Vitreous opacities are one of the most common ocular conditions we deal with in clinical practice—and one that is commonly untreated.1 For many clinicians, discerning the degree of symptom bother is difficult due to a lack of objective criteria for evaluating patients before and after treatment.2 Of the millions of people affected by vitreous opacities globally,3 approximately one-third of respondents to an international survey reported symptoms that were bothersome enough to cause visual disturbances.4 Few studies have evaluated the impact of symptomatic vitreous opacities (SVOs) on patients’ quality of life, but they nevertheless suggest significant interpatient variability in the degree of symptom bother5 and poor correlation between what is observed on examination, what is gleaned from imaging and diagnostics, and what is relayed by the patient.2
Pars plana vitrectomy (PPV) can be a definitive treatment for SVOs in carefully selected patients. Whereas the idea of PPV with floater removal was once verboten, surveys suggest an uptick in its acceptability.6 This development is likely due to real-world experience gained by retina surgeons and those in their referral networks whose patients received treatment for SVO and experienced dramatic improvements in their quality of life as a result.
I had the privilege of leading a roundtable with noted experts in the field of SVO management and treatment, John W. Kitchens, MD, and Edwin H. Ryan, MD, in which we were also joined by a prominent thought leader in optometry, Alison Bozung, OD, FAAO. Our conversation touched on many aspects of managing SVO in real-world practice and was inspired by the growing spirit of collaboration between referral sources and treating specialists in SVO management. Readers are invited to use the QR code below to view full videos of the cases summarized herein.
— Christina Y. Weng, MD, MBA
1. Ivanova T, Jalil A, Antoniou Y, et al. Vitrectomy for primary symptomatic vitreous opacities: an evidence-based review. Eye (Lond). 2016;30(5):645-655.
2. Broadhead GK, Hong T, Chang AA. To treat or not to treat: management options for symptomatic vitreous floaters. Asia Pac J Ophthalmol (Phila). 2020;9(2):96-103.
3. Schulz-Key S, Carlsson JO, Crafoord S. Longterm follow-up of pars plana vitrectomy for vitreous floaters: complications, outcomes and patient satisfaction. Acta Ophthalmol. 2011;89(2):159-165.
4. Webb BF, Webb JR, Schroeder MC, North CS. Prevalence of vitreous floaters in a community sample of smartphone users. Int J Ophthalmol. 2013;6(3):402-405.
5. Wagle AM, Lim WY, Yap TP, et al. Utility values associated with vitreous floaters. Am J Ophthalmol. 2011;152(1):60-65.
6. D’Amico DJ, Berrocal MH, Ho AC, et al. Vitreous opacities current trends and treatment strategies. Retina Today. June, 2021. Available online at: https://retinatoday.com/articles/2021-jan-feb-supplement/vitreous-opacities?pk_vid=b722748cd3b8898217054191287217bb
How Prevalent are Symptomatic Vitreous Opacities?
Christina Y. Weng, MD, MBA: A global survey to gauge perceptions of symptomatic vitreous floaters (SVO) was conducted in 2021 among retina specialists and non-retina specialists, including cataract and refractive surgeons, general ophthalmologists, and optometrists.1 One question in the survey asked about prevalence. Optometrists reported that about one-third of their total patient population has SVO. Retina specialists report a slightly lower percentage of 17%. Do these numbers sound accurate?
Alison Bozung, OD, FAAO: The practice’s patient demographics will inform the response to the question. However, it makes sense that optometrists are reporting a higher percentage of patients with SVO. Our examinations tend to be comprehensive in nature, and we specifically ask about visual symptoms. In the retina physician’s office, the examination is typically more focused and directed.
John W. Kitchens, MD: It’s really primary eye care providers who hear patients talk about how debilitating their symptoms are. My referral network sends patients who are significantly troubled by their SVO and are good candidates for surgery: vitreous opacities for more than 6 months; preferably pseudophakic, but it’s not an absolute exclusion; and lastly, it’s got to drive them crazy. I want patients who say, ‘I can’t focus when I’m reading or driving, and I really am willing to have surgery to have this corrected.’
Gauging Symptom Bother
Dr. Weng: I am often surprised by the lack of correlation between what I find on the clinical examination and the patient-reported symptoms associated with SVO. In fact, patient-reported degree of bother may carry more weight in SVO management than in other pathology we encounter in retina. Are any practitioners grading symptom bother associated with SVO? And are there any objective data we can collect?
Edwin H. Ryan, MD: Symptom grading will document the degree of a patient’s symptoms and whether they’re tolerable or truly a bother. The more important question to me is whether surgery is indicated, and for that, you have to listen to the patient’s perception of the floaters. Additionally, there may be a role for certain imaging modalities in evaluating for SVO. I have found that the infrared imaging with Heidelberg Engineering OCT readily depicts the degree of blockage of light to the retina, which is functionally what these patients are suffering from.
Dr. Bozung: I do not use a formal severity grading scale, but I do tease out the information if the patient is reporting SVO. Ultimately, I want to understand whether the condition is bothering them enough to warrant a referral.
Dr. Weng: Do you follow patients with SVO before sending them off to a retina specialist, and what are the triggers for taking that action?
Dr. Bozung: It depends on the patient. If the patient reports mild symptom bother that is manageable and does not interfere with his or her activities, then I prefer to wait 6 months before rechecking. If the symptoms are more bothersome—interfering with work, for example—I will shorten the follow-up timeframe to about 3 to 4 months.
I will ask the question back to my retina colleagues: Do you want to see the patients at 6 months after their symptoms start?
Dr. Kitchens: It’s a great question, and the real answer is in how much it bothers the patient. I’ll typically wait at least another 6 months once the patient gets to my clinic to allow some symptoms to resolve on their own, but the patients who keep coming back show a commitment to improving their condition.
View Case
Christina Y. Weng, MD, MBA, presents a case of a 68-year-old male with a history of retina tears who waited for 1.5 years to have his SVO treated surgically. The case demonstrates that visual acuity is not always the best measure of the outcome after vitrectomy for SVO, and that multifocal IOLs could be contributing to a rise in SVO by heightening recipients’ awareness of floaters in the vitreous. Scan the QR code to view the entire case.
Considerations for the Physical Examination
Dr. Weng: What do you look for on physical examination in a patient complaining of SVOs?
Dr. Bozung: I start with the anterior vitreous and work my way backward using a 90D lens to see if I can locate where on the visual axis the floaters may be. There may be obvious things to detect, such as whether there has been a posterior vitreous detachment or if there is a Weiss ring close to the nerve or macula. There may also be larger clumps of floaters more anteriorly. Next, I move to a peripheral examination with a 28D lens, making sure I sweep over the center to see if I detect any shadows, which would suggest the presence of floaters. Multimodal imaging adds additional information that we can consider in the evaluation.
Dr. Kitchens: Before I enter the room, I review each patient’s widefield imaging as well as OCT to rule out things like epiretinal membrane.
Dr. Weng: What do you tell patients about the treatment options for SVOs, and is there a potential role for laser treatment?
Dr. Ryan: In short, the results with laser vitreolysis are inconsistent, and because it only works on some types of floaters, we do not offer it to patients. If I had my own floaters that were truly problematic, I would want a vitrectomy, because I know the treatment is definitive.
Dr. Bozung: Our surgeons who perform surgery for SVO prefer vitrectomy, so I mention that as an option to gauge the patient’s reaction.
Turning the question back to my retina colleagues, what do you want the patient to know before they get to you? What makes your job easier and that interaction smoother?
Dr. Kitchens: That is such a great question, and the answer will be different for every clinician. It is good to check with your referral sources to understand what they want patients to know.
If I have a message back to my optometric colleagues, it is to manage the ocular surface in patients with suspected SVOs. Dry eye is something we want to rule out as a potential cause of symptoms, even in eyes that have obvious floaters in the vitreous.
Pearls for Surgical Management of Vitreous Opacities
Using a series of real-world cases, John W. Kitchens, MD, demonstrates tips and tricks for management of symptomatic vitreous opacities. Dr. Kitchens shares pearls for making the diagnosis, correlating symptoms with clinical findings, and what to look for on imaging.
Conclusion: Is Vitrectomy Appropriate for Treating SVO?
Dr. Weng: Another question in the survey asked whether respondents believed that SVO warranted treatment. Across subspecialities, a high percentage of physicians said ‘no,’ including around 30% of retina specialists. Is there reason to believe the sentiment is changing?
Dr. Kitchens: A lot has changed with our surgical instrumentation and with our diagnostic capabilities, and it has slowly become safer and more acceptable to perform vitrectomy with floater removal. I think what is driving wider acceptance of vitrectomy for SVO is simply more surgeons gaining experience in treating patients and witnessing just how life-changing the outcomes can be. The happiest patients in our clinic are not those with macular holes who go from 20/100 to 20/25 UCVA after treatment. Our happiest patients are the ones who present with SVO. Removing them is just life-changing for these individuals.
View Case
A 52-year-old trucker faced the prospect of quitting his job if his SVOs could not be addressed. But with 20/20 visual acuity, phakic lens status, and an attached vitreous, the risk-benefit profile suggested a more cautious approach. After a judicious waiting period, Dr. Ryan performed the surgery. However, the patient subsequently developed cataracts and bilateral retinal detachments, thus requiring three additional ocular surgeries. Despite these complications, the patient said he would do it all again. Why? Because the outcome doesn’t always show up in measures of visual acuity. Scan the QR code to view the entire case presented by Edwin H. Ryan, MD.
Dr. Ryan: To me, the biggest factor driving greater acceptance of performing vitrectomy for SVOs is the results we can get for patients. We have a proven and definitive treatment option in vitrectomy, which can be offered to select patients.
1. D’Amico DJ, Berrocal MH, Ho AC, et al. Retina Today. June, 2021
