Stephen Lash Eye Surgery

Do I operate on vitreous floaters?

The answer is yes but not always! Click HERE for Patient information leaflet

What are Floaters?

Our gel is really important before we are born and then from birth it slowly degenerates and its main purpose seems to be to keep me employed. It is a mix of water and proteins in a gel like solution which looks featureless in young people. With age the proteins start to clump together and fluid pockets appear. These clumps float around and some people can see these when the background is simple like a blue or grey sky, a computer monitor or a white wall. If you really look for them most people will see them, little flecks and chains and bobbles in a line that dart around and move out the way as you try to follow them. The closer the clump to the retina the more distinct a floater it will be. Sometimes the gel develops cloudy patches that float around up at the front of the eye just behind the lens and these can cause a more global blurring of vision, like a cloud suddenly coming across the vision. This can be made even worse after cataract surgery where the gel can move even further forward in the eye up to the nodal point. The nodal point is the most important part of the eye's visual system as all light passes through this point and so floaters in this region can have a significant effect on vision especially when the light is sub optimal.

Dangerous floaters?

A sudden shower of tiny floaters or a sudden change in floaters might be a warning of a retinal tear and possible retinal detachment, especially if accompanied by flashing lights. Seek urgent review with your local optometrist for assessment and if they cannot see you then contact your local eye casualty. You may require laser treatment to spot weld the retina into place if a tear is found in the retina. If a shadow appears you may already be detaching, seek URGENT review at an eye casualty.

Some severe inflammatory conditions in the eye can cause a rapid increase in floaters and patients with diabetes can bleed into the eye resulting in a sudden shower of floaters followed by misty vision. All these need to be seen on an urgent basis by an ophthalmologist.

When Would I offer surgery?

No one jumps out of a first floor window but if a lion walks into the room most would jump. If your floaters are a minor inconvenience, if you can mostly ignore them then there is no reason to take any risk of surgery. If you have the global blurring of vision that some get and this makes driving difficult with vision that is unpredictable then you have good reason to get rid of the floaters. If the floaters are so bad you have lost your vision (with a bleed for example) it may be safer to proceed to surgery even with the small risk of retinal detachment (2%) to ensure the retina is healthy and you are not developing a retinal detachment. If you can think back to the decision process and the discussion we had in clinic and recognise you had very good reasons to proceed to surgery then you will be able to cope if you are one of the few that has a complication and you will not regret your decision. I would offer this story of a patient who had floaters. He was young (in his 40s) and was very bothered by floaters. I could not see much looking in but after discussion we proceeded to surgery. He was happy. Three years after surgery he developed a significant retinal detachment and he required oil. I met him with the oil in his eye, we were unsure how he would do after the oil was removed and I asked him if he was still pleased he had the surgery for floaters and without hesitation he said yes. That is the mark of a good decision. He did well after oil removal but he may not have done.

What is surgery like?

It is day case, local anaesthetic with or without sedation surgery. It is the first part of all the vitrectomy treatments on this website and you can watch any of the videos to see what I do. It is comfortable and calm and many patients quite enjoy the experience especially if they had a little chemical courage (Sedation). Three tiny ports are placed into the eye and through these the fluid drip is placed, the light pipe and the vitreous cutter. The vitreous cutter is a vacuum cleaner and guillotine in one (It cuts at 5000 per minute). This may or may not be combined with cataract surgery depending on your age and the state of the lens as Vitrectomy speeds up the development of cataract especially in the over 50s. Most of the gel is removed from the eye leaving a frill around the edge. The eye is searched for any holes or tears and then if all is well a small air bubble is placed in the eye. This helps me to ensure all the ports are sealed (they will not bubble if sealed) and provides some initial support to the wounds over the first few days. The bubble gets smaller and rounder over a few days and then goes. If you need to fly I can leave the eye fluid filled provided I do not find any tears or holes in the retina and so I cannot guarantee you will be able to fly straight after surgery. If I have to treat the retina I may need to fill the eye with gas and then you cannot see or fly with gas in the eye and this usually lasts two weeks. (See bubbles in the eye). The eye is very comfortable afterwards and you will have drops for a month (See my post op instructions for full details of after care and what to expect).

What are the risks?

There is a 2% risk of retinal detachment where the retina can come off the wall of the eye and, if ignored, the sight will rapidly fade to grey. Retinal detachment can be repaired in 80-90% of cases. I will warn you of shadows appearing post surgery. If you have your natural lens you will develop cataract more quickly and this usually results in the eye becoming more short sighted (Good for near poor for distance). Infection is very rare (<1 in 2000). Bleeding and low pressure are also infrequent (<1 in 100). Pressure may go up after surgery but in most cases this returns to normal.

VItrectomy surgery for floaters is carried out when the patient is bothered enough by the interference with vision to take the risk of surgery. The main risk is retinal detachment at around 2%. Surgery is under local anaesthetic and takes about 20 minutes.

Here you can see the tiny flecks in the jelly like a snow globe door stop.

Thanks to my patient for allowing me to share her vitreous floater. She is thinking about surgery. Have a look and wait for the cloud  (the floater)to come down just behind the lens which is the slightly yellow thing on the left. It was recorded with an 'I phone' against the slit lamp but it works well! It is easy to see how this can cause significant reduction in vision!

Thanks to my patient for allowing me to share her surgery- I finally got around to doing it! She was very bothered by clouds that would come across the vision obscuring detail. Surgery was carried out under a local anaesthetic and took around 15 minutes to complete. You can clearly see the white clouds in her eye in this video and remember the scatter a patient sees is many many times worse than the scatter we see when examining. Looking out of an eyball through floaters is very different to lighting them up and looking into the eye. I saw her yesterday and she was thrilled with results and 'prompted' me to get on with sharing the video!