Sutureless  Small  Gauge  Vitrectomy  for  Relief  of  Symptomatic  Vitreous  Floaters    

Michael  G.  Neimkin,  M.D.1,  John  O.  Mason,  III,  M.D.2,  Duncan  Friedman,  M.D.,  M.P.H.2,  John  O.  Mason,  IV,  David  Kim,  B.A.1,  Christine  Tagayun,  B.S.1,  Tracy  L.  Emond,  M.S.1,  Richard  M.  Feist,  M.D.2,  Martin  L.  Thomley,  M.D.2,  Michael  A.  

Albert,  Jr.,  M.D.2,  and  Jacob  J.  Yunker,  M.D.2  1University  of  Alabama,  Department  of  Ophthalmology  

2Retina  Consultants  of  Alabama,  P.C.  

To  evaluate  the  subjective  and  objective  improvement  in  quality  of  life  (QOL)  following  small  gauge  pars  plana  vitrectomy  (PPV)  for  symptomatic  vitreous  floaters/debris.  

Vitreous  floaters  are  one  of  the  most  common  presenting  complaints  to  eye  physicians;  averaging  up  to  14  new  patients  per  month  for  an  optometrist1.    The  history,  presentation,  underlying  pathology  and  severity  of  symptoms  tend  to  vary  greatly  from  patient  to  patient.    Floaters  can  be  the  result  of  a  serious  vitreoretinal  disorder  or  occur  independently  in  a  normal  eye2.    The  most  common  causes  of  floaters  are  posterior  vitreous  detachment  (PVD)3,4,5,  vitreous  syneresis5,  and  asteroid  hyalosis6,  which  are  generally  a  result  of  normal  aging  or  past  trauma7.    Typical  symptoms  seem  to  occur  after  the  age  of  508,  when  the  vitreous  gel  begins  to  separate  and  condense9.    New  onset  of  floaters  in  any  patient  should  always  be  promptly  referred  to  an  ophthalmologist  for  evaluation,  as  the  most  feared  underlying  pathology  of  a  retinal  detachment  can  lead  to  avoidable  permanent  loss  of  vision  if  timely  treatment  is  not  delivered10.  

After  obtaining  IRB  approval,  a  single  center,  retrospective  chart  search  was  conducted  at  a  multi-­‐physician  vitreoretinal  specialist  practice  (Retina  Consultants  of  Alabama)  yielding  231  patients  who  previously  had  PPV  secondary  to  symptomatic  floaters.    Patients  were  included  if  they  had  symptomatic  vitreous  floaters/debris  that  caused  detrimental  impairment  to  their  daily  functional  activities.    Preoperatively,  all  patients  complained  of  difficulty  reading,  computer  use,  or  driving  affecting  their  QOL  due  to  severe  vitreous  debris.      Patients  were  excluded  if  they  had  other  underlying  retinal  pathology,  which  classified  their  surgery  as  non-­‐elective  (retinal  detachment,  endophthalmitis,  ect).    A  group  of  143  patients  (168  eyes)  met  the  inclusion  criteria,  while  98  patients  were  excluded.    The  eligible  patients  were  then  contacted  via  telephone  by  one  of  two  survey  administrators  and  asked  to  complete  modified  9  question  quality  of  life  (QOL)  survey.  The  QOL  survey  measured  the  patient’s  subjective  responses  with  emphasis  on  the  influence  of  visual  disability  and  visual  symptoms’  impact  on  daily  functioning.    

Our  retrospective  chart  review  yielded  143  eligible  patients  (168  eyes).  Of  the  eligible  patients  whose  charts  were  included,  127  completed  the  survey;  several  patients  were  unable  to  be  reached  or  have  since  deceased.  Only  2  patients  declined  to  participate  in  the  survey.      Of  the  eligible  patients,  the  average  age  at  the  time  of  surgery  was  63.2.  All  patients  had  at  least  1  of  3  diagnoses  responsible  for  their  symptomatic  floaters:  asteroid  hyalosis  (9/168,  5.3%),  vitreous  debris  (156/168,  92.8%)  or  both  (3/168,  1.8%).  114/168  (67.9%)  patients  had  laser  at  the  time  of  surgery,  8/168  (4.7%)  patients  underwent  a  combined  CEIOL/vitrectomy  and  9/168  (5.4%)  patients  had  a  CEIOL  performed  after  their  vitrectomy.    There  were  no  major  complications  that  resulted  in  permanent  vision  loss.    Postoperative  CME  developed  in  1/168  (<1%)  eye,  which  resolved  over  3  months.  2/168  (1%)  eyes  developed  vitreous  hemorrhage;  both  returned  to  vision  equal  or  better  than  preoperatively.  The  average  acuity  improved  from  logMAR  0.25  to  0.16  (p<0.0001).  Only  4/168  (2.2%)  patients  had  decreased  visual  acuity  postoperatively.  The  nine  question  survey  showed  subjective  QOL  improvement  in  125/127  (98%)  of  patients.  

The  underlying  cause  of  floaters  is  disruption  of  the  vitreous  gel9,  which  can  have  a  variable  clinical  course.    Some  patients  will  have  spontaneous  resolution  of  their  symptoms  and  require  no  treatment2,  while  others  will  have  grave  impairment  in  their  daily  life3.    Myopes,  in  particular,  are  at  risk  for  a  PVD  at  an  earlier  age11  and  more  severe  symptoms  because  of  retinal  image  magnification12.    One  of  the  biggest  difficulties  in  forming  treatment  guidelines  is  that  the  objective  measured  visual  acuity  of  the  patients  is  often  a  very  poor  reflection  on  the  severity  of  their  symptoms  and  the  impact  they  have  on  daily  life3.      Unfortunately,  while  originally  proposed  over  a  decade  ago,  there  are  no  universal  guidelines  governing  the  decision  to  operate;  most  likely  due  to  the  lack  of  studies  with  sufficient  sample  size  combined  with  the  difficulty  to  objectively  quantify  the  true  impact  of  floaters  on  patient’s  daily  activities.  As  surgical  technique  continues  to  improve  decreasing  the  risk  of  possible  complications,  removal  of  vitreous  floaters  for  symptomatic  relief  and  improvement  in  quality  of  life  becomes  a  more  viable  option.  However,  like  all  elective  surgeries,  vitrectomy  surgery  does  carry  risks  that  must  be  considered  by  the  patient  and  physician  before  deciding  to  proceed.14  The  patient’s  in  our  study  underwent  the  25-­‐Gauge  PPV  technique;  which  enables  a  sutureless  approach  and  eliminates  the  need  for  conjunctival  peritomies.  This  has  been  shown  to  decrease  surgically-­‐induced  trauma  at  the  sclerotomy  site,  operative  times,  and  post-­‐op  inflammation  which  allows  for  a  more  rapid  post-­‐operative  recovery.15  The  most  devastating  complication  following  a  vitrectomy  is  endophthalmitis,  which  using  the  25-­‐G  approach,  has  been  shown  to  be  as  low  as  0.053%  (1/1,906).16    There  were  no  serious  complications  that  resulted  in  permanent  vision  loss  in  out  patients.  There  wre  2  vitreous  hemorrhages,  both  of  which  cleared  without  needing  further  surgical  intervention  and  1  episode  of  postoperative  CME.  All  3  of  these  patients  rated  their  experience  as  a  complete  success.  Our  overall  patient  satisfaction  score  of  94%  was  equal  to  the  94%  satisfaction  following  laser  vision  correction  (J  Refract  Surg  2009  Jul;25(7S  Suppl):S642-­‐6.      

Figure  1:    Objective  Visual  Acuity  

Figure  4:  Subjective  Severity  of  Daily  Symptoms  

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Figure  2:  Subjective  Severity  of  Daily  Symptoms  

Figure  3:  Subjective  Severity  of  Daily  Symptoms  

Figure  5:  Subjective  Severity  of  Daily  Symptoms