LFR: Does Technology Define When a Condition is Worth Treating?

1 August 2017  /  Dr. Paul I. Singh

“Does Technology Define When a Condition is Worth Treating?”

Historically, as a profession, we have created the perception that vitreous floaters (opacities) are a mere annoyance to our patients.  A condition that, although many people complain of, does not cause a significant enough impact on quality of life and daily functioning to warrant treatment. Why is that? Why is it considered just an annoyance when patients often complain of difficulty driving, reading, or even working on a computer? Is it because it’s part of the normal aging process? Is it because it is such a prevalent condition? Or, could it be because there were not safe and effective treatment options available in the past?  Now, with new YAG laser advancements in both visualization and energy delivery, this perception is starting to change.  To better understand this new paradigm shift, we can turn to historical changes we have seen in other conditions in the eye, such as cataract and dry eye.

For instance, our view of cataracts, and the decision to pursue a surgical option, has changed.  Years ago, we would often tell patients to just “live with it”, suggestingthe cataract was not “ripe enough” to warrant surgery.  Sound familiar? Many of our patients, with less dense cataracts who would have difficulty driving or reading, would be told the cataracts were not dense enough to warrant surgery.  The reason for that approach was because the procedure carried a fairly high adverse event profile, thereby prohibiting surgery on patients with mild or moderate symptoms.  With improvements in phacoemulsification and IOLs  the adverse event profile and postoperative recovery also improved, changing our decision to pursue cataract surgery also changed.  Our definition of a “clinically significant cataract” changed to include less dense cataracts – as long as they had a negative impact on patient’s daily functioning. And daily functioning did not have to be complete loss of activities; even a slight impact was “worth treating” since the risk/benefit profile had improved so much.

The same can be said for ocular surface disease. Before we had the diagnostic and therapeutic options that we have today, many ophthalmologists would ignore the issue of dry eye and recommend OTC tears and tell the patient to “deal with it.”  But with industry involvement and advancing technology, there has been renewed interest in this condition.  We now have a better appreciation of the impact OSD has on patient quality of life. Now, there are OSD-specific questionnaires and ITF guidelines for treatment and follow up.  We appreciate OSD pre- and post-cataract surgery because of the impact on patient satisfaction around cataract surgery and premium lenses.

Brining it back to vitreous floaters: previous studies on the treatment of floaters with YAG lasers were conducted with technology not specifically designed for work in the vitreous.  Difficulty visualizing the floater in the vitreous, and lack of spatial context with the retina, inhibited the ability to treat many of the symptomatic floaters and often led to poor outcomes.  This, in turn, created the perception that nothing could be done for these patients and eventually led to the notion that floaters were not worth treating.  In fact, as a profession, we trained ourselves, and our patients, to ignore floater  symptoms. With coaxial illumination and increased efficiency of YAG laser energy delivery, we are now able to better visualize symptomatic floaters in the middle and posterior vitreous and thereby treat floaters we would historically ignored. Recent studies using this new technology have demonstrated that laser floater treatment is a now a safe and effective option (Shah,C;  Jama Online July 2017).   The Shah study, as well as a retrospective paper we presented at ASCRS 2017 of over 1200 procedures, revealed a low adverse event rate and profile with high patient satisfaction.

After treating thousands of symptomatic floater patients, I have appreciated the true impact floaters have on our patients’ daily functioning. With the improvements in  safety and efficacy afforded by new technology advancements, , the definition of “clinically significant floater” has also changed.  Now, many surgeons no longer view vitreous floaters as just an annoyance, but a condition that is worth treating.