LFT Blog by Dr. Paul I. Singh

21 August 2018

Picking the Right Patient Helps the Learning Curve

When adopting a new procedure or technique, outcomes of the first few cases can shape the surgeon’s perspective of that procedure, and in turn, affect the willingness to continue performing the procedure.  Take Laser Floater Treatment (LFT) for example; although this procedure has been attempted for many years, with new technology and new protocols/techniques, LFT has been reintroduced to the world of ophthalmology over the past 1-2 years.  Because there have been changes to the YAG laser as well as technique, there is a learning curve. Also, if a surgeon picks non-ideal patients, he/she may have a difficult time performing the treatment and thus outcomes may not be as favorable. Therefore, frustration levels rise, and the excitement for the procedure starts to wain and thus the decision on efficacy has been made.  Since the YAG technology employed for LFT has changed with the introduction of Reflex Technology™, as well as technique itself, there is a learning curve. Although the learning curve of LFT is fairly quick, there are a number of skills that a new surgeon needs to learn and master in order to achieve high patient satisfaction early on, and also before attempting to treat a variety of floaters in more types of patients.

Probably the most important skill to master is visualization. Once the surgeon is able to see the floater clearly, firing at the floater is fairly straightforward. There are a number of variables that influence the ease in which a surgeon can visualize the floater; location of the floater, clarity of the cornea and lens, type of lens, and the doctor’s comfort level with the laser.  Being able to correlate the patient’s symptoms with the clinical exam is important as well. For these reasons, we recommend picking patients with solitary floaters, such as a weiss ring.  These types of floaters tend to correlate well with the patient’s symptoms and are usually picked up clearly on exam.  They tend to also be located in the middle of the vitreous, far away from retina and lens. Weiss rings do move, but often stay within a certain area of the vitreous, making them easier to find when treating a patient on a different day than the initial exam.  Patients can often describe the shape and exact location to help guide the surgeon. Based on our experience and data presented at AAO and ASCRS, we have found weiss ring type of vitreous opacities respond very well to the laser plasma and in most cases, only one treatment is necessary to resolve the patient’s symptoms.  The number of laser shots required is also lower for weiss rings than other types of floaters, such as diffuse strings and amorphous clouds. For patients with the clouds and strings, it may often take 500 or more shots and multiple sessions to achieve high patient satisfaction.  These types of patients are still candidates for LFT, but we recommend waiting until one has gained more experience before treating.

We also recommend picking pseudophakic patients at first. In these patients, the media is clear, but more importantly, it removes the risk of inducing a cataract in case one fires too close to the lens. Spatial context is a key part of the learning curve, and it does take some time to build a comfort level with location of the floater in relation to other structures, such as the lens and retina.  In fact, I did hit two lenses out of my first 50 cases, since it took me some time to appreciate how far back I needed to focus behind the lens to avoid inadvertently hitting the lens. It wasn’t until I discovered the unique feature of True Coaxial illumination, which is the ability to titrate the illumination.  In other words, by moving the slit lamp towards the oblique positon, one can “titrate off” some of the extra glare from the coaxial beam to help improve contrast of the floater but still maintain enough visualization of where the retina is.  Moving the slit lamp even further more to an oblique position removes more of the coaxial illumination and thus causes the background to become black, helping to visualize anterior floaters as well as visualizing the posterior capsule.  This titration of illumination is needed to provide the proper spatial context from lens to retina.  

Energy is another aspect to the learning curve.  In the first few cases, try adjusting the power to appreciate the importance of using sufficient energy levels in order to break and vaporize the floater. Weiss rings make it a little easier to appreciate the dual mechanism of breaking and vaporization. The pseudophakic patient provides a new adopter the comfort level to better understand the delivery of energy and obtain a better understanding of how close to the lens one can get.  I recommend firing at different depths to appreciate the plasma cone extension. Playing with the offset is also much safer and easier to appreciate in pseudophakic patients where the floater is in the middle of the vitreous.

In short, picking the ideal patient allows surgeons to work on the various skills needed to master the procedure and venture on to more types of floaters.  Allow for at least 20-30 cases before a true assessment of the efficacy can be made. Picking the “right patient” allows a control of variables to help maximize outcomes early on.  Like any new procedure, don’t be discouraged if you have a hard time visualization, take a little longer than you thought, or don’t see the exact results you expected, that is all part of the learning curve.

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