Floater laser treatment

Depending on your complaints and what is found during an ophthalmological consult, we can prescribe eye drops or spectacle lenses.

Depending on your situation eye drops may bring improvement. If these drops cause too much pupil dilation, you cannot drive while using them. In some cases, the drops bring about sufficient improvement so further treatment is no longer needed. Often this improvement is not sufficient though in which case surgery or floater laser treatment can still be a solution.

How does this treatment work?

At the start of the treatment, you will get pupil-dilating drops. It takes about 15-30 minutes for the drops to take effect. As soon as the pupil is wide enough, the ophthalmologist can examine your eye. If the floaters are clearly visible and treatable, the ophthalmologist can start the treatment.

During the treatment you will be seated on a chair, resting your chin on a support and pressing your forehead against a white band.

The ophthalmologist applies anesthetic eye drops before putting a laser contact lens on the eye. The red or green lights are used to focus the laser. The YAG laser itself is invisible. You will be asked to look in different directions so all floaters can be observed. The ophthalmologist activates the laser by pressing a button. Each button press will produce one or multiple shots. It may feel like subtle tapping. There is no pain.

Small gas bubbles will occur during the laser treatment. They bubble up, but you will see them go down again. After the laser this will remain visible for several hours in the form of tiny balls at the bottom of the screen. Depending on the size of the floater, many (hundreds) or a few (<50) shots are needed. Floaters in the middle of the eye are easiest to treat. Floaters that are occur only after eye movements are the toughest to treat, sometimes even impossible to treat and involve a somewhat higher risk of complications.

The treatment takes about 15 to 45 minutes. The limiting factor is the number of laser shots that can be given. There is only a limited numbers of shots during given time. Another limiting factor is cornea clarity. Due to the friction with the contact lens the outer layer may get slightly irritated, making it hazier. This prevents the laser to focus properly, causing a necessary pausing of the treatment. The haziness will be gone after a day. The treatment can be completed another time.

After treatment, vision will be blurred because of the laser gel and hazy cornea. Moreover, the pupil will still be widened and the eye will be dazzled by light. This will improve after a couple of hours. Per eye, a total of 1 to 5 treatments will be required with an average of 2 to 4 treatments per eye.

A YAG laser is used to evaporate floaters (tissue). Dr. Frankhauser laid the basis for this technique in Switzerland. The floater laser was developed around 1986 by Dr. Geller in Florida and is approved by the Food and Drug Administration (FDA). The YAG floater laser is a good alternative to a vitrectomy (PPV). In 50-95% of the cases, the floater can be successfully treated. It is an outpatient procedure under local anesthesia. The recovery time is short, lasting until the pupil dilation drops stop working.

If laser contains sufficient energy, tissue is vaporized by plasma formation and optical breakdown. The floater absorbs the laser’s energy, turns transparent and changes into gas. You will see a quick flash (micro lightning bolt) and hear a little tap (micro thunder).

Some small fragments that were located too far from the flash to evaporate will be released, but they will pick up enough energy to be broken down. In general, these fragments are so tiny they will not cause any trouble afterwards. When too little energy is used the optical breakdown will occur through fragmentation instead of through evaporation (the floater will be broken into tiny pieces). This fragmentation has been noticed by other ophthalmologists in the past. This is the cause for the existing, incorrect notion that floaters are merely broken into small pieces by laser, and do not disappear.

As mentioned before, every treatment holds risks. The risks of floater laser treatment are very low. Non-serious complications occur in 0.1 to 0.16% of all treatments. Serious complications are so rare there are no accurate numbers for it.

Risks of floater laser treatment

• The main risk is hitting the retina, which may mainly occur if a floater is located close to the retina. If a floater is located far enough from the retina, the risk of damaging it is extremely low. When the floater is located close to the retina, the doctor will deliberate with you and will usually advise against treatment. During treatment in our clinic, chances of hitting the retina are extremely low, at least less than 1 in 1000 treatments. When the retina is hit during a floater laser treatment, a small bruise will develop in the retina. This blood will disappear in the course of a few weeks or months. A few months later, a small scar may be visible. In principle, this has no consequences for the eyesight unless when its location is right in the center of the yellow spot, in which case it may cause a permanently defected vision. In comparison: in the treatment of diabetes it is sometimes necessary to switch off large parts of the retina with an argon laser. Around 1000-2000 shots are needed for this. The patient usually does not notice this at all.
• Another known risk is hitting the lens, which seems to occur mainly in doctors who are learning the technique. This happened to Dr. Gerbrandy once, in 2009, and never again afterwards. Thus, the risk is approximately 1-2 occurrences in 10,000 treatments. If this does happen, it can be solved through cataract surgery, whether or not in combination with a vitrectomy. In comparison: chances of developing cataract after a vitrectomy are about 50 to 100%.
• Raised eye pressure. Some eyes will respond to treatment with a (temporarily) increased eye pressure, most likely because the microscopic remains of floaters block drainage. This occurs in 1-3% of patients. Risk factors for raised eye pressure are: pre-existing raised eye pressure that is treated with drops, many laser shots per session or many shots in total. This is why we limit the number of shots per session and strongly advise the patient to have their eye pressure measured regularly after treatment.

Ophthalmologists who practice floater laser will warn the patient if these risks apply, and will refrain from treatment if the risk is considered too high. This means some people will be rejected for treatment.

Risks of vitrectomy

Risks in vitrectomy are quite high. The pars plana vitrectomy (PPV) has been developed for the treatment of retinal detachments. Without treatment, chances of going blind are virtually 100%.

The most common consequences of vitrectomy are retinal detachments and cataracts. The reported risk of retinal detachment after a floaters-only vitrectomy lies between 2.5 and nearly 10% in the 1-3 years after the vitrectomy: a much higher number than a retinal surgeon may think intuitively. In newer studies (with a short follow-up) this is around 1%.

The reported risk of cataracts in the 2 years after a vitrectomy varies from 50 to almost 100%. In people older than 50 years of age chances of needing cataract surgery within 2 years after a vitrectomy are nearly 100%. More recent studies with a short follow-up indicate lower numbers (30%). However, it is to be expected this percentage will increase with a longer follow up (> 9 months). A vitrectomy may also cause damage to the central retina, possibly leading to long-term or even permanent visual impairment or (virtual) blindness. In the AMC study this was the case in 1 of 116 patients. This means after a vitrectomy, there is a chance of almost 1% to become blind or visually impaired, making it an operation that should only be performed when the burden rate is really high or when the laser has not been effective.

Why do retinal detachments and cataracts develop after a vitrectomy (PPV)?
During a PPV, a medical tool is inserted into the eye. The pressure onto the entering spot in the retina is high enough to tear it or to pull the retina loose. The force needed to do this is about 3 times the strength needed to break your finger through the surface of water (in other words: a tiny bit of power). Vitreous fluid is rather stringy. Pulling it, you may easily tear the retina. During a PPV, traction may occur, resulting in a tear in the retina. The lens is extremely sensitive and can easily develop cataracts after being touched. In PPV, the culprit may be the water flowing through the eye.

During laser treatment, the eye is neither entered nor pulled at. Theoretically speaking, traction is even reduced, as connections within the vitreous fluid are reviewed. This may explain why hardly any retinal detachments are reported after floater laser treatment.

Floater laser is offered very rarely. The reasons are different as to why. In ophthalmology there is a certain kind of dogma. The overal belief is that floaters are harmless and that patients do not need treatment because you can get used to them. Even if you can’t, in most cases ophthalmologists won’t perform surgery because it is too risky.

Thought science progresses and until recently, no scientific evidence existed that floaters could successfully be layered away. A recent study provided the first official proof. Thousands of patients have been treated successfully over the past 30 years.

We are revising our study results for publication right now. Our consecutive case series on 146 eyes shows that the improvement after floater laser is statistically significant. Hardly surprising, when 86% of patients report being satisfied with the result.

To conclude with, there are some technical reasons:

• Floater laser is a difficult technique to learn.
• The treatment is time-consuming treatment. Therefore, most ophthalmic clinics are not able to offer the floater laser.
• Few lasers are suitable. The best laser is the Lasag Microruptor II (MRII), of which only a couple exist worldwide. The latest Ellex laser gets close and is a nice addition to the MR II.
• Financially speaking, floater laser is not an attractive offer: the treatment seems expensive but the rates are still too low, given the time it takes.
• In many countries, vitrectomy generates a lot of money, making it unattractive to switch to cheap laser treatment.

Ophthalmologist Feike Gerbrandy has been treating patients with floaters since 2009. Because he performs about 1000 laser treatments a year he has already performed many thousands of treatments, making him the most experienced floater laser specialist in Europe. On global scale, only American ophthalmologists Geller and Karickhoff are more experienced. As the lasering of floaters is an extremely complex technique to master completely, numbers and experience are essential. The chance of success is much greater when an experienced doctor performs the treatment.

Gerbrandy has noticed that with the majority of his patients, he can usually assess right away whether a floater can be treated with laser and what the chances of success are. He develops new treatment strategies regularly as well as adjusting his technique.

As far as we know, the OMC Amstelland is the only clinic in the world to be equipped with both the latest Ellex laser, the Ultra Q reflex (UQR), and the Swiss Meridian Microruptor II laser (MRII). These 2 lasers complement each other perfectly. Use of which laser depends on the optical properties of the laser’s microscope. One works better for the eye itself and its edges, the other works better behind the eye. Because we can use both lasers, the highest safety and effectiveness can be offered.

Only at the OMC-Amstelland in Diemen floater laser treatment is offered in such a high quality standard. The combination of experience, dedication and equipment makes us the best in Europe. Worldwide, there is only one clinic that is comparable, which is Dr. Geller’s clinic in Florida.

Most of our patients are very satisfied with the results of their floater laser treatment. In some cases we were unable to relieve patients from their floaters. We always do our best to predict the succes rate of a treatment. Generally speaking, this turns out to be quite accurate.