Manage patient expectations to treat vitreous opacities

As we move forward into a new era of ophthalmology, with increased options to address vision issues, patient expectations are more important than ever.

Patients who might be affected by vitreous opacities after cataract surgery are not going to be satisfied, even if their visual acuity is improved. The most important thing we can do as their doctors is manage patient expectations. That starts with examination and discussion with the patient in the clinic.

Patients with vitreous opacities come through the clinic in two ways: Sometimes they see the retina specialist first, and sometimes they see the cataract surgeon first. Either way, we have to work together to ensure discussions take place and to recognize their visual symptoms and complaints. Determining what is bothering them and affecting their quality of life the most is the first step.

I will see phakic patients who complain of degradation of vision and come to me with a referral for floaters or vitreous opacities that may be blocking or bothering their vision. Sometimes their visual complaints can be subtle, and they do not directly use terms such as “floaters” or “spots” in their vision. While some patients use terms like “cloud,” “veil” or “spiderwebs” that move around in their visual field to describe their vitreous opacities, other patients may have more difficulty explaining their visual symptoms. Careful questioning by the physician is often important to elicit this history. We know that vitreous opacities come in many different forms, and their impact on vision goes far beyond just noticing focal areas that move around in vision. I always try to find out if patients feel like their clarity improves when they move their eye around. Do they feel like they are able to move some of the cloudiness out of their visual field temporarily, even for a few seconds?

If I have a patient come in and I feel like their symptoms are consistent with vitreous opacities, I will take a careful look on clinical examination. I do an assessment of both the anterior and mid-vitreous cavity. A lot of times, we can see moderate to significant vitreous syneresis, which can result in fibrillary opacities or even a Weiss ring. Most of these patients who complain of symptoms consistent with vitreous opacities will have a posterior vitreous detachment, but sometimes they do not, and this is important to recognize preoperatively.

I will use OCT to assess the vitreoretinal interface overlying the macula as well as the vitreopapillary interface over the optic nerve. Some patients will have vitreomacular separation of the posterior hyaloid but still be attached at the nerve. Others have fairly significant vitreous opacities, but you have to approach them in a slightly different way and recognize that you might have to consider surgically inducing posterior vitreous detachment at the time of surgery to fully remove the vitreous.

There is another group of patients we see who have undergone cataract surgery and are unhappy with their vision postoperatively. As vitreoretinal surgeons, we need to identify these unhappy patients, but the challenge comes with identifying the exact issue. Is the patient not tolerating a multifocal IOL? Is there a posterior capsular opacity that is bothering them? Do they have vitreous opacities?

There are good clinical studies and data that suggest that patients who have multifocal or extended depth of focus IOLs may be more likely to be bothered by vitreous opacities than patients with monofocal IOLs. They may have multiple complaints, and sometimes it is simply that they are not happy that they have good distance vision but not near vision. They expected with a premium IOL that they would be happy with their distance at multiple focal lengths, and they are not. With these patients, I may counsel that they may not get an improvement in all of their symptoms. There may be multiple factors at play, but if I feel like vitreous opacities are contributory, then I have a fairly low threshold for surgery. We tend to find that these patients become much happier once their vitreous opacities are removed.

For more information:

Marc Mathias, MD, an associate professor of ophthalmology at the University of Colorado Anschutz Medical Campus, can be reached at marc.mathias@cuanschutz.edu.

Click here to read the Cover Story, “Vitrectomy offers relief for vitreous opacities.”

Published by:

Read more about

This post was originally published on this site