LFT Blog by Dr. Paul I. Singh

16 July 2018

When is a condition 'Bad Enough to Treat?'

In medicine, our decision to treat or not to treat a condition has been based on the risk-benefit ratio associated with the treatment. Basically, the higher the risk, the worse the symptoms usually have to be before the surgeon and patient are willing to perform the surgery. As technology has advanced, the risk associated with many procedures has generally decreased, subsequently leading to surgeons and patients opting to perform the procedure much earlier in the disease process.

For instance, the old paradigm of cataract surgery has changed. A cataract does not have to become 'ripe' before it can be removed. In the past, the lens was not extracted safely from the eye unless it was at a relatively advanced stage of development. This was due to the higher risk involved with the surgery, and the older technique often required a denser cataract to remove the lens. With modern advances in cataract surgery, there is a benefit to removing the cataract lens earlier in its development, since the less dense the cataract, the less energy needed to remove it, and quicker the recovery. With this new change in paradigm, our definition of 'clinically significant cataract' has also changed. For instance, if the vision is still fairly 'good' on the office chart, but the patient has a difficult time driving at night due to glare from the cataract, many surgeons will define this as a cataract worth removing. Patients now do not have to suffer quite as much or as long before warranting surgery. Advances in glaucoma procedures, and more specifically the advent of minimally invasive glaucoma surgery (MIGS), has also changed paradigms by allowing patients to decrease, or even eliminate, the need for glaucoma medication by lowering the IOP with lower risk than traditional glaucoma surgery. This in turn, has allowed doctors to offer glaucoma surgery earlier in the disease process and has also redefined the need for 'traditional' surgery. Now, quality of life has become a large part of the definition of 'uncontrolled glaucoma.'

Historically, the treatment of vitreous floaters was a surgery known asvitrectomy. This procedure works very well to eliminate the symptoms, but there are significant risks involved with the procedure, such as cataract formation and retinal detachment.  Vitrectomy surgery removes the vitreous gel and replaces it with a saline-type solution.  There is a post-operative healing time, during which patients may be off of work for a few days to weeks and may be on eye drops for a few weeks to months. For many surgeons and patients, the overall risk and cost from the surgery is greater than the issues caused by the floater. Therefore, the definition of clinically significant vitreous floater (CSVO) usually includes a severe limitation to daily activities and is often caused by multiple larger floaters. Now, with advances in laser technology, the adverse event profile is more favorable with laser floater treatment and does not often require post-operative time off of work and usually no additional eye drops are needed. Due to this less invasive approach, the definition of CSVO has also changed.  With modern laser floater treatment, patient symptomology does not have be as severe as that for a vitrectomy. Smaller floaters, such as Weiss rings and other types of floaters (amorphous clouds and strings), that were often thought of as not clinically significant to warrant surgery in the past, are now treated with this new laser floater procedure.

 “With modern laser floater treatment, patient symptomology does not have be as severe as that for a vitrectomy.”

It is important to note; laser floater treatment is not intended to replace or complete with vitrectomy.  The patient who often undergoes the laser option has been told they are not good candidates for a vitrectomy.  This can be the case if the patient has their natural lens, has a smaller type floater, or may have one large opacity not worth the risk of the vitrectomy. This is similar to the glaucoma patient.  A mild to moderate glaucoma patient is not likely a good candidate for a traditional trabeculectomy surgery but is likely a good candidate for SLT or MIGS procedure due to less invasive nature of these latter procedures. They all have their place in our treatment paradigm. *We will discuss this topic in more detail in our next blog.

 “… laser floater treatment is not intended to replace or compete with vitrectomy.”

In the past, surgeons like me would often tell their patients: “Floaters are usually just a nuisance. Floaters become less noticeable or more tolerable over time and can even disappear entirely. You need to just live with it.” We would tell patients to ignore floaters because we felt the vitrectomy option was not worth the risk. This caused us to undermine and often overlook the impact floaters have on patient’s quality of life.  Now, when I merely ask a patient, even with even a simple Weiss ring, I am amazed as to how many people describe the presence of floaters to be debilitating to the point of interfering with vision and daily functioning. In my practice, this is the key to defining CSVO. So, now with safer, more advanced laser treatment options, a floater can be considered 'bad enough' and to thereby warrant treatment when it interferes with a patient’s daily life, regardless of the number or size of the floater.

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