March 9, 2018 Conference
YAG Vitreolysis for Symptomatic Floaters
Chirag P. Shah, MD, MPH
NEOS March 2018
About two-thirds of patients older than 65 years have a posterior vitreous detachment; many are bothered by their floaters. Ophthalmologists often inform patients they will neuro-adapt to the floaters with time, which is often true. But some patients have residual symptoms that can significantly affect their quality of vision and thus their quality of life.
There are only two known treatment options for floaters: vitrectomy and YAG vitreolysis. Small gauge vitrectomy systems may have lowered our threshold to offer vitrectomy for floaters, but there are inherent risks to vitrectomy. Everyone gets a cataract. Studies have reported rates of retinal detachment to be as high as 10.9% . Further, there is a small risk of infection, as well as the inherent risks of anesthesia.
YAG vitreolysis may serve as a middle-ground treatment option for floaters between observation and vitrectomy. However, the evolution of YAG vitreolysis has contributed to its controversy; providers have performed the procedure for years without sufficient clinical trial data.
Recently, a pilot study randomized 52 patients to YAG vitreolysis versus sham laser, reporting a moderate improvement in floater symptoms with no significant adverse events . YAG treated patients reported a 54% improvement in their symptoms compared to a 9% improvement in sham treated patients after a single treatment session. The VFQ-25 showed improved general vision and peripheral vision, with less role difficulties and dependency among the YAG laser group. Objectively, a masked grader found that the floater appearance was significantly or completely improved in 94% of YAG treated eyes on wide-field color photography.
The field of YAG vitreolysis is still in its infancy, with more studies needed to better understand its efficacy and safety, as well as to better identify which floater-types and patient-types are best suited for this procedure. Indeed, further randomized controlled trials are underway in Japan, Germany, and France. At present, glaucoma, cataract, retinal damage, and retinal detachment are all known risks of YAG vitreolysis, but we need large studies with long follow-up to determine the rates of these risks. We should have more clinical trial data about YAG vitreolysis in the next few years.