeks.
This was a good thing, since I had over a hundred days of sick leave, so
I spent two weeks at home at full pay.

 

My vitrectomy was done with the older 20-gauge equipment, which
required sutures. One day post-op my eye was practically swollen shut
and bright red. I looked terrible, although it wasn't painful. I
later developed a severe suture reaction, which was reportedly related
to the (mis)placement of the sutures (put in by a resident who--in my
opinion--didn't know what he was doing.) This left an unsightly red
mound on the white of my eye that lasted for weeks.

But happily, surgery with the newer 25-gauge "sutureless" equipment
inflicts no such torture on the patient. I believe the surgery time is
quicker, and recovery is reported to be faster and painless. I believe
that Charles has a lot to gain from the procedure and should certainly
schedule a consultation with the best retinal surgeon in his area.
(This does not require a referral from an optometrist.)

I haven't kept up with my reading in the area of retinal surgery.
However, I do know that just a few years ago a vitrectomy was not done
to remove a macular pucker until vision was worse than 20/60. Today,
with better equipment and technique, some surgeons will operate on a
patient with 20/20 vision if the distortion from the pucker is
bothersome. I also believe that vitrectomies for floaters are
performed more frequently today than in the recent past.

 

I think the chance of endophthalmitis is pretty small, given modern day
procedures and antibiotics. And I think that "cracked" is a poor choice
of words to use with someone who is not familiar with the procedure,
where 3 very small holes are cut in the eye
for the instrumentation. It is minor in that the patient is usually not
under deep anesthesia, and intubation of the trachea is usually not
needed. I think vitrectomies for major vitreous opacities is becoming
more common, as it is quite successful. This person should indeed
consult a vitreous surgeon before consulting a psychiatrist.

w.stacy, o.d.

 

According to a June '06 article on emedicine.com, postoperative
endophthalmitis is a rare complication of intraocular surgery. Data
from Bascom Palmer from '84 to '94 show that only 0.05% of patients
developed endophthalmitis after pars plana vitrectomy. (The rate was
0.08% for patients undergoing cataract extraction.)

Even with the older 20-gauge equipment, having a vitrectomy is not a
painful ordeal. My surgery was done at a teaching hospital with local
anesthesia alone. (I opted to skip the sedation.) I experienced no
pain during the surgery and was actually able to see the instruments in
my eye and follow the action. (A fascinating and hopefully
once-in-a-lifetime experience.) After the surgery (with one eye
patched), I had lunch and then walked over to the local multiplex,
where I stayed for a double feature. My vision improved from 20/50 to
20/20 during the weeks that followed.

You guys really perform a valuable service for us nonprofessionals by
posting info on this web site. But I really disagree with you in this
case, Anon E. Muss, and your comment about antidepressant medication is
a little offensive. Have some empathy--how would you feel living your
life with the types of problems that Charles has been experiencing?

 

20/20 is a subjective finding, not an objective one. And floaters
notoriously cause 20/20 vision to drop to 20/100 or worse as the floater
passes over the macula.

w.stacy, o.d.

 

I should rephrase that: "large floaters notoriously CAN cause 20/20
vision to drop to 20/100 or worse as the..."

 

Once again I disagree with the "standard" then. Acuities and
*subjective* refraction data belong together in the SUBJECTIVE area.
Retinoscopy and auto-refractions belong in the OBJECTIVE area.

But you cannot determine the degree of "honest and proper effort".
That's why it's so variable and subjective.

Nor can you ALWAYS tell if they are hysterical or malingering.

I also put these in the subjective realm.

Fake a strabismus? Or more important, fake orthophoria when the patient
is a strab? I think not. But obviously these are objective, as we are
making direct OBSERVATIONS by definition. OTOH, things like phorias and
fixation disparity measurements are just as obviously subjective items.

Some of those are signs, some are symptoms. You're lumping them
together, I think unnecessarily and confusingly.

Agreed with those, if reported by the patient and not observable (eyes
bug out should easily be observable as exophthalmos or proptosis).

A very good objective test, don't you think? I'll bet you're using it
more than you used to "order it" from your glaucoma guy? I had a nice
exchange with a lecturer at the Monterey Symposium in which he asked for
a show of hands as to who was "modifying goldmann readings" by the
pachymeter. I was about the only one to raise my hand. He challenged
me and I said I do it in my head, not on paper. Helps me get a feel of
what's going on. He then explained patiently that my correction tables
are not all that accurate. I patiently explained to him that in most
aspects of medicine even variable or imperfect corrections are better
than no corrections at all. Love to make those guys squirm. He allowed
that it was a good point.

w.stacy, o.d.

 

Indeed. But thanks for taking the time to so concisely present the
issue. This is precisely what the glaucoma specialists in my
neighborhood live by and that which most of us have come to accept as
valid rationale for the diagnosis and management. At least for now.

But on another, possibly related issue:
What of the thousands of LASIK's/PRK'd people with now thin corneas?
Might they have to classified as higher risk glaucoma suspects? Do thin
corneas alone predict risk or is there an underlying genetic cause that
relates simultaneously to thin cornea and glaucoma? Inquiring
minds........

LB, O.D.
(rarely seen around these parts these days)

 

Given the context of your post, I think you meant never measured >22.

w.stacy, o.d.

 

Agreed, it's just that your quote translates: "many people with iops
never measured "LESS THAN 22mm Hg develop glaucoma." That statement is
certainly true, although it would be more meaningful to have said "most
people who never measured less than 22mm Hg have glaucoma".

But what I think you were trying to say was what I originally answered
above.

It's kind of a pet peeve of mine, like when people specify + when they
meant - in an Rx. Or when the order says "DNR" when the patient is not
terminal. Little things like that sometimes are important.

w.stacy, o.d.