Vitreous Floaters: Evaluation and Treatment

What are Floaters? Randall V. Wong, M.D. Retina Specialist, Fairfax, VirginiaVitreous floaters are any spots or shapes which move back and forth with eye movement.  Floaters are very common and can arise from a variety of conditions.  New onset floaters should always be checked to ensure there is no tear in the retina or signs of other disease.

Floaters may be from blood, cells from underneath the retina, inflammation, asteroid hyalosis, from a PVD or from condensation/changes in the proteins within the vitreous.

What Causes Floaters?

Blood:  Floaters from blood most commonly occur as complications of a retinal tear, diabetic retinopathy or a retinal vascular problem.

Inflammation:  Another term is uveitis.  This is like having arthritis in the eye.  Cells from the immune system (white cells) actually migrate into the vitreous and clump.  Treatment of the inflammation doesn’t always resolve the floaters.

Asteroid Hyalosis is a special benign condition where white specs normally accumulate in the vitreous.  Very similar to driving through a snowstorm, these asteroid bodies often make examining the retina very difficult.  Miraculously, most people with asteroid hyalosis don’t complain of floaters, but on occasion, some do.

Posterior Vitreous DetachmentChange in vitreous proteins are probably the most common cause of floaters.  A PVD causes floaters or a “cobweb” moving through your vision as the proteins condense or change in clarity.

The floaters can disappear, become tolerable or annoy you to no end.  They can blur or decrease your vision and cause glare.

Vitrectomy (FOV) Removes Floaters

For the myriad of you in whom the floaters don’t disappear, you can get rid of them.  Vitrectomy surgery is the safest and best way to rid yourself of the floaters.  There are a few doctors who promote the YAG laser, but none are retina specialists.

With vitrectomy, the bulk of the vitreous is surgically removed.  We don’t need the vitreous.  It’s a vestigial tissue (i.e. a tissue we need during development, but serves no function once we are born.  Another example?  The appendix!).

The vitreous is similar to jelly fish…mostly water, but has some structure (that’s why you can catch a jelly fish with a net).  With vitrectomy eye surgery, the vitreous gel, and floaters, are simply replaced with 100% water, or saline.

My Doctor Can’t See the Floaters

It is my practice to consider vitrectomy if; 1) the floaters you see definitely move back and forth with eye movement, and 2) you understand the risks and benefits of surgery.  I don’t have to actually “see” your floaters.

The vitreous is usually optically clear to you, i.e. you shouldn’t see your own vitreous.  As a doctor, everything in your vitreous, however, should be visible to me.  Large floaters can easily be seen and identified to be the culprit, but this doesn’t occur that often.

More often, I can’t see the floaters because they are either too small for me to appreciate or I simply don’t know which one is causing the problem.

Anything moving back and forth with eye movement has to be located in the vitreous and no where else in the visual pathway.  I believe the issue with “seeing” the floater stems from the fact that using a laser to treat floaters requires a “target.”

With vitrectomy, this is not necessary.

What Does This Mean?

I don’t understand why patients suffering with floaters have been discounted.  There is a clear treatment available.  The risks of the surgery have changed since vitrectomy was first invented in the 1970’s.  The procedure has become much safer and is comparable to cataract surgery.

Because of the inability of physicians to knowledgeably council their patients, there are too many myths and rumors about vitreous floaters and the treatment.  I’ll be adding articles about risks and benefits of surgery, risks of cataract formation, etc. in the near future to help set the record straight.

Randall V. Wong, M.D. 
Ophthalmologist, Retina Specialist
Fairfax, Virginia

Comments

  1. Fagner Kisner says:

    Dr. Young, I’m Brazilian 31 years, many eye floaters right, I have no PVD, I follow your site to 2 years, and their website encouraged me to do the vitrectmomy, my surgery is scheduled for 4/28/14, the surgeon said that surgery is 98% reliable, but is worried that my surgeon will not induce a PVD will only remove the nucleus is located where the vitreous floaters, my fear is to stay with the “frill” and get even more depressed . He commented that not induce PVD to decrease the risk of dislocation and cataract, my question is what are the chances that I get the “frill” after the FOV, have until 27/04 to decide.

    Tank You Dr.

  2. Hi Dr Randall,

    If i have a very thin retina, would eye movements increase the chance of a tear? i am afraid since i have a habit of trying to catch my floaters and in the process, tend to jerk my eyeball back n forth. would this movements aggravate or provoke a tear?

    Thanks for ur clarification!

  3. Dear cindy,

    I don’t think you are hurting yourself. Remember that during REM sleep, your eyes beat back and forth rapidly and forcefully.

    Randy

  4. Fagner,

    How did surgery turn out?

    Randy

  5. Hey randy its been a while,things have been great up until a couple of days ago,I noticed some visual anomalies in my left eye,im no doctor but I think I might be getting a pvd,I know one of your patients had this problem and he ended up betting it removed,im going to see an opthamologist to see whats up,I just wanted to know your thoughts?

  6. Paul,

    It’s possible that you’re getting a PVD. What symptoms are you having?

    r

  7. I had flashes for a few days,and now I have floaters theyare semiattached,Idont have any tears,I got checked .I belive your assesment is right though.

  8. Paul,

    Glad to hear!

    Randy

  9. Nikolay says:

    Dear Dr. Wong,

    In one of the comments on this site, you mentioned a patient who was chronically infested with S. aureus, and got an eye infection after FOV. I’ve had S. aureus as long as I can remember, mostly in my throat, but also skin, etc. Does this mean I’m not a candidate for FOV? Do I have a significantly higher chance of losing the eye to infection?

  10. Nikolay,

    No, everyone has S. Aureus. This does not alter your candidacy for the operation.

    Randy

  11. Dr Wong –

    I’m interested to hear why you’ve started advocating for PVD induction during FOV operations. A core FOV, while presenting a higher risk of residual floaters or “frill,” seems to have demonstrated a much lower risk profile in regards to retinal detachment during the surgery. Many doctors present this as the reason for performing core vitrectomy for floaters.

    Additionally, leaving vitreous body against the retina and lens allows that vitreous to perform its role in consuming oxygen and preventing oxidation of the lens (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2683478/).

    I understand that any entry into the eye presents risks for endophthalmitis and/or hypotony, so you can make the argument to “get it all” while you’re in there. But since many patients may have their most troubling floaters removed by a core FOV, I see no strong argument for removing the oxygen barrier and peeling membrane from the retina in all cases de facto, especially in eyes under 40 that have no natural PVD and many years until cataract formation.

    Would it not make sense to first perform a core vitrectomy and then see if symptoms resolve?

  12. Ymperator says:

    Dear dr. Would you suggest fov to young people (under 30 old)? Im from italy and 26 only. Have my floaters since 13 old. Here in italy, oculists says kinda always that floaters have to be kept by patients, the only way is to bear them. There are so few medics who would operate with a fov, 99 of 100 medics are against such an invasive operation for floaters only. Italian patients are kinda overfullfiled with the same general answers and they dont feel understood by medics. Floaters are just seen as a disturb of vision by oculists, thats unbelievable since there are people who really suffer for those and their quality of life is so reduced. I cant understand if its because italian medical school is too old and not up to date but im just telling about my experience seeing so many desperate people gatering on facebook asking for a treatment. There is laser but often young people are not eligible due to the floaters near the retina, so the solutiom would be fov, core fov, but among the medics who can operate with fov, there are some who dont accept to operate young people under 30old that much. What would you raccomand to a 26 years old guy with no dpv and with medium high myopia both eyes ? To take risks with core fov? Which are the risks? Young people like me seem to live in a middle way situation, no laser but too risk with vitrectomy. So what to do… i cant wait till im 50 old to have my fov so to do it with cataract too. But iguess the riskof cataract doin it now would be high… i read that 27g fov will reduce that risk much. Whats your opinion doctor?

  13. John,

    In my experience, patients who develop “frill” after successful vitrectomy are as obsessed with the “Frill” as they were with the floaters. It occurs only in the young age group complaining of flaoters.

    “Frill,” in my experience, is the boundary between cut/removed vitreous and remaining vitreous. Inducing a PVD allows me to remove more vitreous safely.

    If done correctly, inducing a PVD, can cause a tear, but the risk is not necessarily increased dramatically.

    Regarding your comment about residual vitreous and oxidation of the lens – this is only a hypothesis. Cataract formation is not necessarily increased in my patients who have had a straight vitrectomy (FOV).

    I leave the option of PVD up to every patient. You are right, a practical approach might involve performing a “core” and seeing what remains.

    Thanks for commenting.

    r

  14. Ymperator,

    I have successfully operated on teenagers – your age is not an issue.

    Risks are;

    1. Blindness from infection (not as high as cataract surgery)
    2. Retinal tear which could lead to retinal detachment (probably about the same as cataract surgery, say 1% or so).
    3. Cataracts happen to everyone – with or without FOV.
    4. 27 g may be safer, but not on the market yet.

    Randy

  15. Hi Dr. Wong,

    I was wondering what would be the best way to reach your office for discussing FOV? I emailed the ‘Contact Us’ form two weeks ago but haven’t gotten a response. I assume that email sees tons of activity so no need to apologize either, just would like to start discussing my options.

    27 year old male – severe floaters right eye that can be seen in all contrast backgrounds. If I squint this floater is very large!

    Thank you in advance,

    Rob

  16. Rob T.,

    I’m guessing you sent an email that was improperly configured on “vitrectomyforfloaters.com” – ooops, my mistake.

    We also got hacked two weeks ago, but I think the above situation explains never getting a message from you.

    I’ll email Chrissy to reach out to you. You should here from her very shortly.

    Randy

  17. Dear Dr. Wong,

    I am 27 years old. I have been suffering eye floaters in both eyes since I was 15.
    The floaters are really bothering me and have a significant impact on the quality of my life.
    My local eye doctor said, “Your floaters are benign because the cause of your floaters is due to the PVD. You just have to live with them. Maybe they will disappear in the future”.
    It has been 12 years but my floaters are still in my eyes.
    I am really hoping that I can find someone who can help me.
    Thus, I discovered your websites and Youtube Channel early this year.
    Thank you for being so compassionate towards patients who have been tortured by eye floaters.
    And, thank you for the webinars about the treatment for floaters.
    I think the webinars are very helpful and informative.

    I am looking forward to meeting you in the near future to discuss whether or not I am a suitable candidate for the FOV surgery.

    Moreover, I would like to know how much the surgery costs.
    Please forward my message to one of your “Labron Jameses” for more information regarding the financial aspects of the surgery.

    I assume that the surgery cost might be different for me since I do not live in the United States.

    Lastly I have two additional questions regarding the surgery.
    After the Vitrectomy surgery, is it still passable to do weightlifting or other heavy exercises?

    And, why eye pressure will not be affected after the surgery since vitreous body has been removed? (I understand the fact that my natural eye saline will replace the artificial saline but natural saline and vitreous substance are still different in terms of different composition. Won’t that cause different eye pressure?)

    Thank you very much in advance!

  18. Dear Jason,

    Awesome comment! I get a chuckle everytime I think about the webinar the “Lebron” references.

    I’ll connect you with Chrissy via email.

    Weightlifting and other heavy exercises are fine after surgery.

    Pressure won’t change. Both have the density of water (water without protein vs. water with protein (vitreous))

    r

  19. thank you Dr. Wong for addressing my concern

  20. Jason,

    Stay well. You are welcome.

    r

Trackbacks

  1. [...] am hosting my first webinar.  Two similar events to review the evaluation and management of floaters.   The webinars will be live and I plan to present the same material.  They are free and anyone [...]

  2. […] Floaters are anything (specks, dark spots) which move to and fro with your eye movement.  Floaters are located within the vitreous, the gel-like substance filling the eye, and cast shadows on to your retina. […]

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