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From Reddit someone asked: "What's wrong with vitreolysis?"

I got transparent floaters, which are rarely visible indoors (if only against a white sunlit windowsill), but are visible outdoors especially when I look up. So I want to ask - what's wrong with vitreolysis? Why do so few of eye floater sufferers do it? In my country, the cost of living is pretty low, so the procedure doesn't cost much money for me. But our clinics use the same YAG devices as in Europe and the US (for example - Ellex Ultra Q Reflex). Okay, let's say that the one procedure may not remove floaters completely. But if I will see at least a small effect, then I can visit it for 5, 10 or even more times. Money is not so trouble in this case. Okay, doctor can refuse to do vitreolysis if patient's floaters based near the retina. But wouldn't those kind of floaters be dark? If I have transparent ones, doesn't that mean they are far away from the retina for the safety of procedure?


My Lengthy Response:

There are a few challenges and problems with the procedure and this response is from someone who has been treating eye floater exclusively for since 2007. 1. FLOATERS ARE NOT CONSIDERED A PROBLEM. They are difficult to see on examination, and the amount that we can see does not correlate with the patient's distress. As an example, in many younger floater-sufferers, I (we) may not be able to see the eye floaters as they are microscopic and below the resolution of our exam instruments. And yet, if you ask them, they'll tell you it is 10/10 distress, anxiety, and depression. Every other standard measure of eye optics and health may otherwise be normal. This leads one of my sayings: "Floaters are something that the patient sees, but the doctor doesn't see or fully appreciate. In addition, in our training and in the literature, when someone comes in complaining of new onset moving shadows or similar, we are trained to look at the retina, rule out retinal pathology, offer some reassurance to the patient ("Give it 6 months", "you'll neuro-adapt", etc.), and move on to the next patient. 2. MANY (MOST?) OF THE ACTIVE MEMBERS OF ONLINE FLOATER SUPPORT COMMUNITIES ARE YOUNGER and this age demographic are much less likely to be good candidates for treatment with the laser. Why? Their vitreous generally is clear overall, they have not have a posterior vitreous detachment or other comprehensive disorganizational disruptions to the vitreous and their floaters are most often very very close to the retina. They are simply not candidates for treatment with the laser. I have a lot of experience with the laser (>13,000 procedures) and I have a pretty good sense of what is treatable and what it not. When I have the opportunity to examine a younger patient here, I am looking at their drawing/description and trying to correlate that with what I see in their vitreous. There can be some vitreous anomalies that might be in a safer region to treat, but in my experience, it my not correlate with what they are seeing. To treat those would only introduce risk, but very little expectation for reward. Those are not good odds. A good surgeon knows not only how to treat the difficult stuff, but also knows when NOT to treat. Which leads me to... 3. THERE IS NO TEACHING, TRAINING, COURSE OF INSTRUCTION for ophthalmologists to learn how to treat eye floaters. Several years ago, one of the prominent laser manufacturers starting promoting their YAG laser as "With our laser you can treat eye floaters too". That's pretty much it for the training. If you have a medical license and bought the laser you can offer the treatment of eye floaters. I have had many patients come to me after getting 'treatment' elsewhere and their experiences are all over the place. Rarely injured, but lots of homeopathic-level treatment that are so light that I wouldn't expect any noticeable change and that's precisely what they report to me. I do have a lengthy video describing my experience as a legal expert witness in an unfortunate case where a man got a very very aggressive treatment, developed a very high eye pressure, got seen a couple days later and the doctor never checked the pressure. That bad outcome could have been avoided with early medical intervention and frequent follow up. So this is a bad combination of doctor ego and not knowing what you don't know. My most power statement in deposition was: " If a patient complained of anything soon after treatment, my top three differential diagnosis would be a) pressure, b) pressure, and c) pressure. 4. IT IS INEFFICIENT & EXPECTATIONS NEED TO BE MANAGED ASSIDUOUSLY. Even for the older, post-PVD, good candidates for laser vitreolysis, it takes more than one, and often a few treatments to get to that better place. What is that 'better place?' It means different things to different people. I spend a lot of time with each patient and a lot of that time is educating, but also managing their expectations. I never use words like "cure" "remove" "restore" "eliminate" as that would be setting unreasonable expectations. My definition of success with the laser might be as vague as " a lot, lot better". I agree it is not very science-y or quantifiable but it is the best we can do sometimes. Another measure of success is getting things good-enough better that they no longer consider the vitrectomy. There is an understandable amout of suspicious and negativity regarding laser vitreolysis here, but I have made a career of treating eye floaters exclusively. "I can't treat everyone, but I can treat everyone well" For a procedure that still exists in the shadows of ophthalmology and for all its shortcomings, I am proud of pretty-much all 5-star reviews on independent review sites like yelp and google. I think people are pretty forgiving of imperfection (that they can't be treated, or less than 100% results) if they know that the doctor has their best interests in mind and is trying their best. I can not stress enough how important it is though that experience in the laser operator is paramount importance. There simply are not very many who have put in their Malcolm Gladwellian 10,000 hours of focused practice to develop mastery. I am not sure if I have the 10,000 hours at the laser, but I am now somewhere 18- 20,000,000 individually, manually aimed shots of the laser. Oh, one last thing. Floaters close to the retina do not have to be dark, they can be transparent as well. Sometimes I'll describe them as 'crystal worms'. Maybe a better way to describe them is that the edges and borders are distinct and well defined. The further away the shadow-casting object is from the shadow cast surface, the softer the edges. u/Jolly0Grape36 did not state his/her/their age. This answer is more directed to the younger, <35-40 age group. I have treated some younger patients, but those were pretty exceptional. For the younger patients, I'll more often recommend low dose atropine, a mild pupil-dilating agent that has been a fantastic addition to my practice as now I can offer safe, eye drop treatment that plays with the shadows and reduces the subjective awareness of the floaters.

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