OPHTHALMOLOGY 2015 - UCSF CME€¦ · • Floaters get less noticeable with time due to gravitational settling • Floaters get less noticeable with time due to neuro-psychological

12/4/2015

1

Kirk H. Packo, MDProfessor & ChairmanRush University Medical CenterChicago, IL

2015OPHTHALMOLOGYUPDATESan Francisco, CaliforniaDecember 4-5, 2015

The author acknowledges compensation as consultant to:The author acknowledges compensation as consultant to:

The author’s institution has received grant supportfrom: The author’s institution has received grant supportfrom:

• Alcon Surgical, Inc• Allergan, Inc.• Genentech• Optoview• Regeneron Pharmaceuticals, Inc

• Alcon Surgical, Inc• Allergan, Inc.• Genentech• Optoview• Regeneron Pharmaceuticals, Inc

• Alcon Surgical, Inc• Alimera Sciences• Alcon Surgical, Inc• Alimera Sciences

No conflicts relevant to this discussionNo conflicts relevant to this discussion

“Exogenous” Sources:• Hemorrhage (red cells)

• Inflammation (white cells)

• Infiltration (tumor cells, amyloidosis, RPE cells)

• Asteroid hyalosis(calcium deposits)

“Endogenous” Vitreous Sources:• Aggregation of vitreous fibrils

• Posterior vitreous cortex & Parapillary glial tissue* * Hyaluronic acid drops

& Vitreous liquefiesCollagen fibers aggregate

12/4/2015

2

Similar to Cotton Candy Sugar Fibers Clumping

Weiss Ring &Posterior Vitreous Cortex

Weiss Ring &Posterior Vitreous Cortex

Sebag, J

• Degenerative opacities composed of hydroxyapatite (calcium soaps & phospholipids)

• Slight association with diabetes

• Rarely noticeable to patient – only very rarely justifies vitrectomy to improve symptoms

• View in by doctor is much worse than patient’s view

• Able to see fundus much better with fluorescein angiography

12/4/2015

3

Asteroid Ultrasound

AsteroidOCT Imaging

Optos Imaging Fluorescein Angiography

12/4/2015

4

• Blue light (430 nm) is absorbed by RBC’s in capillaries.

• Brain "edits out" the shadow lines of the capillaries by dark adaptation of the photoreceptors lying beneath the capillaries.

• WBCs do not absorb blue and create gaps in the blood column

• WBCs appear as bright dots

• Focus behind lens with slit lamp

• Have patient look up + look straight against a red reflex

• 78D Biomicroscopy with joystick pulled back

• Kinetic ultrasonography

• OCT imaging

• Kinetic OCT imaging of infrared view Biomicroscopy

12/4/2015

5

Kinetic Ultrasonography

BMC Ophthalmol 2015:15:22-24

• Case report of a large floater (vitreous cyst)

• OCT used to qualitate the impact of the floater on the vision

Clinical Appearance

Ultrasound

Patient Drawing

BMC Ophthalmol 2015:15:22-24

OCT Infrared Image 3D Reconstruction Standard OCT showing “ring” scotoma - peripheral shadowing

Kinetic OCTLarge Floaters Small Floaters

12/4/2015

6

• Floaters are always caused by a PVD

• Floaters get less noticeable with time due to gravitational settling

• Floaters get less noticeable with time due to neuro-psychological adaptation

• People who complain of floaters have a psychologic problem

Am J Ophthalmol 2011:152(1):60-65

• 266 patients with floaters (age > 21) surveyed and utility value assessed

• Utility Value:• Value 1.0 = “Perfect Health”• Value 0.0 = “Death”

• Metric Used to Calculate Utility Value:• Time Trade Off (TTO): Willingness to trade off #years life out of every 10 years

to get rid of problem• Standard Gamble (SG): Willingness to risk death or blindness to rid problem

Am J Ophthalmol 2011:152(1):60-65

• Utility Value of Floaters:• Is the same as vision loss from AMD• Is lower than diabetic retinopathy or glaucoma• Is the same as mild angina, mild stroke, colon cancer, and asymptomatic HIV• The same for acute floaters (< 1 month) or chronic floaters (> 1 year), thus do

not become less frustrating with time• Unilateral floaters had the same UV as bilateral floaters

• Time Trade Off (TTO) of Floaters:• Willingness to trade off 1.1 years of life out of every 10 years

• Standard Gamble (SG) of Floaters:• Willingness to accept an 11% risk of death and 7% risk of blindness

12/4/2015

7

• Absolute size of floaters

• Floaters in the visual axis

• Floaters clumped anteriorly near lens

• Myopia – magnifies the retinal images

• Multifocal Intraocular Lenses

ReSTORDiffractive

TechnisRefractive

• Often verydistraught

• May be doctor shoppers

• Shops the internet ~ participates in blogs

• Professional surgical patient (LASIK, YAG)

• Young patients more intollerant

• Often very happy when floaters removed

12/4/2015

8

• 143 patients with floaters surveyed• 77 (54%) were first time patients

66 (46%) had seen multiple doctors• Women & non-myopes most likely doctor shoppers

• Is doctor shopping related to the patient’s personality or due to doctors not being sympathetic to patient’s complaint?

Int. J. Environ. Res. Public Health 2015, 12, 7949-7958

12/4/2015

9

1. Observation

2. Refer for psychologic counseling

3. Hyaluronidase (Vitrase™) enzyme

4. Holistic, herbal & other “treatments”

5. YAG laser vitreolysis

6. Vitrectomy

YAG Vitreolysis

Vitrectomy

• Should be tried first, especially with acute onset of floaters/PVD

• Consider occupational needs

• Does it impact any activities?

• Is the patient phakic?

• Is there other retinal pathology?’

• Often does not lessen with time

12/4/2015

10

• Patients can train themselvesto see minimal floaters – then become fixated

• Can possibly train themselves to disregard them?

• Anxiolytic medications?

• Patients usually are very resistant to this suggestion

• Vitrase™ - Ovine hyaluronidase

• FDA approved as a tissue spreading agent

• Off label use intraocularly

• Theoretically will decrease hyaluronidase thus liquefying vitreous allowing floaters to fall inferiorly

• Study in Mexico showed 10% patients were made worse

Herbal Eye Drops

Ayurvedic WarmEye Bath Treatments

Exercises &Palming Massage

Mystery Cure$17

The Silva Healing Method

12/4/2015

11

• Minimal evidence on efficacy & safety

• Not covered by insurance ($2,500 - $5,000 per eye)

• May require special Q-switched laser

• Promoted by handful of ophthalmologists that do treatment exclusively; promoted on internet

www.vitreousfloaters.com www. thefloaterdoctor.com www.EyeFloaters.com Dr. Karickhoff ’s book$225.00

12/4/2015

12

• 31 patients (42 eyes) with floaters from PVD underwent 54 procedures with Nd:YAG laser

• Outcome was “subjective improvement”

• 38%were “moderately” improved; 61.5%had no improvement

• 36%underwent subsequent vitrectomy

• 1 patient developed a retinal detachment

Eye (London)2002 Jan;16(1):21-6.

• “FOV” – Floaters Only Vitrectomy

• Controversialamong retinal surgeons

• More common with small gaugesurgery

• Phakic eyes will develop cataract

• Balance against other risksof typical vitrectomy (RD, tears, endophthalmitis, glaucoma)

• The only true way to remove floaters

12/4/2015

13

• 0.44 mm diameter(cf. 20 ga = 0.95 mm)

• The smallest gauge instrumentation

• Sclerotomies easily seal without sutures

• Full complement of instruments (probe, light, laser, forceps)

• Produced by multiple companies

Am J Ophthalmol 2011:151:995-998

• Review of 116 consecutive floaterectomiesin Amsterdam, Netherlands

• Intraoperative Adverse Problems:• 16.4% iatrogenic retinal tears• 1 case of intraop choroidal hemorrhage (resolved)

• Postoperative Adverse Problems:• 2.5% (n=3) retinal detachment• 50% of phakic eyes developed cataract in 1 year• 7.8% transient increased IOP

12/4/2015

14

Graefes Arch Clin Exp Ophthalmol (2013) 251:1373–1382

• Review of 110 consecutive floaterectomiesin Nijmegen, Netherlands

• 23 ga vitrectomy; assessed for satisfaction, complication, VFQ-25

• 85% were satisfied or “cured” – 9.3% were dissatisfied

• Complications:

• 10.9% Retinal detachment (4.5% in first 3 months)• 5.5% Cystoid macular edema• 3.6% Epiretinal membrane (macula pucker)• 0.9% Each of: Glaucoma surgery – Macular hole - Scotoma


Complications Outcomes of the Patients with Retinal Detachments

Postop retina tear


Overall Patient Satisfaction after Vitrectomy


Time Troubled by Floaters BEFORE Vitrectomy

12/4/2015

15


Time Troubled by Floaters AFTER Vitrectomy


Difficulty Reading Small Print Before & After Vitrectomy


Difficulty Driving at Night Before & After Vitrectomy


Would You Recommend Vitrectomy to a Friend with Floaters ?

12/4/2015

16

Retina 34:1055–1061, 2014

• Review of 168 consecutive floaterectomiesin Birmingham, Alabama

• 25 ga vitrectomy; assessed for satisfaction, complication, VFQ-25

• 96% were satisfied or “cured” – 4% were dissatisfied

• Complications:

• 0 Intraop or Postop Retinal detachment • 1 pt Transient cystoid macular edema• 2 pts. Transient vitreous hemorrhage• 7.1% Intraoperative retinal breaks - treated

Retina 34:1062–1068, 2014

• Review of 66 consecutive 25 ga. floaterectomiesin California

• Causes: 80% from PVD; 32% from myopic vitreopathy

• NO PVD was induced in the 20% not having a PVD preop

• VFQ was 28% lower in preop floater patients than age matched controls VFQ improved by 29% after vitrectomy

• NO cases of retinal tears, RD or infection.

• Only 24% developed cataract at 15 months (zero below age 53)

Henry CR, Schwartz SG, Flynn HW Clinical Ophthalmology 2014:8 1649–1653

• 24 y/o female – 20ga floaterectomy

• Inflammation on 1st postop day

• Staphylococcus capraeendophthal.

• Recovered 20/80 vision (from 20/20)

12/4/2015

17

Simple Vitrectomies?

Only happen Over the Rainbow

• Examine! – Are significant floaters there?

• Consider Surgery:• Has the patient tried a period of observation?• Are floaters anterior/clumped behind lens?• Is there a multifocal lens?• Does the patient have a convincing story/need?• Is the patient ready to accept risks?

• Discourage Surgery:• Is the patient phakic?• Is there other pathology? (Lattice, High myopia)

• Already had multiple procedures? (LASIK, YAG Vitreolysis)

Thank You !

OPHTHALMOLOGYUPDATESan Francisco, CaliforniaDecember 4-5, 2015

12/4/2015

18

Documents

OPHTHALMOLOGY 2015 - UCSF CME€¦ · • Floaters get less noticeable with time due to gravitational settling • Floaters get less noticeable with time due to neuro-psychological