By DrJohnson | October 17, 2016 | Uncategorized |  Like |

I recently received an email with some very reasonable questions regarding success rates. Specifically, this patient asked “What type of success rates do we usually see with the initial and follow-up sessions?” Also, “What are the long-term success levels of your former patients?” followed by “do many require follow-up treatments in later years?”

In all actuality, these are very difficult questions to answer in part because there is no objective, standardized way of measuring floaters and even if there were such a thing available, it would not necessarily correlate with the patient’s subjectiveley-perceived “bothersomeness” of the floaters.

When I started Vitreous Floater Solutions nearly a decade ago I registered the corporation as “VITREOUS FLOATER SOLUTIONS CONSULTATION AND RESEARCH GROUP, INC.”. The intent was to legitimize the practice of treating floaters with the laser by publishing studies. What I found, though, is that documenting the improvement of floaters is nearly impossible. It is much like the assessment of pain or the persistent ringing of the years associated with tinnitus. For instance in both the research and clinical setting in the evaluation and management of pain, the patient is often given a scale for them to mark their level of pain they are currently experiencing. That pain assessment scale will show at one end a sad face graduating to a neutral face in the middle and at the other end of the spectrum, a happy face.

pain-rating-scale-chart

It is truly a subjective assessment of their pain which is moderated by their personality, family situation, co-morbid disorders, personality disorders, as well as cultural influences.

An orthopedic doctor may look at the x-rays of somebody with moderate arthritis and predict that the patient may be in only mild discomfort, and yet the patient may describe it as 9/10 pain level.

This is a similar problem we have in evaluating the problem of eye floaters. The patients subjective description of bothersomeness sometimes does not correlate well with what the doctor/examiner can see. In many ways, the treatment of eye floaters becomes a very practical and pragmatic treatment process. Along with these challenges, it is very difficult to define success in terms of treating floaters. Is a subjective 70% reduction in floaters success? Is a greater than 90%? Or must the vitreous be perfectly crystal clear and 100% better to be considered a treatment success?

If we are starting off with a complete mess of the vitreous, the proverbial ‘dirty fish tank’ of disorganized vitreous, the patient might be quite happy with a 50 or 60% improvement. And there are some that return multiple times trying to chase down the last 5% or 10%. I was discussing this with a patient last week and she mentioned the 80/20 rule. This may very well apply here. It feels like I’m spending 80% of my time trying to chase down the last 20% of the floater problem.

None of the above takes into consideration the differences in personality types. Should some patients are a bit more compulsive in chasing the results and others not so much. In addition, I haven’t even begun adding to this complexity the different types of floaters, their location within the eye, associated quality of optics of the eye which affects laser energy, and whether it is a singular floater or a distributed mess. All of these multitude of variables keeps me on my toes and interested as every patient is truly a new set of challenges.

So to get back to some of the original questions. The simplest way to answer these questions is with the classic fallback answer of the experienced physician: “it depends”. There are some generalizations that might help answer these questions. Firstly, I want the first treatment to have something of a “Wow! effect”. I don’t think that it should take two or three treatments to start to notice an improvement. If things are complex, I would like to at least have that first treatment get over the 50% improvement range. That might be a reasonable first treatment expectation for a more complex type of problem. If someone walks in the office with a Weiss ring type of floater, then 80 to 95% improvement after the first treatment may be typical. None of this takes into account the tendency for certain types of floaters, the cloudlike syneresis types, to reform and reaggregate a bit after treatment. These treatments may feel like three or four steps forward and then one or two steps backwards and regression. This is not a complication of the procedure, but a common and anticipated part of the process.

Without knowing anything about your eye floater problem, I can say that Weiss ring derived or variant floaters associated with a posterior vitreous detachment are the most efficient and satisfying to treat with 85 to 95+ percent improvement after just a couple of treatments. On the other hand, a large and diffuse cloudlike floater will likely take more overall treatments because of this regression and reaggregation tendency. That said, a lot of improvement can still be made in three or four consecutive day treatments for this type of floater problem. Before, it is not unusual for me to see patients months later in a continued effort to try to get out that last 20% or so.

Unfortunately, there’s no simple set of questions I can ask or a way that you could describe your problem that would allow me to very accurately predict your particular experience with treatment, or whether you’re a candidate for treatment at all. Those over the age of 45 to 50 are very likely treatable, and those under the age of 30 are very unlikely to be candidates for treatment. With some overlap, the in-between age group is hit or miss as far as their candidacy for treatment.

I spend a lot of time via my website, personal emails, and sometimes phone calls doing my best to manage people’s expectations. All in all, my specialty practice has helped a lot of patients who have been told nothing can be done. I prefer to educate my patients extensively and bring them onboard in the decision-making process. As a business style and approach, I prefer to under-promise and over-deliver. Ultimately, this prepares patients for the possibility that it may take a few treatments to get them to the level of satisfaction.

The floater material that is directly hit by the laser should be permanently vaporized. That small mass of material should never come back. Immediately adjacent to the laser focal spot, the long collagen molecules may be fractured and broken into small, microscopic, and invisible fragments. We theorize that one of two things may happen to this material: 1. Some of it is liberated into the fluid portion of the eye and flows out with the natural fluid drainage of the eye (trabecular meshwork), and/or 2). The fractured collagen molecules become “sticky” and may regroup or clump up to form a smaller and differently shaped floater. These “reformed” floaters are usually quite treatable with subsequent, follow up laser treatments. Because of this tendency, it is rare to be able to treat someone in just one treatment session. Most people will need a second and 3rd (and sometimes more) treatments to achieve a satisfactory outcome. This expectation of the need for re-treatments is logistically easier for those that live in the Southern California area. Those that travel longer distances may need to allow for longer stays, or leave open the possibility to return at some future date.

UNTREATED SYNERESIS TYPE OF VITREOUS FLOATER. This is a large, diffuse, cloud-like floater that is commonly seen in our practice. They are more gradual in onset, and appear as a large ‘gauze’, haze, or cloud across the vision.	SYNERESIS FLOATER AFTER TREATMENT with re-formation, re-aggregation, and clumping of remaining collagen protein fragments despite an adequate and aggressive first treatment. The aggregated floater most often appears as a ‘fuzzy’ linear strand. Although there is much less material involved, these floaters can still be quite bothersome.	SAME FLOATER AFTER FURTHER TREATMENT  may continue with the ‘3-4 steps forward and 1-2 steps back. Continued re-formation of smaller fuzzy linear strand may continue until there is less material, or the remaining material is not bothersome, or no more material reforms. There is no way to predict how many treatments it takes to get to these ‘endpoints’ as it varies from eye to eye.