April 02, 2025
10 min read
Eric D. Donnenfeld, MD, said that some ophthalmologists downplay the effects of more serious floaters, which he called vitreous opacifications.
In this second of a two-part series on vitreous floaters, Healio | OSN spoke with another group of clinicians about differential diagnosis and the finer points of performing vitrectomies.
“We are all familiar with vitreous floaters — and vitreous floaters can certainly be very annoying to patients — but the ones that are visually significant aren’t so much the small floaters that we see or even the Vossius rings that we see occasionally,” he said. The problems come from “sheets of vitreous that condense to form a haze that reduces a patient’s quality of vision.”
Donnenfeld, a Healio | OSN Cornea/External Disease Board Member, said patients with this opacification will tell him that it looks like there is Vaseline in their eye or that there is an amoeba moving across their field of vision. This sheet will constantly shift in and out of their visual field.
“You may look at the patient and not see much because it is just this sheet of vitreous,” he said. “But it can have a profound effect upon visual quality.”
The main effect these opacifications have on vision is a loss of contrast sensitivity, and Donnenfeld said this can be compounded in pseudophakic eyes with multifocal IOLs, which may also cause a loss of contrast sensitivity.
Richard S. Davidson, MD, said the condition is fairly common in patients who have undergone cataract surgery. While their vision might be improved, they still are not satisfied due to complaints of cloudy vision.
Richard S. Davidson
“They just feel like the vision is not as sharp as they want it to be,” he said. “Sometimes, they will say the vision improves after they blink. A lot of this gets blamed on dry eye after cataract surgery, which can happen, but if you speak to the patient more specifically, a lot of times they will tell you about a cloud rolling. That, in my opinion, is when they’re seeing the vitreous moving in the back of the eye.”
In recent years, Donnenfeld said one of the most significant developments in his practice has been directly addressing these opacifications with pars plana vitrectomy. Advances in technology and technique have made this procedure safer and a useful tool for helping patients, he said.
“For years, many of us completely ignored these vitreous opacities, and we viewed them as just small, incidental findings that had no significant effect of patients’ visual outcomes, and we could not have been more wrong,” he said. “The advent of pars plana vitrectomy for patients with symptomatic vitreous opacifications has been an enormous improvement in patient care, vision and patient satisfaction.”
In cataract patients who have a history of vitreous floaters or opacification, Davidson said a combined cataract surgery and vitrectomy is scheduled. This has been his practice’s standard for some time, but vitrectomy for patients after cataract surgery is a little newer.
“If they start to notice them, we do give them a little time to see if it gets better,” he said. “There is a small subset of patients where it becomes less bothersome over time. We like to give it several months to really see if it remains visually significant. That usually means we wait at least 3 or 4 months to see how they are doing. For those who are continually annoyed, those are the patients that I’ll refer to vitrectomy.”
Problems for patients
Sonia B. Dhoot, MD, said there is some debate about whether uncomplicated cataract surgery causes opacities and floaters. She said any procedure in the eye has the potential to increase the chances of vitreous opacities, but they are more commonly just a part of aging.
“When we are born, our vitreous gel is solid in consistency and firmly attached to our retina,” she said. “As we get older, that vitreous gel undergoes changes and becomes more liquefied, and eventually, it separates from the retina. As light comes into the eye, all the microparticles within the vitreous now cast a shadow on the retina because now there’s a separation there.”
If floaters seem like they appear after cataract surgery, Dhoot said that might be because the patients can see everything better, including their floaters.
“Patients will just notice them more because their vision is clearer,” she said. “They see everything better, including their floaters. It’s really not uncommon that we hear this complaint after cataract surgery, but that doesn’t mean the surgery necessarily causes them.”
The main concern with new onset floaters is assuring that the vitreous has detached without causing a retinal tear, which can happen about 15% of the time, Dhoot said. Over time a patient’s brain can adjust and learn to ignore floaters, as long as they are not large or situated in the central vision.
“As you can imagine, if the floater is in your line of sight, then that can be pretty debilitating,” Dhoot said. “Some patients are unable to drive or read if the large floater is in the center of their vision. They are unable to do what they need to do on a daily basis. Those are the patients who are the best candidates for surgery and are extremely happy with vitrectomy surgery.”
The diagnosis
Vitreous opacities are not easy to diagnose. Donnenfeld said the general haze that is the hallmark of vitreous opacification can be seen on ultrasound and sometimes on OCT, but it is not easily seen on exam.
“For these patients, I look through my laundry list of things that may be problematic for them,” he said. “I start with refractive error. I look at ocular surface disease, such as a dry eye check. I’ll check the capsule again for residual refractive error. When everything else has been exhausted, then I look for vitreous opacification. Very commonly you see that, and patients will complain about a haze that waxes and wanes across their vision. That is the cardinal sign that there is vitreous opacification. For these patients, I’ve been referring them for visual rehabilitation with pars plana vitrectomy.”
Davidson said he follows a similar process, and the diagnosis is usually made after excluding other possibilities.
“I’m going through an exam and really checking for everything,” he said. “You’ve got to rule out dry eye, posterior capsule opacification and cystoid macular edema. You’ve really got to look at the whole eye, and I never make a diagnosis unless everything else checks out normally. You have to check against all of these other causes of blurred vision, and it’s more of a diagnosis of exclusion.”
Patient selection
Donnenfeld said his practice has been doing more vitrectomy in these cases because patients are more demanding. They have higher expectations for their vision after cataract surgery, and because of premium lenses, they have higher interest in quality of vision.
Eric D. Donnenfeld
“Vitreoretinal surgeons are doing a much better job with the surgery, and it’s become safer and more effective,” Donnenfeld said. “Probably most importantly, we’re recognizing that this is a problem that we never realized before. It’s been hiding in plain sight. The problem was there, but we never recognized it. Now that we recognize the problem, we’re doing something about it.”
In a study published in the Journal of VitreoRetinal Diseases in 2020, Fink and colleagues at a retina-only practice evaluated small-gauge pars plana vitrectomy for visually significant vitreous floaters. The retrospective case series reviewed complication rates and surgical outcomes, including visual acuity and percentage of second eye surgery.
In the study of 104 eyes, mean visual acuity improved from 0.16 ± 0.17 logMAR before surgery to 0.12 ± 0.15 logMAR at the last follow-up after vitrectomy (P = .008). More than 43% of patients underwent vitrectomy in their other eye, according to the study, and there were no cases of postoperative retinal tears, breaks or endophthalmitis.
Donnenfeld said determining which patients would benefit from surgery starts with having a conversation to ensure they understand the risks. If patients are not that bothered by vitreous opacities, he will tell them it might be better to just leave them alone.
“If it is a significant bother to the patient, then it’s worth considering,” he said. “I will tell them that there is a 1% chance of retinal detachment and a one in 500 risk of endophthalmitis with the procedure, but these are extremely small risks. If they understand the risks associated with the surgery, then I send them to a vitreoretinal surgery who will again outline the risks and benefits of the procedure.”
As a vitreoretinal surgeon, Deepika Malik, MD, has criteria that patients meet before performing vitrectomy for vitreous opacities.
“I always see how long patients have had the symptoms,” she said. “Are the symptoms debilitating? Do the symptoms make it difficult to drive or read? Are the symptoms bothersome for more than 50% of the time while performing their daily routine activities? Are the symptoms present for at least 6 months, which is the time I believe is necessary to allow for neuroadaptation or spontaneous resolution? Do they have posterior vitreous detachment? Patients with debilitating visual floaters, decreased contrast sensitivity, a decreased visual function questionnaire score and posterior vitreous detachment receive maximum benefits from vitrectomy. In my experience, I have noticed that patients with symptomatic vitreous opacities, who have also had refractive surgery or multifocal intraocular lenses, report nearly 75% resolution of their symptoms post-vitrectomy.”
Surgery and risks
Dhoot has one main factor for patient exclusion in these cases.
“I do not offer surgery to patients who have not had a full posterior vitreous detachment,” she said. “You can see floaters even if your vitreous hasn’t separated yet, but the surgery is much more dangerous. We can surgically lift up the vitreous and remove it, and we have to do that in cases for different conditions. However, whenever we lift that vitreous, we always worry that it can induce a tear in the retina, which can lead to a retinal detachment.”
As surgeons start to wrap up a vitrectomy, Malik said it is important to perform a meticulous scleral depressed examination.
“It is vital to make sure that no retinal tears have been missed,” she said. “Even if you determine there might be an area of retinal tear or attenuation, it is best to proceed with laser treatment. If there are micro-tears well covered by the vitreous prior to vitrectomy, once we have removed the vitreous and created a pocket of fluid around the retinal tear, there is a potential for retinal detachment. With a combination of meticulous patient selection, modern technique and ultra-high-speed vitrectomy, some of the concerns about the risks of surgery, including retinal detachment and vitreous hemorrhage, have significantly diminished. Ultra-high-speed vitrectomy reduces the traction on the retina, decreasing the risk of inadvertent retinal tear formation. In addition, I make highly beveled incisions with 27-gauge trocars to achieve self-sealing entry wounds, thus mitigating the risk of endophthalmitis.”
Dhoot tells patients that potential surgical risks include retinal detachment, endophthalmitis and vitreous hemorrhage.
“I used to use peribulbar blocks or retrobulbar blocks for anesthesia, and I now use sub-Tenon blocks, which are much less invasive and tend to offer anesthesia equivalent to that of the peribulbar or retrobulbar blocks,” Dhoot said. “That is the first thing I can do to make the surgery a little bit safer because there is less risk of globe perforation or retrobulbar hemorrhage. I usually use 25-gauge trocars because the incisions are more likely to self-seal and less likely to need sutures at the end of the case. I will perform as much of a vitrectomy as is safely possible with a good 360° scleral depression at the end of the case to make sure there are no small holes or tears.”
Dhoot said the procedure has the potential to accelerate cataract in phakic patients. However, this is not a deal-breaker for patient selection because, eventually, the cataract will have to be removed anyway, she said.
Malik said that the higher risk for cataract development is a result of intravitreal oxygen levels that increase after vitrectomy.
“To reduce the risk of cataract formation post-vitrectomy, I have made some modifications in my vitrectomy approach,” she said. “I leave a few millimeters of vitreous behind the lens. The rationale of leaving some intact vitreous near the posterior surface of the lens is that the antioxidants in the vitreous help mitigate cataract formation. The data suggest that the incidence of cataract at 24 months is 35% with this modified approach vs. 87% with the extensive approach of vitrectomy.”
Unmet needs
Donnenfeld said vitrectomy for vitreous opacifications has been a game changer for patients. However, he wants to see more research so that surgeons can better inform their patients.
“We need to have a better understand of the real risk and benefit of the procedure and quality of vision,” he said. “It would be very good to do some studies that look at contrast sensitivity, Snellen visual acuity and dysphotopsia profile and measure those against the potential risks for the procedure. All of that would be very helpful.”
Modern instruments and the skill of vitreoretinal surgeons have made vitrectomy a viable option, Davidson said, but there are still risks.
“It’s still a surgical procedure, and you have to be careful about that,” he said. “I wouldn’t tell a patient not to do it if it’s really affecting their quality of life. But there are still some retina surgeons who aren’t on board with this. If you’re doing a lot of cataract surgery and you have a lot of these patients, you really need to find retina surgeons in your community who also believe in this procedure. There are still some people out there who don’t, and that’s OK too. It’s just personal preference.”
Although she does not necessarily consider vitrectomy to be a last resort in these cases, Dhoot said it is important to carefully select the right patients.
“Unfortunately, the risks that we mentioned do happen, so it’s important that you get a very detailed informed consent from the patient,” Dhoot said. “I will ask patients if they can live with their floaters. I tell them I would prefer they live with them and only recommend surgery if they are debilitating and interfering with their activities of daily living. Only they are going to be able to tell me how bothersome the opacities are to their vision. If it were my family member, I might try to talk them out of surgery. However, in patients who are debilitated by them so much that they can’t function, they are generally very happy after surgery, and it can be life changing.”
Reference:
- Fink S, et al. J Vitreoretin Dis. 2020;doi:10.1177/2474126420961736.
For more information:
Richard S. Davidson, MD, of UCHealth Sue Anschutz-Rodgers Eye Center, can be reached richard.davidson@cuanschutz.edu.
Sonia B. Dhoot, MD, of Harvard Eye Associates in Laguna Hills, California, can be reached at sdhoot@harvardeye.com.
Eric D. Donnenfeld, MD, of Ophthalmic Consultants of Long Island, can be reached at ericdonnenfeld@gmail.com.
Deepika Malik, MD, of Ophthalmic Consultants of Long Island, can be reached at dmalik@ocli.net.
Sources/Disclosures
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Disclosures:
Davidson, Dhoot, Donnenfeld and Malik report no relevant financial disclosures.
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