Indications for vitrectomy for symptomatic vitreous opacities include:
Vitreous floaters occur commonly. Fortunately, the majority of vitreous floaters do not impact vision enough to affect patient quality of life. However, some individuals experience degradation in contrast sensitivity function and experience vision-degrading myodesopsia. A study by Rostami et al showed that vitrectomy for visually significant floaters improved best corrected visual acuity, contrast sensitivity, and patient quality of life. Furthermore, vitrectomy surgery is highly cost-effective from a health-economics perspective.
It is important to manage expectations when counseling a patient who desires surgery for floaters. Since most patients with visually symptomatic floaters have excellent objectively measured visual acuity, the risks of vitrectomy surgery, including acceleration of cataract, post-operative vitreous hemorrhage, retinal tear and or retinal detachment, and endophthalmitis should be carefully explained to the patient. Often, patients complain of bothersome floaters while performing near tasks or in bright illumination environments in which the contrast for the vitreous opacity is greatest. Such patients with mild symptoms can be persuaded to learn to adapt with tips on better lighting conditions to reduce scattering of incident light by clumps of vitreous opacities. Some patients complain of severe floaters but if the clinical exam fails to confirm their presence, the option for surgery may be discussed. Patients who benefit from vitrectomy generally have significant debris in the vitreous cavity over the posterior pole that move in and out of vision with saccades, rather than a single smudge / floater in their vision. Patients with multifocal lenses may be more symptomatic. Those who find that their activities of daily living (e.g. driving) are impaired by the floaters will benefit the most from surgery.
Vitrectomy for symptomatic floaters is ideally reserved for pseudophakic patients with pre-existing posterior vitreous detachment; however, the patient population primarily presenting with myodesopsia may not match these requirements (Figure 18.1.2). Presence of extensive peripheral pathology or lattice degeneration is a relative contraindication given a higher risk of retinal breaks. A small gauge pars plana vitrectomy set up is preferred to minimize morbidity from the procedure.
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