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Treatment of Vitreous Floaters With Neodymium YAG Laser
Treatment of Vitreous Floaters With Neodymium YAG Laser
Treatment of Vitreous Floaters With Neodymium YAG Laser
Figure IA Preoperative fundus photograph ofthe eye ofcase Figure IB Postoperative appearance. Note that the ring-
4 with a freefloating prepapillary opacity (arrows). The shaped opacity has been completely disrupted (arrow). The
underlying retina appears blurry because focusing was on the patient's symptom has completely disappeared.
vitreous opacity. There are medullated nerve fibres
surrounding the optic disc (shoum on the top of the
photograph). laser burst was effective, the optical breakdown
with fragmentation could be seen. In the first
exceeding 4 mJ in the instrument which was few cases of our study, approximately one half of
manufactured in 1990). One pulse per burst was the bursts produced sparks. Gradually, as we
used for all patients who required only a single became more experienced, the effectiveness
treatment session each. The contact lens used improved to nearly 100%. The entire course of a
was a flat fundus lens. Either a fundus laser lens treatment session for each patient usually took 20
or a Goldmann's three mirror lens would be minutes; this again became shorter as our tech-
suitable. The image of the aiming beam was first nique improved. When the opacity was hit it
focused on the retina and then moved slowly bounded away and soon returned to the original
backwards to focus on the opacity. If the opacity site. At the same time, it gradually fragmented,
was too small to be precisely focused on, then the became amorphous, and promptly disappeared
aiming beam was focused on a spot which (Figs 1B, 2B, 3B, and 4B). It took longer to
included the opacity and its immediate vicinity. completely disrupt the bigger prepapillary
opacities.
In the initial five cases, the intraocular pres-
Results sure was checked daily for 3 days and a fluor-
Whether there was posterior Atreous detachment escein angiography was taken on the third day.
or not, where laser treatment was concerned the There were no significant changes detected,
localised opacities of the 15 cases could be therefore we discontinued these tests and only
categorised into two groups: prepapillary and followed up the patients with regular examina-
centrovitreal opacities.' The prepapillary tions.
opacities were single membranous ring-shaped There were five patients with complaints of
opacities (Weiss's ring)2 with shape and size seeing floaters in both eyes. For these five
corresponding to the contour of the optic disc patients, only one eye was treated; the fellow eye
(Fig 1A and Fig 2A). The centrovitreal opacities was left untreated. We found that the floaters
we defined were faint, discrete, fibrous opacities, and opacities disappeared in all of the five treated
floating freely near the centre of the vitreous ev es but persisted and remained unchanged in
cavity (Fig 3A and Fig 4A). The number of these the untreated eyes. These patients no longer had
opacities varied from one to three (Table 1). anxiety, possibly because of assurance obtained
The required laser energy varied with the size from the positive results in the treated eyes.
of the opacity in each case, ranging from 71 0 to All patients were satisfied with the treatment
742-0 mJ, with an average of 286-49 mJ. If the and stated that their floaters disappeared
Figure 2A Preoperativefundus photograph of the eye ofcase Figure 2B Postoperative appearance. Note that the opacity
8 showing a prepapillary opacity (arrows). has been completely disrupted (arrow).
Treatment ofvitreousfloaters with neodymium YAG laser 487
Figure 3A Preoperative ifndus photograph of the eye ofcase Figure 3B Postoperative appearance. The opacity has been
10 with afibrous centrovitreal opacity (arrow). disrupted, only traces could be seen with a direct
ophthalmoscope (arrow). The patient's symptom has
completely subsided.
immediately after the operation; their anxiety
was dramatically relieved, too. During the 12
month follow up period, no patient showed any which needed other specific treatment. Based on
significant visual deterioration or recurrence of our experience, we estimate that about 90% or
subjective floaters. more of all vitreous floaters are technically
treatable, regardless of their indications.
Application of Nd-YAG laser in the posterior
Discussion segment is not popular as in the anterior seg-
In 1983, Murakami and associates' reported the ment.34 Most of the reports were on vitreolysis
vitreous changes in 148 eyes with sudden onset of for vitreoretinal tractions in proliferative dia-
floaters. They had observed that 76% of the betic retinopathy678 or sickle cell retinopathy.9
patients saw one or a few floaters and 24% saw Other applications of laser for the treatment of
many. The floaters were located primarily in the vitreous cysts,'0 cystoid macular oedema," or
central field of vision. Eighty six per cent of the rhegmatogenous retinal detachment'2 have been
136 patients were 50 years of age or older. There rarely reported. To our knowledge, use of
were two kinds of vitreous opacities that were Nd-YAG laser for treatment of vitreous floaters
responsible for floaters: prepapillary vitreous has not been previously described. The obstacle
opacities and vitreous opacities in the posterior to more common application of the Nd-YAG
vitreous cavity near the macula. Our clinical laser in vitreous pathology is that it is known to
observation is generally in agreement with potentially cause damage to the chorioretina.
Murakami's findings in all aspects mentioned The complications include choroidal haemor-
above. In our present study, the number of rhage,6"1 damage to the retinal pigment epithe-
opacities was usually one for prepapillary opaci- lium,'4 transient retinal haemorrhage,5 and
ties and one to a few in centrovitxeal opacities. bleeding from perfused vascular bands.7
The patients were usually 50 years or older. As However, some studies indicated that the
far as treatment is concerned, most of the threshold of the retinal damage caused by Nd-
younger patients who complained of many float- YAG laser is related to the potency of power used
ers were usually untreatable because no opacity and the distance of focus from the retina. '5
could be found using an ophthalmoscope. On the Because of the high power of laser energy, the
other hand, older patients who complained of focus should be kept to a minimum of 4 mm away
many floaters were usually not suitable candi- from the retina. ' Although this result was
dates for laser treatment because the opacities obtained from an animal experiment, it still
had usually resulted from retinal pathology, could be applied to clinical treatment. '4 Fortu-
Figure4A Preoperative fundus photograph of the eye ofcase Figure 4B Postoperative appearance. The opacity has been
12 with a centrovitreal opacity (arrow). completely disrupted (arrow).
488 Tsai, Chen, Su
Table I Summary of 15 patients who underwent neodymium YAG laser treatmentfor vitreous compared the direct ophthalmoscope with
floaters the indirect ophthalmoscope and preferred the
Duration Vitreous opacities former, simply because it has a higher magnifica-
offloaters Laser doses tion and so opacities can be localised more easily.
Patient before Distance Duration of Theoretically, potential complications such as
No/Age treatment from the Burst Total follow up
(years)/Sex (months) Type Number Size retina (mm) (mJ) (mJ) (months) chorioretinal damage and lens damage might be
1/63/M 4 Centrovitreal 1 M 10 7-1 340-8 18 expected, yet we never experienced any compli-
2/42/F S Centrovitreal 3 M 6-7 50 400 0 18 cations in our series. Fluorescein angiography
3/66/F 4 Prepapillary 1 L 6 50 600-0 18 performed after treatment disclosed no damage to
4/53/F 2 Prepapillary 1 L 6 7-1 742-0 18
10-0 the retina, either. We believe that precise focus-
5/55/M 3 Centrovitreal 1 M 4 7-1 284-0 14 ing is the most important factor in avoiding
6/55/M 3 Centrovitreal 3 2S 5-7 7-1 217-1 14
iM complications.
7/51/F 7 Centrovitreal 1 S 9 7-1 149-1 13 It was reported that vitreous floaters are highly
8/54/F 3 Prepapillary 1 L 4 7-1 660-3 13
9/62/M 4 Prepapillary 1 S 6 7-1 149-1 13 related to the posterior vitreous detachment
10/55/F 4 Centrovitreal 1 M 5 50 140-0 13 (PVD).' In our series, there were only two cases
11/70/M 6 Prepapillary 1 S 6 7-1 142-0 12
12/52/F 4 Centrovitreal 1 S 5 50 140-0 12 (case 2 and case 5) with no PVD before treat-
13/57/F 4 Prepapillary 1 L 7 50 120-0 12 ment, while in the other 13 cases, complete PVD
14/58/F 5 Centrovitreal 2 S 5-6 7-1 71-0 12
15/61/F 4 Centrovitreal 2 M 6-7 7-1 142-0 12 was detected preoperatively. At the end of the
follow up period, the two eyes with no PVD
S=small; M=medium; L=large. Size of opacity is defined as small when its diameter is smaller than remained unchanged. However, in case 5, the
1/2 disc diameter, medium: 1/2 to 1 disc diameter and large when it is larger than 1 disc diameter. In
fibre-like opacities, the size is small when its length is smaller than 1 disc diameter and medium when untreated fellow eye developed complete PVD
larger than it. within 1 year. It is obvious that laser treatment
would not influence the course of PVD.
Although we confined the indications for
nately, almost all of the opacities that caused treatment to very strict criteria, by accumulating
floaters in otherwise normal eyes happened to be samples and experience, Nd-YAG laser may
located beyond this distance; this could be prove to be a safe and ideal method for treatment
confirmed by ultrasonogram measurement. of all persistent vitreous floaters in the future.
Moreover, the avascular nature and high
mobility of opacities are additional advantages 1 Murakami K, Jalkh AE, Avila MP, Trempe CL, Schepens
for laser treatment. Owing to their high mobility, CL. Vitreous floaters. Ophthalmology 1983; 90: 1271-6.
2 Duke-Elder S. Diseases of the vitreous body. In: System of
it is easy to segregate the opacities from the ophthalmology. St Louis: Mosby, 1976: Vol XI; 322, 341.
underlying macula, optic disc, and major vessels 3 Steinert RF, Puliafito CA. The Nd-YAG laser in ophthalmology:
principle and clinical application of photodisruption.
simply by changing the position of the eyeball. In Philadelphia: Saunders, 1985: 134-7.
addition, the shield effect of the opacities may 4 Keates RD. Q-switched nanosecond pulsed Nd YAG laser. In:
Aron-Rosa DN, ed. Pulsed YAG laser surgery. New Jersey:
also reduce the amount of laser energy that Slack, 1983: 51-5.
reaches the retina.'415 All of these factors make 5 Aron-Rosa D, Greenspan DA. Neodymium:YAG laser
vitreolysis. Int Ophthalmol Clin 1985; 25: 125-34.
photodisruption of vitreous opacities less risky 6 Fankhauser F, Kwasniewski SF, van der Zypen E. Vitreolysis
than expected. with the Q-switched laser. Arch Ophthalmol 1985; 103:
1166-71.
The importance of contact lens in vitreolysis 7 Brown GC, Benson WE. Treatment of diabetic traction retinal
cannot be overemphasised.1617 Both effect and detachment with the pulsed neodymium-YAG laser. Am J
safety should be considered in its use. We realise Ophthalmol 1985; 99: 258-62.
8 Brown GC, Scimeca G, Shields JA. Effects of the pulsed
that the contact lenses that are specially designed, neodymium:YAG laser on the posterior segment.
such as Peyman's 25, 18, and 12 5 mm, are Ophthalmic Surg 1986; 17: 470-2.
9 Hrisomalos NF, Jampol LM, Moriarty BJ, Serjeant G,
useful for vitreolysis.3 1' However, they are not Acheson R, Goldberg MF. Neodymium-YAG laser
vitreolysis in sickle cell retinopathy. Arch Ophthalmol 1987;
suitable for disruption of localised vitreous 105:1087-91.
opacities because their magnification is so high 10 Ruby AJ, Jampol LM. Nd:YAG treatment of a posterior
vitreous cyst. AmJ Ophthalmol 1990; 110: 428-9.
that too many of the details of the vitreous body 11 Katzen LE, Flieschman JA, Trokel S. YAG laser treatment of
make the target opacity difficult to identify. cystoid macular edema. AmJr Ophthalmol 1983; 95: 589-92.
12 Fleck BW, Dhillon BJ, Khanna V, McConnell JM, Chawla
Therefore, we recommend using the flat fundus HB. Nd:YAG laser augmented pneumatic retinopexy.
lens of the Goldmann three mirror contact lens Ophthalmic Surg 1988; 19: 855-8.
13 Puliafito KA, Wasson PJ, Steinert RF. Neodymium-YAG
even though we realise its divergent effect on laser surgery on experimental vitreous membrane. Arch
laser energy is less than that of Peyman's. The Ophthalmol 1984; 102: 843-7.
14 Jampol LM, Goldberg MF, Jednock N. Retinal damage from
focal depth of a flat fundus lens is greater, which a Q-switched YAG laser. AmJr Ophthalmol 1983; 96: 326-9.
makes the operator able to focus on the opacity 15 Bonner RF, Meyers SM, Gaasterland DE. Threshold for
retinal damage associated with the use of high-power
and observe the background retina simultane- neodymium-YAG lasers in the vitreous. Am J Ophthalmol
ously. This will not only give the operator a sense 1983; 96: 153-9.
16 Loertscher H, Fankhauser F. YAG laser contact lens theory
of security but also enable him to avoid damaging (advanced). In: March WF, ed. Ophthalmic laser: current
the macula, disc, and major vessels. On the other clinical uses. Thorofare, NJ: Slack, 1984: 69-83.
17 Peyman GA. Contact lenses for Nd:YAG application in the
hand, in examining the vitreous opacities, we vitreous. Retina 1984; 4: 129-31.