Dr. Manuel Jose Diaz-LlopisDr. Manuel Jose Diaz-Llopis is Professor of Ophthalmology and Head of Ophthalmology at Faith Hospital and the University of Valencia, Spain.
[This interview was originally conducted in Spanish]

Q: Can you describe the enzymatic vitreolysis treatment you use?

It consists of the administration of one to three injections similar to those performed in diabetics but with different composition and separated by 15 to 30 days. The patient is numbed with drops and can return home after the injection.

Q: How does it work?

By liquefying the vitreous gel structure.

Q: Has it been proven to be effective with miodesopsias?

The effectiveness varies. There is clinical satisfaction or a sense of clear improvement by the patient in 40% of cases.

Q: Are there any risks or potential unwanted side effects?

There is the possibility of an inflammatory reaction and the risk of infection exists in any medical procedure. These do not usually occur, but patients should be given preventive treatment and post-injection.

Q: Is there any data available as clinical studies or statistics about treatment?

It is available in English at this link. http://www.ncbi.nlm.nih.gov/pubmed?term=Diaz-Llopis%20plasmin

Q: Is the treatment covered by Social Security?

Yes, it is covered by Spanish Social Security.

Dr OrioneDr Orione is a YAG laser physician working in Italy. [This interview was conducted in English and Italian]

About you

Q: Please can you give a brief outline your professional background: qualifications, memberships and experience in the field of ophthalmology and in the treatment of Degenerative Vitreous Syndrome.

Mi sono specializzato in Oftalmologia nel 1992 e da allora ho iniziato ad appassionarmi delle nuove tecnologie per la diagnostica, la terapia e la chirurgia oculare.
Mi sono avvicinato ai laser con la chirurgia oftalmoplastica e, da 2 anni, ho iniziato ad interessarmi alla vitreolisi Yag laser dei Floaters. ho contattato il Dott. Karickhoff ed ho studiato il suo libro.

Ho quindi iniziato ad eseguire questi trattamenti seguendo i suoi preziosi consigli. Ultimamente ho contattato il Dott. Geller per effettuare una fellowship presso il suo Eyefloaters Center e sarò da lui in ottobre 2011 dopo l’AAO.

Q: How many procedures on floaters have you carried out?

48 trattamenti effettuati su 135 pazienti visitati. Molti pazienti visitati non potevano essere trattati perchè non idonei altri, invece, hanno rimandato il trattamento.

Q: What is your complication rate? How is this measured?

Non ho avuto complicanze importanti, 2 pazienti hanno avuto un lieve ipertono oculare risoltosi nelle 24 ore
In un solo caso, (quando ho iniziato ad effettuare questa tecnica e con una lente a contatto non specifica per i floaters) ho colpito la capsula posteriore del cristallino, ma dopo 2 anni non ci sono state conseguenze e non si è sviluppata cataratta.

In alcuni pazienti ho dovuto fermarmi perchè il Floaters si era avvicinato troppo al cristallino o alla retina oppure è andato in una zona non ben visualizzabile.

Q: How does your approach differ from other people working in this field, if it does?

Io seguo i consigli di Karickhoff avendo studiato sul suo libro.

Q: Many consultants are reluctant to treat floaters, can you explain why you are prepared to?

Ho una buona conoscenza dei laser ed ho iniziato con molta cautela ad utilizzare questa tecnica.

About your approach to treatment

Q: What kinds of patients and floaters do you feel are best suited to treatment?

Pazienti tranquilli che non si agitano durante il trattamento. Eseguo sempre, durante la prima visita, una simulazione al laser per vedere come si comporta il paziente, escludendo quelli che non stanno fermi e si spazientiscono.

Q: Can you describe the examination process, including any specialist equipment you use.

Faccio descrivere e disegnare i Floaters, facendo numerare in ordine crescente quelli più fastidiosi, e segno il movimento che mi descrivono. Visita oculistica completa.
Controllo del vitreo con lenti non a contatto e poi a contatto sia alla LAF dello riunito che alla LAF del Laser.

Se i Floaters sono aggredibili, eseguo una simulazione al laser per testare la collaborazione del paziente.

Q: Can you describe how you carry out the procedure, including the equipment you use.

My laser is an Optopol and usually I prefer to use the Karickhoff off axis lens I treat before floater number 1 and the other days I vaporize the follows I hit the cap of the floater before, because the bubles could be hide it I use no more than 300 spots for day.

Q: What is the recovery period and follow-up process?

The next day I can follow the treatment, if it’s necessary, or the patient can return to work after the ophthalmic visit.

Q: Have you experienced any patients reporting visual disturbances or a worsening of their condition as a result of treatment?

No one in my experience.

About the condition

Q: Where do you see the future of floater research and treatment?

Parlerò della mia esperienza in Italia nel Congresso che organizzo all’Isola d’Elba dal 10 al 12 settembre di quest’anno mettendola a confronto con la Vitrectomia (Point Counterpoint tra me ed un Chirurgo vitreoretinico).
Nel Congresso che organizzerò nel 2012 ho già avuto la conferma da Geller che verrà in Italia per confrontarci con la sua esperienza ed organizzerò un Corso, che dirigerò con lui, per insegnare questa tecnica agli oculisti italiani sensibilizzandoli a questo problema.

Ritengo che il laser dia dei buoni risultati, ma in molti casi è controindicato. Spero in un miglioramento della tecnica di vitrectomia e nella scoperta di un enzima che sciolga i floaters senza danneggiare le altre strutture oculari.

Q: Are you aware of any current projects that may lead to the development of an effective treatment for vitreous degeneration?

La vitreolisi enzimatica.

Q: In your opinion, why hasn’t the ophthalmologic profession been more aggressive in the pursuit of a less invasive, complication free, treatment for floaters?

Ritengo che molti miei colleghi sottovalutino il fastidio, a volte invalidante, che possono procurare i Floaters.

Dr. James JohnsonDr. James Johnson is an Irvine, California based Ophthalmologist who includes laser vitreolysis as a treatment for floaters in his practice. He is a diplomate with the American Board of Ophthamology.

Q: What exactly happens to floaters that are lasered?

The YAG laser emits the beam in a cone-shaped pattern. At the apex (or tip) of the cone, there is a concentration of energy. Using focusing lights, this apex is directed onto the front surface of the floater material.
The laser “shot” lasts 20 to 30 nanoseconds (0.000000030 seconds), and at that moment the concentrated laser light creates a small plasma bubble.

Plasma is the fourth state of matter, the first three being solids, liquids and gas. Matter that has been converted to plasma has the electrons pulled away from their usual location and creates a high-energy state of the matter. This process actually converts the floater material to a micro-gas bubble that floats away.

It is important to understand that the laser does not break the floater into small pieces, but actually changes it to a gas. The gas is reabsorbed into the bloodstream over the coarse of several hours.

Q: What determines how many floaters can be removed during the procedure?

Time, location, and total energy. For longer treatments, I am working against the clock. After 30 to 45 minutes, I’ll notice that the laser shots are becoming less effective, probably in part due to a little swelling (or edema) of the cornea. In addition, floaters that are too close to the retina or lens may not safely be treated.
During the treatment, I monitor the energy of each shot, as well as the total energy used during the treatment and keep it within a certain range.

Q: How do you prevent the patient from moving his/her head during surgery?

There is a head strap on the laser that snugly holds the head in place. In addition, a hand-held contact lens stabilizes the eye quite well. The combination allows me to focus on objects that are very small with great accuracy. Sedatives are available to patients who think they may not feel comfortable sitting still for a prolonged period of time.

Q: What short and long term complications or side effects is the patient at risk for? What are the odds of these complications?

Short Term: dilation of pupil, corneal swelling, occasional discomfort (mild to moderate) from the corneas being a little scuffed up from the contact lens. I have not witnessed any rise in eye pressure but that is a potential problem.
I continually monitor and remain aware of the location of my treatment, and avoid aiming near the lens or retina. A misfired shot could conceivably cause a cataract formation or injury such as bleeding from the retina or damage to the receptors. There have not been any documented cases of loss of vision, but we must state that possibility.

Q: How should a patient prepare for laser surgery of floaters? What type of exam(s) are needed in advance?

A complete eye examination should be completed prior to any laser treatment. Most people come to us already with the diagnosis of floaters after an exam that includes a dilating the retina to ensure that there is no retinal detachment or area at risk for same. I also perform or repeat this exam prior to any laser treatment.

Q: Are there cures for all of these potential complications? Which, if any, would have no remedy?

If a cataract were to develop, the patient might need cataract surgery. If the retina were hit in the periphery, it would not likely be noticed, but if it were hit in the center of the vision (in the macula) there could conceivably be a decrease in visual acuity. None of these have been reported yet.

Q: Can an ophthalmologist train to become a specialist in vitreous issues? Are there resources available to obtain credentials for this type of expertise?

Currently, there is no official or unofficial training or courses for Laser Vitreolysis techniques and applications. There is, though, a Vitreo/Retinal subspecialty of ophthalmology. These specialists perform vitrectomy procedures.
In our residency training, there is a supervised training and certification on the YAG laser. General ophthalmologists may use this laser hundreds of times in the course of a year.

Usually the laser is used for anterior segment procedures, namely, Capsulotomies and Iridectomies. The use of the laser in the vitreous is an adaptation of a laser we are already familiar with.

Q: What are a patient’s odds of seeing significant improvement? No improvement?

I went back to look at the interview you reference here. First understand that that interview with Kelley Garrison took place about two years ago. Much of the information is technical and stands up to scrutiny, but a lot of floaters have passed through the crosshairs since then and if I were asked the same question I would answer it differently. Here again is the original.

Q: What are a patient’s odds of seeing significant improvement? No improvement?

It depends on a number of factors. The age of the patients, the type and volume and distribution of floaters present, and other optical characteristics that may make the procedure more difficult, less efficient, and challenging. The well defined, distinct, large Weiss-ring type floaters associated with a posterior vitreous detachment are the most successfully treated. With that type, it is not uncommon for the patient to perceive a 70-95 percent reduction in the bothersome floaters in the first treatment. Older patients with diffuse, cloudy and hazy syneresis type floaters are much more unpredictable and generally will benefit from more treatments spaced out in time if feasible. This type of floater mass has the most tendency to “backslide” and reform some strings and strands and part of its 3-4 steps forwards, 1-2 steps backwards campaign. Young people in their 20-30′s are more difficult to predict. they typically have much less floater mass with the tendency to form thin cobweb-like strands intersperse with otherwise clear vitreous that has not seperated or diffusely degenerated. These floaters tend to be small, dense and fibrous, posteriorly located and quite mobile. Their shadows also tends to be quite distinct and bothersome. It these can be treated successfully, these patients are elated, and if you can’t treatment them successfully they are often the most despondent and depressed over their condition.
All in all it is impossible to get 100% of the floaters. The endpoint of treatment and treatment success is indeed hard to define sometimes as floaters are seen and interpreted somewhat by the personality type of the floater sufferer. The numbers don’t always tell an accurate story either. For instance, a 95% percent “patient-perceived” reduction in floater mass and volume is great, unless there is even a small residual fine strand moving across the central vision that is still bothersome. I think a better definition of success is a functional one: The goal of a treatment series is to return the patient to activities of daily living (reading, driving, sports, etc.,) where they are not constantly aware and reminded of the presence of distracting moving shadows across their vision and the ultimate goal of improving the quality of vision and the quality of life. Only the patient can fully assess the success or failure of that goal. Objective measurements (e.g. photos, ultrasounds) can not do that.

Q: How does your procedure compare to that of floater treatment specialists, Dr. Geller (Florida) and Dr. Karickhoff (Virginia)?

The procedure and experience should be very similar with all three. We do have different lasers, but that is just a technical difference and personal preference.

Q: What is your hope for the future of floater treatment? How can the doctors, the public and floaters sufferers best help the cause?

Eye care professionals can be collectively blamed for not listening to patients and taking the floaters seriously. If we did, there would be. We have always considered it adequate to pronounce the eye as healthy, and send the patients on their way. I am more attuned to how people suffer these floaters – usually suffering in silence because no one wants to take them seriously.
I am looking into better ways of locating and documenting the floaters, possibly with B-scan ultrasound or better yet, Ocular Coherent TomographyThe optics of lasers were designed for working on the anterior portion of the eye, and it is difficult to deliver the laser to the periphery of the eye. Maybe someday there will be a nontoxic way of enzymatically removing the floaters. Until then, Laser Vitreolysis is an attractive, noninvasive alternative to a much more aggressive Vitrectomy procedure.

It is really exciting to be on the cutting edge of a newer treatment. I do want to thank doctors Geller and Karickhoff for being the true pioneers and establishing the credibility and success for this procedure. It is incredibly rewarding to help these patients, in some ways even more so than our LASIK patients since some of our floater patients are on the border of functional disability. I am promoting this part of my practice slowly and cautiously so as to maintain it’s credibility. The biggest obstacle will be convincing other eye care specialist that it is a legitimate treatment so they can help refer their long suffering floater patients.

About me

Dr IdreesQ: Please can you give a brief outline your professional background:  qualifications, memberships and experience in the field of ophthalmology and in the treatment of Degenerative Vitreous Syndrome (severe eye floaters).

I did my MBBS basic medical qualification at Quaid E Azam University in Pakistan in 1983 and then I passed my FRCS (Fellow of The Royal College of Surgeons of Edinburgh, UK) in Ophthalmology.

Q: How many procedures on floaters have you carried out?

I have been doing Laser Vitreolysis for eye floaters since 2006 and I think I have performed more than 500 procedures so far on different types of eye floaters.

Q: What is your complication rate? How is this measured?

I have not come across any significant complications since I started doing the procedure in 2006.

Q: How does your approach differ to other people working in this field, if it does?

My approach is detailed preoperative evaluation, documentation and pre laser counselling to set realistic expectations, with a policy of under promise and over delivery.

Q: Many consultants are reluctant to treat floaters, can you explain why you are prepared to?

Most consultants have not heard of it and many who have are fearful of the risks and possible complications.

Personally I took it as a challange for those patients who are just given verbal reassurances by other eye doctors as many patients suffer a lot of visual discomfort and disability because of these floaters.  The problem can be felt only by the one who suffers and above all most of the time such patients get an answer to live with it, it will go away with the passage of time and worst of all that nothing can be done or offering an expensive and risky alternate of  surgical vitrectomy.

About treatment

Q: What kinds of patients and floaters do you feel are best suited to treatment?

The floaters in the visual axis are the most annoying to the patent and I usually prefer to treat these.  I started treating the mid vitreous floaters in the beginning but with experience  I can now treat those close to the retina and those close to the posterior lens capsule as well.

Q: Can you describe the examination process, including any specialist equipment you use.

Examination includes slit lamp examination with a Goldman 3 mirror contact lens, direct and indirect ophthalmoscope and Mainster lens to locate the depth of the opacity regarding proximity to the lens or retina, photographic recording and drawing by me to document the shape and location of the floater with reference to the visible landmarks.

Before offering the treatment to the patient I take the patient to the Laser unit and I examine them there as well to see if I can accurately focus the floater.  Only then will I offer this treatment to the patient as the floater which can not be clearly focused is usually not treatable.

Q: Can you describe how you carry out the procedure, including the equipment you use.

I dilate the pupil with Mydriacyl eye drops.  When the pupil is fully dilated  I instill topical anesthesia eye drops, instruct the patient not to move the eyes, face or body up/down, right/left, backward/forward during the procedure as it affects the focus of laser shooting and can create complications and unsatisfactory outcomes.  In case the patient gets tired, I instruct them to inform me and we will stop it for some time as concentration by the doctor and patient is very important during this procedure; a single wrong laser shooting can cause immediate disaster.  Presently I am using the Zeiss VISULASE  Nd YAG laser machine and  the IDREES VITREOLYSIS LENS designed by me and made by the VOLK   Optical Company USA with a clear viscoelastic gel.  I am using  EYE FILL  2.5 ml Croma-Pharma GmbH.

Q: What is the recovery period and follow-up process?

Most of my patients feel relief within 5-10 minutes when the effect of  bright light of the slit lamp during treatment on the eye goes away.

Q: Have you experienced any patients reporting visual disturbances or a worsening of their condition as a result of treatment?

None of my patients have reported any visual disturbances except very few say that there is still a little floater remaining. Immediate dramatic relief is reported by almost every case.  Residual floaters are treated in the next session if there is a need and it appears to be safe. No one has ever complained of a worsening of their problem.

About the condition

Q: Where do you see the future of floater research and treatment?

I think the future of laser treatment of eye floaters is very  bright, but we need to understand that this procedure has a definite learning curve and it needs training, teaching and promoting it by the laser manufacturers by arranging seminars, conferences, symposiums and lectures by experienced doctors.  As well as funding the further research and publishing the research articles by the experts on this procedure.

Q: Do any current projects show promise for the development of an effective treatment for vitreous degeneration?

In my opinion currently ongoing research is focused on inducing complete posterior vitreous detachment like ocriplasmin.  Any undue intravitreal injection is more risky than a properly done laser vitreolysis by an expert eye doctor.