Zarys ogólny

Chociaż często męty łatwo jest zbagatelizować jako częsty symptom zwyrodnienia ciała szklistego, to niekorzystny wpływ, jaki mogą wywierać na jakość życia pacjenta jest niekiedy na tyle poważny, że należy zastosować terapię. Pomimo stosunkowo dobrej ostrości widzenia (BVA), pacjenci cierpiący z powodu mętów mogą doświadczać pogorszenia się jakości ich życia związanego ze zdrowiem. W oparciu o badanie 311 pacjentów ambulatoryjnych Wagle i wsp. informuje, że męty mają taki sam negatywny wpływ na jakość życia jak związane z wiekiem zwyrodnienie plamki żółtej.
(Wagle AM, Lim WY, Yap TP, et al. Utility values associated with vitreous floaters. Am J Ophthalmol. 2011;152(1):60-65.)

W porównaniu z wcześniejszym klinicznym wykorzystaniem w latach 80tych XX wieku, nowoczesne laserowe usuwanie mętów zapewnia skuteczniejsze i bezpieczniejsze wykorzystanie energii oferując wiarygodne i powtarzalne wyniki, przy niskim odsetku powikłań i wysokim poziomie zadowolenia pacjenta.

Ostatnie innowacje w dziedzinie laserowego usuwania mętów obejmują stopniowe oświetlenie koaksjalne (Titratable Coaxial Illumination – TCI). Platforma laserowa Technologii Reflex firmy Ellex umożliwia uzyskanie zbieżności pola widzenia, oświetlenia lapmy oraz wiązki laserowej na tej samej osi oraz płaszczyźnie optycznej. Pozwala to na ogniskowanie współosiowe, zwiększając głębie osteości oraz obrazowanie struktur przeszczennych. Ponadto wykorzytanie oświetlenia koaksjalnego poprawia wizualizację usuwanych zmętnień poprzez zastosowanie czerwonego Reflexu dna oka jako kontrastu.

Z kolei tradycyjne lasery YAG sprawiają, że oświetenie i wiązka lasera padają z niskiej, niekoaksjalnej pozycji o większych strefach zbieżności, co sprawia, że nacelowanie na męty oraz ich usuwanie jest ogromnie trudne. Tradycyjne lasery YAG wymagają również zastosowania wysokich poziomów energii, co rodzi poważne ryzyko uszkodzenia otaczającej tkanki oka oraz wystąpienia skutków ubocznych, takich jak zaćma czy gwałtowny wzrost ciśnienia wewnątrzgałkowego.

„Nowoczesne laserowe usuwanie mętów to inny zabieg. Nie jest to już ta sama procedura co w przeszłości. Wcześniejsze próby usuwania mętów nie zawsze były udane, gdyż technologia nie była zoptymalizowana dla tego zabiegu.”
Dr Karl Brasse, MD, MRCOphth (Niemcy)

Treatment Guidelines

Clinical studies have shown Laser Floater Removal to be an effective treatment approach for vitreous strands and opacities. It also offers a high degree of patient satisfaction. When performed with a YAG laser designed specifically for use in the posterior segment, reported side effects and complications associated are rare. As an added benefit, if Laser Floater Removal is not effective, or if the floaters return, surgical intervention is still an option.

John Karickhoff, MD, USA has performed the procedure more than 5,000 times and reports a success rate of 90%. In a Dutch study by Cees van der Windt, MD, and colleagues, 100 eyes with PVD-related floaters persisting for more than nine months were treated with laser floater removal (n=65) or pars plana vitrectomy (n=35). After all eyes were treated, both the YAG and vitrectomy groups reported an improvement in vision at 80% and 90% respectively. Furthermore, over a follow-up period of eight years, no complications were observed among patients treated with laser floater removal. These findings echo those of two small-scale studies carried out by Tsai, et al, and Toczolowski, et al, in the 1990s. In both studies, a near 100% rate of floater removal was achieved with laser floater removal and no intra- or post-operative complications occurred in any patient.

Despite these advantages, Laser Floater Removal is generally not taught, nor endorsed, by medical schools. This is due, in part, to the belief that floaters are benign and do not require treatment. Indeed, many ophthalmologists consider floater treatment to be unnecessary. Furthermore, the technical constraints of conventional YAG laser technology, which offers a limited view of the vitreous, can make it difficult to visualize the vitreous strands and opacities and to perform the procedure. These conventional YAG lasers also require the use of high levels of energy, which poses a significant risk of damage to surrounding ocular tissue, as well as of side effects such as cataract and intraocular pressure (IOP) spike. As a result, Laser Floater Removal is not widely practiced and is performed only by a small number of specialists.

The following guidelines have been provided to help ophthalmologists new to Laser Floater Removal better understand the procedure and are provided for information purposes only. It is the operating physician’s responsibility to familiarize themselves with the latest recommended techniques.

  • Laser Floater Removal is well suited to the Weiss-ring type of vitreous strand/opacity caused by a PVD. Because these vitreous strands/opacities are fibrous, they absorb the laser energy well and can be vaporized more efficiently. In addition, they are usually located safely away from the crystalline lens and the retina.
  • Do not attempt to treat the diffuse, cloud-like syneresis type of vitreous strand/opacity, which is much more difficult to visualize and to treat effectively. Treatment of these strands/opacities should be undertaken only once sufficient experience with Laser Floater Removal has been gained.
  • Because the laser energy used in Laser Floater Removal has to pass through more optical media than during capsulotomy treatment, more energy will typically be required to perform the procedure as compared to standard YAG laser procedures. Regardless, always start with a lower level of energy and titrate upwards until there is adequate optical breakdown and vaporization of the vitreous collagen.
  • Commence treatment with a single pulse per shot. Set energy at the minimum level required to create the optical breakdown in the vitreous cavity (typically 3-4 mJ). Most treatments can be performed at approx. 5 mJ per shot. It is not uncommon, however, for surgeons to use higher energy levels of approx. 8-10 mJ. It is important to note that you should titrate the power up, however, rather than starting at the higher energy levels.
  • More energy will be required if the floater is located deep in the posterior vitreous. For example, the same floater may be vaporized at 4 mJ in the anterior vitreous, at 5 mJ in the mid-vitreous and 6 mJ in the posterior vitreous.
  • The number of shots required will vary depending on the type of floater to be treated. For physicians new to the technique, it is recommended to limit the number of shots per treatment session to a maximum of 300-400 shots, single pulse (Note: refer to pulse counter on laser remote display). You can always bring the patient back for a follow-up treatment session.
  • There is no limit to the maximum energy or number of shots, but most physicians limit each procedure to a maximum of 1000 shots. This is largely due to the fact that, after a significant number of shots, gas bubbles can build up and make visualization more difficult.
  • It is important to note that there is a non-linear relationship between the increased dispersion of energy in the eye and energy setting on the laser. In other words, increasing the energy from 5 mJ to 10 mJ does not double the amount of dispersed energy; instead, it represents an approx. 40% increase. This non-liner relationship is what allows for increased energy settings to be used during Laser Floater Removal.
  • It is important to maintain an adequate distance of more than 3-4mm from the lens and more than 3-4 mm from the retina. This is referred to as the “safe zone”. (Note: When starting out, consider observing a wider margin of safety and treat only in the central third of the vitreous and always avoid the direction of the macula.)
  • If the aiming beam is not clearly in focus, avoid firing. If in doubt, focus on the vitreous strand/opacity and pull back the joystick slightly: this will enable you to clearly visualize the two aiming beams before refocusing them to one spot.
  • When the system is in on-axis mode, the red glow of the fundus can make it difficult to visualize the aiming beams. If you are confident that you are not near any structures i.e. retina is not in focus, it is ok to fire on the floater after you have gained more experience. You can also place the system in off-axis mode to reduce the amount of the red glow to allow for increased contrast, which can help to visualize the aiming beams and the floaters.
  • The vitreous strand/opacity may be seen to move or become mobile during Laser Floater Removal due to the shock wave introduced with each shot fired. When firing directly at a mobile floater, always wait for it to settle into position before continuing with treatment. This avoids unnecessary energy delivery into the eye.
  • In the presence of multiple floaters, commence treatment anteriorly and proceed inwards. This will enable you to first remove those vitreous floaters that may impede your vision of the posterior structures. Likewise, try and treat from the top down as gas bubbles may impede vision of higher floaters if the lower ones are treated first. Although, it is important to treat the floaters that are easiest to see first.
  • If the floater is over the macula and the retina is also in focus, do not fire. If you are not sure of the distance between the floater and retina, move the eye up and down to try and move the floater to a different position.
  • Moving the eye up and down, or left and right, can also be a very useful tool to help move hard to reach floaters into a more easily treatable position. If the floater is too far in the periphery of the contact lens, the laser energy will not achieve the necessary therapeutic effect.
  • Singh MidVitreous Lens (Volk)
  • Ocular Karickhoff 21mm Vitreous Lens (Ocular Instruments)
  • Ocular Karickhoff Off-Axis Vitreous Lens (Ocular Instruments)
  • Ocular Peyman Wide Gield YAG Laser Lens (Ocular Instruments)
  • CGVL Vitrectomy Contact Lens (Haag Streit)
  • CGPL Capsulotmy Contact Lens (Haag Streit)

Resource Center

The Clinical Impact of Floaters

Paul Inder Singh (USA)

In this whitepaper, laser floater removal expert Paul Inder Singh, MD (USA) addresses the significant negative impact caused by floaters on quality of life. Indeed, whether patients with symptomatic floaters should be offered treatment or told to “carry on regardless” continues to be debated. One thing is for certain, however; more patients are complaining of floaters and the impact they have on their quality of life.

Assimilating Laser Vitreolysis into Daily Practice

Paul Inder Singh (USA)

In this whitepaper, Dr. Singh addresses the positive impact laser vitreolysis has had on his practice – and his patients.

“Having performed nearly 400 procedures with the Ultra Q Reflex, I now realize the impact floaters have on patients’ daily life. We have become accustomed to just ignoring these complaints, but now, with this laser, we finally can take care of these patients.”

Expanding Possibilities: Treating Floaters with Laser Vitreolysis

Allan J. Whitehead, MD (USA) and Peter Lagouros, MD (USA)

In this whitepaper, Dr. Whitehead and Dr. Lagouros share their experiences of laser vitreolysis using the Ultra Q Reflex™ laser. Whilst vitrectomy has been commonly considered the gold standard for the treatment of debilitating floater symptoms, the significant risk of complications means that it may not be a suitable solution for all patients. Under such circumstances, minimally invasive laser vitreolysis provide a viable option to eliminate the visual disturbances caused by floaters.

Laser Floater Removal Treatment Guidelines

More energy is typically required to perform laser floater removal compared to capsulotomy. This is because the laser energy has to pass through more optical media. It is always recommended to start with a low level of energy and titrate up until there is adequate vaporization and optical breakdown of the vitreous collagen, however. Read the Laser Floater Removal Treatment Guidelines for more information.

Note: The Laser Floater Removal Treatment Guidelines are provided for information purposes only. It is the operating physician’s responsibility to familiarize themselves with the latest recommended techniques.

Tango Reflex Product Brochure

The new Tango Reflex™ from Ellex combines multiple treatment platforms — SLT for glaucoma, laser vitreolysis for floaters, and capsulotomy and iridotomy treatments – in a single laser system.

Ultra Q Reflex Product Brochure

Whether you are performing anterior or posterior capsulotomy with new generation IOLs, peripheral iridotomy for glaucoma or YAG laser vitreolysis for the treatment of vitreous strands and opacities, Ultra Q™ with Reflex Technology™ delivers higher accuracy and greater control.

Laser Vitreolysis E-Book

The Laser Vitreolysis E-Book brings together the industry’s leading Laser Vitreolysis surgeons to provide clinical and practical insight.

AAO 2016
Modern Laser Floater Removal

Paul I. Singh, MD
Eye Centers of Racine and Kenosha, USA

Watch a recording of Dr. Paul Singh’s Laser Floater Removal (LFR) presentation from the American Academy of Ophthalmology (AAO) 2016, in which he addresses his treatment pearls and clinical tips for LFR in the treatment of symptomatic floater patients. Dr. Singh also highlights titratable axis illumination and coaxial visualization, and how these new technologies have improved the safety profile and efficacy of LFR.

AAO 2016
Floaters. To Treat or not to Treat?

Paul I. Singh, MD
Eye Centers of Racine and Kenosha, USA

Dr. Paul I. Singh was one of the first adopters or modern Laser FLoater Removal (LFR) and has performed more than 1500 procedures to date. In this webinar, he discusses how advanced screening technologies such as the iTrace™ Wavefront Aberrometer and Corneal Topographer (Tracey Technologies LLC), allows him to objectively measure the improvement in quality of vision in his patients following LFR. Specifically, the iTrace™ provides a breakdown of the contribution between corneal and internal aberrations, including the lens, the posterior cornea, macula and the vitreous.

AAO 2016
Modern Laser Floater Removal

Karl G. Stonecipher, MD
TLC Greensboro, USA

A refractive surgeon, Dr. Karl Stonecipher addresses the role of Laser Floater Removal (LFR) in his daily clinical practice. He also discusses how the innovation of technologies such as titratable axis illumination allows you to toggle between on- and off axis modes in order to better visualize floaters – and to assess their position relative to the lens and/or retina.

A Paradigm Shift in the Management of Symptomatic Floaters

Paul I. Singh, MD
Eye Centers of Racine and Kenosha, USA

Having performed more than 250 YAG Laser Vitreolysis procedures, Dr. Paul Singh reports a success rate of more than 90%, combined with a high safety profile. Watch the webinar to learn more.

EURETINA/ESCRS 2014
YAG laser Viterolysis:
A Safe and Effective Alternative to Vitrectomy?

Marc Veckeneer, MD
Rotterdam Eye Hospital, Rotterdam, Netherlands

EURETINA/ESCRS 2014
YAG Laser Vitreolysis:
Membranotomy in Patients With Multifocal IOLs

Cees van der Windt, MD
Ziekenhuis Rivierenland, Tiel, Netherlands

AAO 2013
Vitreolysis Vs. Vitrectomy

Paul I. Singh, MD
Eye Centers of Racine and Kenosha, USA

Vitrectomy is a highly effective treatment for the removal of vitreous strands and opactiies but also carries significant risks, including cataract. Vitreolysis is a simple, outpatient-based alternative, which vaporizes the vitreous strands and opacities and may delay or obviate the need for surgery.

AAO 2013
Vitreolysis: the Challenges and the Rewards

Paul I. Singh, MD
Eye Centers of Racine and Kenosha, USA

Vitreolysis is an outpatient-based procedure, which involves the use of a specially designed YAG laser to vaporize the vitreous strands and opacities. Highly effective, it has a low complication rate and offers a high degree of patient satisfaction. It can also delay or obviate the need for surgery.

AAO 2012
YAG Laser Treatment of Vitreous Floaters: My Five Year Experience

James H. Johnson, MD

James H. Johnson, Medical Director of Vitreous Floater Solutions, Irvine, is considered an expert in the treatment of floaters. At the 2012 annual meeting of the American Academy of Ophthalmology, Dr. Johnson addressed AAO delegates regarding the latest advancements in Nd:YAG laser-based floater treatment.

Physician Stories

LFR: An Objective Evaluation of Improvement in
Quality of Vision
Paul I. Singh, MD
The Eye Centers of Racine and Kenosha, USA

Having performed more than 1500 LFR procedures, Dr. Paul Singh consistently reports a positive response from his patients in regards to the improved quality of vision afforded by the procedure. With the advent of screening technologies such as the iTrace wavefront aberrometer, he can now objectively assess his patients’ improvement in quality of vision following treatment with LFR.

“We’ve known for over four years how much of a difference LFR has made to patients’ quality of vision, based upon subjective questioning. But what we wanted was an objective evaluation. Using the iTrace we can now truly understand the positive impact of LFR on internal quality of vision.”

Laser Floater Removal
Paul I. Singh, MD
The Eye Centers of Racine and Kenosha, USA

In this video interview, Paul Inder Singh addresses the clinical impact of floaters and the success of laser floater removal in his practice.

“I have been privy first-hand to the changes in how our profession perceives laser vitreolysis. On one hand, the poor historical data and the fact that many consider laser vitreolysis beyond their comfort zone (because it does not follow traditional conventions and is not taught in medical schools and residency programs), has led to initial pushback. On the other hand, patients and ophthalmologists are becoming increasingly aware of this procedure and the new technology, which is triggering growing acceptance of the potential benefits of laser vitreolysis. Although it is still considered novel and “outside-of-the-box” to apply a different use to something as familiar as a YAG laser, doctors are now beginning to grasp the potential benefits of using different energy profiles and visualization systems to make treatment of floaters possible.”

Vitreolysis. Redefining Convention
Paul I. Singh, MD
The Eye Centers of Racine and Kenosha, USA

Clinical studies have shown vitreolysis to be an effective treatment approach for vitreous strands and opacities. It also offers a high degree of patient satisfaction. In this video interview, Paul Singh, MD, of The Eye Centers of Racine and Kenosha, Wisconsin, discusses the fundamentals of vitreolysis in the management of floaters.

Laser Floater Removal
Paul I. Singh, MD
The Eye Centers of Racine and Kenosha, USA

In this video interview, Paul Inder Singh addresses the clinical impact of floaters and the success of laser floater removal in his practice.

“I have been privy first-hand to the changes in how our profession perceives laser vitreolysis. On one hand, the poor historical data and the fact that many consider laser vitreolysis beyond their comfort zone (because it does not follow traditional conventions and is not taught in medical schools and residency programs), has led to initial pushback. On the other hand, patients and ophthalmologists are becoming increasingly aware of this procedure and the new technology, which is triggering growing acceptance of the potential benefits of laser vitreolysis. Although it is still considered novel and “outside-of-the-box” to apply a different use to something as familiar as a YAG laser, doctors are now beginning to grasp the potential benefits of using different energy profiles and visualization systems to make treatment of floaters possible.”

Vitreolysis in the Spotlight
Paul I. Singh, MD
The Eye Centers of Racine and Kenosha, USA

In this video interview, Dr. Paul Singh of The Eye Centres of Racine and Kenosha, Wisconsin, shares his pearls for success with vitreolysis. Drawing on his experience with the Ultra Q Reflex™ multi-modality laser, he addresses a number of topics ranging from patient selection to treatment protocol, including recommended laser lenses and energy settings.

Laser Vitreolysis for the Refractive Surgeon
Karl G. Stonecipher, MD
TLC Greensboro, USA

In this video interview, refractive specialist Karl G. Stonecipher, MD (Clinical Associate Professor of Ophthalmology at the University of North Carolina, and Medical Director of TLC Laser Eye Centers in Greensboro, North Carolina) addresses his decision to incorporate laser floater removal into clinical practice.

“For many if not most of my refractive surgery colleagues, the idea of treating floaters with a YAG laser was taboo. They felt it was crossing a line, that these were healthy eyes that did not require surgical intervention, and that the risks outweighed any potential benefits. I understood and even shared some of their skepticism, but I really felt that we owed it to our patients to offer them something more than just a sympathetic ear when they explained the negative impact of floaters on their quality of life.”

Modern Laser Vitreolysis
Karl Brasse, MD MRCOphth (Germany)

Compared with its early clinical use in the 1980s, modern laser vitreolysis provides more efficient and safer energy profiles, offering reliable and repeatable outcomes that provide a low rate of complications combined with a high degree of patient satisfaction. In this interview, Dr. Karl Brasse addresses his experience to date using the Ultra Q Reflex laser in the treatment of symptomatic floater patients.

“Karickhoff, one of the original pioneers of laser vitreolysis, in my opinion, may have advocated the procedure before its time; the technological capabilities were not as superior as they are today. I strongly believe that the success I have encountered with laser vitreolysis is due to the system that I use.”

Reflex Technology™

Traditional YAG lasers typically have larger and less-controlled plasma with more inconsistent power output and were equipped for capsulotomy and iridotomy procedures only. Since it can be difficult to focus on small structures — such as vitreous strands — when using these systems, collateral ocular tissue damage may occur.

Indeed, previous attempts at laser floater removal were not successful for a number of reasons, including:

  • Lack of visualization
  • Energy settings too low
  • Number of shots not enough
  • Inefficient energy beam
  • In contrast, Reflex Technology™ from Ellex features an ultra-Gaussian beam mode, teamed with a fast-pulse rise time and a small-spot size: with a higher-power density and tightly controlled plasma, fewer shots are required to perform procedures with less cumulative energy delivered to the patient.

    Furthermore, Reflex Technology™ incorporates a proprietary slit lamp illumination tower design, which converges the operator’s vision, the target illumination, and the treatment beam along the same optical path and onto the same optical plane. The illumination tower can be used coaxially to enhance the view of the target opacity and more effectively vaporize it.

    In short, Reflex Technology™ minimizes the potential for focusing errors and reduces the risk of damage to the natural lens or the retina.

    ON AXIS

  • Gives you great visualization of the middle and posterior vitreous
  • Allows for spatial context – especially near the retina
  • Red Reflex helps with contrast for certain floaters
  • Hard to see anterior floaters well…
  • OFF AXIS

  • Can’t see floaters behind anterior vitreous
  • Beneficial for visualizing anterior floaters
  • Lose red reflex which allows for floaters to appear “white”
  • Helps with defining posterior capsule
  • Decreases glare in some situations
  • + Overview

    Zarys ogólny

    Chociaż często męty łatwo jest zbagatelizować jako częsty symptom zwyrodnienia ciała szklistego, to niekorzystny wpływ, jaki mogą wywierać na jakość życia pacjenta jest niekiedy na tyle poważny, że należy zastosować terapię. Pomimo stosunkowo dobrej ostrości widzenia (BVA), pacjenci cierpiący z powodu mętów mogą doświadczać pogorszenia się jakości ich życia związanego ze zdrowiem. W oparciu o badanie 311 pacjentów ambulatoryjnych Wagle i wsp. informuje, że męty mają taki sam negatywny wpływ na jakość życia jak związane z wiekiem zwyrodnienie plamki żółtej.
    (Wagle AM, Lim WY, Yap TP, et al. Utility values associated with vitreous floaters. Am J Ophthalmol. 2011;152(1):60-65.)

    W porównaniu z wcześniejszym klinicznym wykorzystaniem w latach 80tych XX wieku, nowoczesne laserowe usuwanie mętów zapewnia skuteczniejsze i bezpieczniejsze wykorzystanie energii oferując wiarygodne i powtarzalne wyniki, przy niskim odsetku powikłań i wysokim poziomie zadowolenia pacjenta.

    Ostatnie innowacje w dziedzinie laserowego usuwania mętów obejmują stopniowe oświetlenie koaksjalne (Titratable Coaxial Illumination – TCI). Platforma laserowa Technologii Reflex firmy Ellex umożliwia uzyskanie zbieżności pola widzenia, oświetlenia lapmy oraz wiązki laserowej na tej samej osi oraz płaszczyźnie optycznej. Pozwala to na ogniskowanie współosiowe, zwiększając głębie osteości oraz obrazowanie struktur przeszczennych. Ponadto wykorzytanie oświetlenia koaksjalnego poprawia wizualizację usuwanych zmętnień poprzez zastosowanie czerwonego Reflexu dna oka jako kontrastu.

    Z kolei tradycyjne lasery YAG sprawiają, że oświetenie i wiązka lasera padają z niskiej, niekoaksjalnej pozycji o większych strefach zbieżności, co sprawia, że nacelowanie na męty oraz ich usuwanie jest ogromnie trudne. Tradycyjne lasery YAG wymagają również zastosowania wysokich poziomów energii, co rodzi poważne ryzyko uszkodzenia otaczającej tkanki oka oraz wystąpienia skutków ubocznych, takich jak zaćma czy gwałtowny wzrost ciśnienia wewnątrzgałkowego.

    „Nowoczesne laserowe usuwanie mętów to inny zabieg. Nie jest to już ta sama procedura co w przeszłości. Wcześniejsze próby usuwania mętów nie zawsze były udane, gdyż technologia nie była zoptymalizowana dla tego zabiegu.”
    Dr Karl Brasse, MD, MRCOphth (Niemcy)

    + Treatment Guidelines

    Treatment Guidelines

    Clinical studies have shown Laser Floater Removal to be an effective treatment approach for vitreous strands and opacities. It also offers a high degree of patient satisfaction. When performed with a YAG laser designed specifically for use in the posterior segment, reported side effects and complications associated are rare. As an added benefit, if Laser Floater Removal is not effective, or if the floaters return, surgical intervention is still an option.

    John Karickhoff, MD, USA has performed the procedure more than 5,000 times and reports a success rate of 90%. In a Dutch study by Cees van der Windt, MD, and colleagues, 100 eyes with PVD-related floaters persisting for more than nine months were treated with laser floater removal (n=65) or pars plana vitrectomy (n=35). After all eyes were treated, both the YAG and vitrectomy groups reported an improvement in vision at 80% and 90% respectively. Furthermore, over a follow-up period of eight years, no complications were observed among patients treated with laser floater removal. These findings echo those of two small-scale studies carried out by Tsai, et al, and Toczolowski, et al, in the 1990s. In both studies, a near 100% rate of floater removal was achieved with laser floater removal and no intra- or post-operative complications occurred in any patient.

    Despite these advantages, Laser Floater Removal is generally not taught, nor endorsed, by medical schools. This is due, in part, to the belief that floaters are benign and do not require treatment. Indeed, many ophthalmologists consider floater treatment to be unnecessary. Furthermore, the technical constraints of conventional YAG laser technology, which offers a limited view of the vitreous, can make it difficult to visualize the vitreous strands and opacities and to perform the procedure. These conventional YAG lasers also require the use of high levels of energy, which poses a significant risk of damage to surrounding ocular tissue, as well as of side effects such as cataract and intraocular pressure (IOP) spike. As a result, Laser Floater Removal is not widely practiced and is performed only by a small number of specialists.

    The following guidelines have been provided to help ophthalmologists new to Laser Floater Removal better understand the procedure and are provided for information purposes only. It is the operating physician’s responsibility to familiarize themselves with the latest recommended techniques.

    • Laser Floater Removal is well suited to the Weiss-ring type of vitreous strand/opacity caused by a PVD. Because these vitreous strands/opacities are fibrous, they absorb the laser energy well and can be vaporized more efficiently. In addition, they are usually located safely away from the crystalline lens and the retina.
    • Do not attempt to treat the diffuse, cloud-like syneresis type of vitreous strand/opacity, which is much more difficult to visualize and to treat effectively. Treatment of these strands/opacities should be undertaken only once sufficient experience with Laser Floater Removal has been gained.
    • Because the laser energy used in Laser Floater Removal has to pass through more optical media than during capsulotomy treatment, more energy will typically be required to perform the procedure as compared to standard YAG laser procedures. Regardless, always start with a lower level of energy and titrate upwards until there is adequate optical breakdown and vaporization of the vitreous collagen.
    • Commence treatment with a single pulse per shot. Set energy at the minimum level required to create the optical breakdown in the vitreous cavity (typically 3-4 mJ). Most treatments can be performed at approx. 5 mJ per shot. It is not uncommon, however, for surgeons to use higher energy levels of approx. 8-10 mJ. It is important to note that you should titrate the power up, however, rather than starting at the higher energy levels.
    • More energy will be required if the floater is located deep in the posterior vitreous. For example, the same floater may be vaporized at 4 mJ in the anterior vitreous, at 5 mJ in the mid-vitreous and 6 mJ in the posterior vitreous.
    • The number of shots required will vary depending on the type of floater to be treated. For physicians new to the technique, it is recommended to limit the number of shots per treatment session to a maximum of 300-400 shots, single pulse (Note: refer to pulse counter on laser remote display). You can always bring the patient back for a follow-up treatment session.
    • There is no limit to the maximum energy or number of shots, but most physicians limit each procedure to a maximum of 1000 shots. This is largely due to the fact that, after a significant number of shots, gas bubbles can build up and make visualization more difficult.
    • It is important to note that there is a non-linear relationship between the increased dispersion of energy in the eye and energy setting on the laser. In other words, increasing the energy from 5 mJ to 10 mJ does not double the amount of dispersed energy; instead, it represents an approx. 40% increase. This non-liner relationship is what allows for increased energy settings to be used during Laser Floater Removal.
    • It is important to maintain an adequate distance of more than 3-4mm from the lens and more than 3-4 mm from the retina. This is referred to as the “safe zone”. (Note: When starting out, consider observing a wider margin of safety and treat only in the central third of the vitreous and always avoid the direction of the macula.)
    • If the aiming beam is not clearly in focus, avoid firing. If in doubt, focus on the vitreous strand/opacity and pull back the joystick slightly: this will enable you to clearly visualize the two aiming beams before refocusing them to one spot.
    • When the system is in on-axis mode, the red glow of the fundus can make it difficult to visualize the aiming beams. If you are confident that you are not near any structures i.e. retina is not in focus, it is ok to fire on the floater after you have gained more experience. You can also place the system in off-axis mode to reduce the amount of the red glow to allow for increased contrast, which can help to visualize the aiming beams and the floaters.
    • The vitreous strand/opacity may be seen to move or become mobile during Laser Floater Removal due to the shock wave introduced with each shot fired. When firing directly at a mobile floater, always wait for it to settle into position before continuing with treatment. This avoids unnecessary energy delivery into the eye.
    • In the presence of multiple floaters, commence treatment anteriorly and proceed inwards. This will enable you to first remove those vitreous floaters that may impede your vision of the posterior structures. Likewise, try and treat from the top down as gas bubbles may impede vision of higher floaters if the lower ones are treated first. Although, it is important to treat the floaters that are easiest to see first.
    • If the floater is over the macula and the retina is also in focus, do not fire. If you are not sure of the distance between the floater and retina, move the eye up and down to try and move the floater to a different position.
    • Moving the eye up and down, or left and right, can also be a very useful tool to help move hard to reach floaters into a more easily treatable position. If the floater is too far in the periphery of the contact lens, the laser energy will not achieve the necessary therapeutic effect.
    • Singh MidVitreous Lens (Volk)
    • Ocular Karickhoff 21mm Vitreous Lens (Ocular Instruments)
    • Ocular Karickhoff Off-Axis Vitreous Lens (Ocular Instruments)
    • Ocular Peyman Wide Gield YAG Laser Lens (Ocular Instruments)
    • CGVL Vitrectomy Contact Lens (Haag Streit)
    • CGPL Capsulotmy Contact Lens (Haag Streit)
    + Bibliography
    + Resource Center

    Resource Center

    The Clinical Impact of Floaters

    Paul Inder Singh (USA)

    In this whitepaper, laser floater removal expert Paul Inder Singh, MD (USA) addresses the significant negative impact caused by floaters on quality of life. Indeed, whether patients with symptomatic floaters should be offered treatment or told to “carry on regardless” continues to be debated. One thing is for certain, however; more patients are complaining of floaters and the impact they have on their quality of life.

    Assimilating Laser Vitreolysis into Daily Practice

    Paul Inder Singh (USA)

    In this whitepaper, Dr. Singh addresses the positive impact laser vitreolysis has had on his practice – and his patients.

    “Having performed nearly 400 procedures with the Ultra Q Reflex, I now realize the impact floaters have on patients’ daily life. We have become accustomed to just ignoring these complaints, but now, with this laser, we finally can take care of these patients.”

    Expanding Possibilities: Treating Floaters with Laser Vitreolysis

    Allan J. Whitehead, MD (USA) and Peter Lagouros, MD (USA)

    In this whitepaper, Dr. Whitehead and Dr. Lagouros share their experiences of laser vitreolysis using the Ultra Q Reflex™ laser. Whilst vitrectomy has been commonly considered the gold standard for the treatment of debilitating floater symptoms, the significant risk of complications means that it may not be a suitable solution for all patients. Under such circumstances, minimally invasive laser vitreolysis provide a viable option to eliminate the visual disturbances caused by floaters.

    Laser Floater Removal Treatment Guidelines

    More energy is typically required to perform laser floater removal compared to capsulotomy. This is because the laser energy has to pass through more optical media. It is always recommended to start with a low level of energy and titrate up until there is adequate vaporization and optical breakdown of the vitreous collagen, however. Read the Laser Floater Removal Treatment Guidelines for more information.

    Note: The Laser Floater Removal Treatment Guidelines are provided for information purposes only. It is the operating physician’s responsibility to familiarize themselves with the latest recommended techniques.

    Tango Reflex Product Brochure

    The new Tango Reflex™ from Ellex combines multiple treatment platforms — SLT for glaucoma, laser vitreolysis for floaters, and capsulotomy and iridotomy treatments – in a single laser system.

    Ultra Q Reflex Product Brochure

    Whether you are performing anterior or posterior capsulotomy with new generation IOLs, peripheral iridotomy for glaucoma or YAG laser vitreolysis for the treatment of vitreous strands and opacities, Ultra Q™ with Reflex Technology™ delivers higher accuracy and greater control.

    Laser Vitreolysis E-Book

    The Laser Vitreolysis E-Book brings together the industry’s leading Laser Vitreolysis surgeons to provide clinical and practical insight.

    AAO 2016
    Modern Laser Floater Removal

    Paul I. Singh, MD
    Eye Centers of Racine and Kenosha, USA

    Watch a recording of Dr. Paul Singh’s Laser Floater Removal (LFR) presentation from the American Academy of Ophthalmology (AAO) 2016, in which he addresses his treatment pearls and clinical tips for LFR in the treatment of symptomatic floater patients. Dr. Singh also highlights titratable axis illumination and coaxial visualization, and how these new technologies have improved the safety profile and efficacy of LFR.

    AAO 2016
    Floaters. To Treat or not to Treat?

    Paul I. Singh, MD
    Eye Centers of Racine and Kenosha, USA

    Dr. Paul I. Singh was one of the first adopters or modern Laser FLoater Removal (LFR) and has performed more than 1500 procedures to date. In this webinar, he discusses how advanced screening technologies such as the iTrace™ Wavefront Aberrometer and Corneal Topographer (Tracey Technologies LLC), allows him to objectively measure the improvement in quality of vision in his patients following LFR. Specifically, the iTrace™ provides a breakdown of the contribution between corneal and internal aberrations, including the lens, the posterior cornea, macula and the vitreous.

    AAO 2016
    Modern Laser Floater Removal

    Karl G. Stonecipher, MD
    TLC Greensboro, USA

    A refractive surgeon, Dr. Karl Stonecipher addresses the role of Laser Floater Removal (LFR) in his daily clinical practice. He also discusses how the innovation of technologies such as titratable axis illumination allows you to toggle between on- and off axis modes in order to better visualize floaters – and to assess their position relative to the lens and/or retina.

    A Paradigm Shift in the Management of Symptomatic Floaters

    Paul I. Singh, MD
    Eye Centers of Racine and Kenosha, USA

    Having performed more than 250 YAG Laser Vitreolysis procedures, Dr. Paul Singh reports a success rate of more than 90%, combined with a high safety profile. Watch the webinar to learn more.

    EURETINA/ESCRS 2014
    YAG laser Viterolysis:
    A Safe and Effective Alternative to Vitrectomy?

    Marc Veckeneer, MD
    Rotterdam Eye Hospital, Rotterdam, Netherlands

    EURETINA/ESCRS 2014
    YAG Laser Vitreolysis:
    Membranotomy in Patients With Multifocal IOLs

    Cees van der Windt, MD
    Ziekenhuis Rivierenland, Tiel, Netherlands

    AAO 2013
    Vitreolysis Vs. Vitrectomy

    Paul I. Singh, MD
    Eye Centers of Racine and Kenosha, USA

    Vitrectomy is a highly effective treatment for the removal of vitreous strands and opactiies but also carries significant risks, including cataract. Vitreolysis is a simple, outpatient-based alternative, which vaporizes the vitreous strands and opacities and may delay or obviate the need for surgery.

    AAO 2013
    Vitreolysis: the Challenges and the Rewards

    Paul I. Singh, MD
    Eye Centers of Racine and Kenosha, USA

    Vitreolysis is an outpatient-based procedure, which involves the use of a specially designed YAG laser to vaporize the vitreous strands and opacities. Highly effective, it has a low complication rate and offers a high degree of patient satisfaction. It can also delay or obviate the need for surgery.

    AAO 2012
    YAG Laser Treatment of Vitreous Floaters: My Five Year Experience

    James H. Johnson, MD

    James H. Johnson, Medical Director of Vitreous Floater Solutions, Irvine, is considered an expert in the treatment of floaters. At the 2012 annual meeting of the American Academy of Ophthalmology, Dr. Johnson addressed AAO delegates regarding the latest advancements in Nd:YAG laser-based floater treatment.

    + Physician Stories

    Physician Stories

    LFR: An Objective Evaluation of Improvement in
    Quality of Vision
    Paul I. Singh, MD
    The Eye Centers of Racine and Kenosha, USA

    Having performed more than 1500 LFR procedures, Dr. Paul Singh consistently reports a positive response from his patients in regards to the improved quality of vision afforded by the procedure. With the advent of screening technologies such as the iTrace wavefront aberrometer, he can now objectively assess his patients’ improvement in quality of vision following treatment with LFR.

    “We’ve known for over four years how much of a difference LFR has made to patients’ quality of vision, based upon subjective questioning. But what we wanted was an objective evaluation. Using the iTrace we can now truly understand the positive impact of LFR on internal quality of vision.”

    Laser Floater Removal
    Paul I. Singh, MD
    The Eye Centers of Racine and Kenosha, USA

    In this video interview, Paul Inder Singh addresses the clinical impact of floaters and the success of laser floater removal in his practice.

    “I have been privy first-hand to the changes in how our profession perceives laser vitreolysis. On one hand, the poor historical data and the fact that many consider laser vitreolysis beyond their comfort zone (because it does not follow traditional conventions and is not taught in medical schools and residency programs), has led to initial pushback. On the other hand, patients and ophthalmologists are becoming increasingly aware of this procedure and the new technology, which is triggering growing acceptance of the potential benefits of laser vitreolysis. Although it is still considered novel and “outside-of-the-box” to apply a different use to something as familiar as a YAG laser, doctors are now beginning to grasp the potential benefits of using different energy profiles and visualization systems to make treatment of floaters possible.”

    Vitreolysis. Redefining Convention
    Paul I. Singh, MD
    The Eye Centers of Racine and Kenosha, USA

    Clinical studies have shown vitreolysis to be an effective treatment approach for vitreous strands and opacities. It also offers a high degree of patient satisfaction. In this video interview, Paul Singh, MD, of The Eye Centers of Racine and Kenosha, Wisconsin, discusses the fundamentals of vitreolysis in the management of floaters.

    Laser Floater Removal
    Paul I. Singh, MD
    The Eye Centers of Racine and Kenosha, USA

    In this video interview, Paul Inder Singh addresses the clinical impact of floaters and the success of laser floater removal in his practice.

    “I have been privy first-hand to the changes in how our profession perceives laser vitreolysis. On one hand, the poor historical data and the fact that many consider laser vitreolysis beyond their comfort zone (because it does not follow traditional conventions and is not taught in medical schools and residency programs), has led to initial pushback. On the other hand, patients and ophthalmologists are becoming increasingly aware of this procedure and the new technology, which is triggering growing acceptance of the potential benefits of laser vitreolysis. Although it is still considered novel and “outside-of-the-box” to apply a different use to something as familiar as a YAG laser, doctors are now beginning to grasp the potential benefits of using different energy profiles and visualization systems to make treatment of floaters possible.”

    Vitreolysis in the Spotlight
    Paul I. Singh, MD
    The Eye Centers of Racine and Kenosha, USA

    In this video interview, Dr. Paul Singh of The Eye Centres of Racine and Kenosha, Wisconsin, shares his pearls for success with vitreolysis. Drawing on his experience with the Ultra Q Reflex™ multi-modality laser, he addresses a number of topics ranging from patient selection to treatment protocol, including recommended laser lenses and energy settings.

    Laser Vitreolysis for the Refractive Surgeon
    Karl G. Stonecipher, MD
    TLC Greensboro, USA

    In this video interview, refractive specialist Karl G. Stonecipher, MD (Clinical Associate Professor of Ophthalmology at the University of North Carolina, and Medical Director of TLC Laser Eye Centers in Greensboro, North Carolina) addresses his decision to incorporate laser floater removal into clinical practice.

    “For many if not most of my refractive surgery colleagues, the idea of treating floaters with a YAG laser was taboo. They felt it was crossing a line, that these were healthy eyes that did not require surgical intervention, and that the risks outweighed any potential benefits. I understood and even shared some of their skepticism, but I really felt that we owed it to our patients to offer them something more than just a sympathetic ear when they explained the negative impact of floaters on their quality of life.”

    Modern Laser Vitreolysis
    Karl Brasse, MD MRCOphth (Germany)

    Compared with its early clinical use in the 1980s, modern laser vitreolysis provides more efficient and safer energy profiles, offering reliable and repeatable outcomes that provide a low rate of complications combined with a high degree of patient satisfaction. In this interview, Dr. Karl Brasse addresses his experience to date using the Ultra Q Reflex laser in the treatment of symptomatic floater patients.

    “Karickhoff, one of the original pioneers of laser vitreolysis, in my opinion, may have advocated the procedure before its time; the technological capabilities were not as superior as they are today. I strongly believe that the success I have encountered with laser vitreolysis is due to the system that I use.”

    + Reflex Technology

    Reflex Technology™

    Traditional YAG lasers typically have larger and less-controlled plasma with more inconsistent power output and were equipped for capsulotomy and iridotomy procedures only. Since it can be difficult to focus on small structures — such as vitreous strands — when using these systems, collateral ocular tissue damage may occur.

    Indeed, previous attempts at laser floater removal were not successful for a number of reasons, including:

  • Lack of visualization
  • Energy settings too low
  • Number of shots not enough
  • Inefficient energy beam
  • In contrast, Reflex Technology™ from Ellex features an ultra-Gaussian beam mode, teamed with a fast-pulse rise time and a small-spot size: with a higher-power density and tightly controlled plasma, fewer shots are required to perform procedures with less cumulative energy delivered to the patient.

    Furthermore, Reflex Technology™ incorporates a proprietary slit lamp illumination tower design, which converges the operator’s vision, the target illumination, and the treatment beam along the same optical path and onto the same optical plane. The illumination tower can be used coaxially to enhance the view of the target opacity and more effectively vaporize it.

    In short, Reflex Technology™ minimizes the potential for focusing errors and reduces the risk of damage to the natural lens or the retina.

    ON AXIS

  • Gives you great visualization of the middle and posterior vitreous
  • Allows for spatial context – especially near the retina
  • Red Reflex helps with contrast for certain floaters
  • Hard to see anterior floaters well…
  • OFF AXIS

  • Can’t see floaters behind anterior vitreous
  • Beneficial for visualizing anterior floaters
  • Lose red reflex which allows for floaters to appear “white”
  • Helps with defining posterior capsule
  • Decreases glare in some situations