Expectations of Laser Treatment

INTRODUCTION TO LASER VIDEO

TREATMENT EXPECTATIONS 1 | SIMPLE WEISS RING

We have created a model to better understand how the YAG laser interacts with the collagen of the vitreous fluid. We use cooked noodles on a cross-section cartoon of the eye.

The normally clear vitreous fluid is 99.9% water with the remaining material mostly collagen. Collagen is a non-cellular, long-stranded, polymer structure. It is normally dispersed throughout the vitreous, and it is invisible.

noodle model of eye collagen

fig.1 This first image shows a cross-section of the eye with multiple random oriented strands of cooked, soft noodles which are meant to represent the long stranded collagen fibers in the viscous vitreous fluid.

Around the optic nerve head is a particular thickening that may become obvious when it pulls away and separates which is typical of a posterior vitreous detachment (PVD). There is a naturally occurring outer thickened layer of the vitreous shown here as a shiny and reflective food wrap sheet. It is the material that is adherent to the retina and often collapses into semi-transparent fold or wrinkled sheets after the collapse of the vitreous and separation.

noodle model of the eye with pvd

fig.2 This illustration represents a posterior vitreous detachment. The thickened group in the center of the eye is known as a Weiss ring. this is one of the simplest and most classic type of floaters.

The Weiss ring type of floater is our favorite type of floater to treat. They are usually easily seen, they correlate very well with the patient’s description of the moving shadows and they are typically tethered fairly stably in the central part of the eye.

noodle model of the eye after treatment

fig.3 This illustration shows what the eye may look like after even one treatment with the YAG laser. there may be some residual small bits of debris, but an 80-95% improvement would not be unusual in this circumstance.

treatment graph

fig.4 This chart may seem complicated at first, but it illustrates a number of important points and concepts. On the left-hand vertical axis is the subjective scale that represents how much the floaters bother the patient. Generally, for someone to seek our care, they will usually be quite bothered by the floaters and score high on that scale. The red dot on that vertical scale represents where they are prior to any treatment. The first treatment may drop them down on the scale with perhaps a 60 to 70% improvement. The blue line represents some theoretical line of satisfaction wherein they claim they will be satisfied with results below that line. In the case of the treatment for a Weiss ring, the first or second treatment will often achieve the desired effect. The treatment for Weiss rings tend to be stable and remain in a satisfactory range after treatment.

TREATMENT EXPECTATIONS 2 | MORE COMPLEX

This next example illustrates a much more complex situation with a mixture of various types of vitreous thickening and densities. There may be a mixture of strands, and dense clouds, and thicker fibrous material.

NOODLE EYE MODEL OF THE EYE

fig.5 This is a much more complex vitreous degenerative condition. This massive amount of degeneration will require more treatment.

noodle model of the eye

fig.6 As we progress with the laser treatment, there is further vaporization and evaporation of collagen material as well as microscopic fragmentation of the collagen strands. These microscopic fragments are too small to cast a shadow and go into solution.

noodle model of the eye

fig. 7With even further treatment, there is significant improvement in the appearance and further fragmentation of the collagen. If we could stabilize and freeze the results here, the patient would be quite pleased.

These small residual fragments of collagen have the opportunity to do one of two things: 1) Now that they are liberated from the original tangled mass of vitreous condensation, they can break free and work their way into the eye’s own drainage system. There is a naturally occurring recirculating pump and drainage of fluid in the front part of the eye. It occurs where the cornea meets the iris which drains fluid (trabecular meshwork). The small fragments of collagen may find their way into the eyes drainage system and exit the eye as a secondary manner. 2) Unfortunately, some of this fragmented collagen has a strong attraction towards itself and may re-form. The reformed clumps typically form as long, soft and fuzzy strands as illustrated here.

noodle model of the eye

fig.8 This long, winding strand is typical of the re-formed or regressed formation of floaters after treatment. Overall, there is less material present and the patient may describe 40 to 60% improvement, but that residual strand may be quite bothersome and overall intolerable suggesting that more treatment is warranted and indicated.

The situation described above is not that unusual and is in fact quite common when there is a large, three-dimensional, cloud-like floater mass to begin with. This regression of treatment is not a treatment failure, but a not-uncommon treatment challenge. Typically, these long fuzzy strands are quite treatable even though a bit resistant to the laser energy. Further treatments are usually necessary to break it down and reduce the mass and volume of the residual floater material. This may take two or three or sometimes more treatments to get to the desired effect.

graph showing potential zig-zag treatment success

fig. 9 This graph is more complex and shadows a more jagged treatment progression. The first treatment may show a significant improvement, but over the ensuing 24 hours there is a regression perhaps of 20 to 40%. I have described this as a “journey of 3 to 4 steps forward and then 1 to 2 steps backwards”. In this example the second treatment continues the noticeable improvement with some backsliding 20 to 40% again.

We think it is important and beneficial to understand these concepts prior to treatment as it is all about setting appropriate expectations for the patient. If our patients have these large, three-dimensional, thick masses of floaters we want them to understand that it will take more than 1 to 2 treatments to get a stable improvement. It is better to describe this in advance as it better prepares the patient for the treatment series.

gas bubbles in the roof of the eyeWhat happens to the vaporized collagen? It is converted directly to gas bubbles. You can see the bubbles float away in the videos. They go to the roof of the eye (seen here using a mirrored lens way out in the periphery of the retina). Here is one larger bubble and approximately 60-80 very small micro-bubbles. They will only last about 10-30 minutes where they will dissolve into the surrounding fluid.

 

So what can you expect for a treatment or treatment series. The answer is that it is very difficult to know in advance of the initial consultation and evaluation with Dr. Johnson. It is often difficult to know after the evaluation or even after the first treatment. Each eye is different and each eye behaves and responds differently. Some floater types are more likely to regress or reform than others. It is one of the weaknesses of the laser procedure, this difficulty in predicting its behavior. We strongly believe it is better to educate and prepare the potential patient prior to treatment rather than proffer excuses and explanations after their 1st or 2nd treatment. We look forward to your thoughts and comments.


Please do no use the comments section to leave personal contact information or detailed personal medical information. Keep it to comments, questions, or stories that will benefit other readers and floater sufferers. If you do have personal questions or requests, please go to the Email Dr. Johnson Page.

31 Responses to Expectations of Laser Treatment

  1. Peter Steinblums says:

    I am a 56-year old male. Six months ago I had a “sudden-onset” PVD in my right eye starting with “flashing lights” shooting across the horizon that eventually were limited to a vertical up-and-down “flash” in my peripheral vision. From looking at the photos on your website, I clearly could see the “Weiss Ring” and a transparent “saran-wrap like” membrane with specs inside it and “wrinkles” or hair-like floaters.

    At the time, I became alarmed and immediately saw an eye doctor who diagnosed “PVDs” with no retinal tears or damage. I can say that the Weiss Ring and other floaters have NOT dissipated in 6 months. But I do not notice them as much; I Googled something about the brain “learning to ignore them.”

    As the eye doctor predicted six months ago, a few days ago I got a sudden-onset PVD in my left eye, with flashing lights, the Weiss Ring and some impressive, long “wrinkles” or hairs in the saran-wrap-like cloud floater. Now I have “stereo” kaleidoscope entertainment in both eyes, but the PVD that started a few days ago seems much more noticeable and annoying than the six-month-old PVD debris in my right eye. Perhaps because it is still “in-process” of developing?

    In both eyes, it seems like most of the “junk” floating around tends to want to gravitate back to my peripheral vision area, but I can reluctantly “make it go” toward the center, only to quickly drift back toward the periphery

    Monday I go to the eye doctor to check the new PVD and make sure the retina is not damaged, etc. I am in the Los Angeles area and plan to ask her about your YAG laser procedure, but will not be discouraged with a negative opinion, which is human nature to reject new ideas.

    But my question to you…is there a period of time (number of months, etc.) you would recommend waiting AFTER the PVD occurs before you perform your initial consultation and YAG laser procedure to allow the PVDs to stabilize?

    Thanks,
    Peter

  2. sheryl fisher says:

    I have had bilateral PVD. First the right eye and then the left within a couple of weeks. I am left with floaters and flashes. My right eye has a very large annoying floater. It has been nearly a year with no change. No Retinal tears. Can laser help?

    • The bulk of the patients I prefer treat (because they enjoy the highest levels of safety and satisfaction) are over the age of 45, sudden-onset floaters associated with a posterior vitreous detachment (PVD) with a prominent, dominant floater. It kind of sounds like you situation. I can not promise or guarantee anything without examining in person, but if I were a betting man, I’d suggest you are more likely to be a candidate for treatment with the laser.

  3. Gina says:

    Is your procedure covered by insurances or medicare?

  4. Sandy says:

    Hello Doctor
    About a year ago my doctor noticed I had a tear on my right eye and he performed short lazer surgery, everything was fine untill now. Yesterday I noticed round cloud floater in the center of my eye and few cobweb cloud floaters at the corner of my eye so I went to see my retina doctor. He checked mye eye ans saw no tear than he did an ultrasound and spoted a molle (Beauty mark) in my eye. He did not say that’s what causing the floaters but will keep an eye on it. From what I read on this page, these floaters present Posterior Vitreous Detachement but my doctor did not say that. I have to go see him in a week for another checkup. Should I mention to him PVD and treatment of YAG or should I remain silent…what would you suggest I do.
    Thank you !

    • Ask your doctor if you experienced a posterior vitreous detachment or if it is just diffuse degeneration of the vitreous without a PVD. Ask him/her if they can see the floaters and if it looks like your drawing of the floater. You can ask their opinion of the YAG laser treatment. Likely they will not recommend it – not based on any specific patient experience, just “because”. It’s common, and it doesn’t hurt my feelings.

  5. Martin says:

    Hi Dr. J,

    I am 24 years old and today I was diagnosed with loose vitreous floaters. I have had floaters in my vision, on both eyes, since about 17. Now that I’ve done some reading online it is worrying me that the majority of people in my position are at least double my age. Do I have the eyes of a 50 year old? Is there any special care I should take of my eyes? My doctor today didn’t say anything except not to go bungee jumping. Is there something that could be responsible for the shrinking of my eyes at such a young age? Any advice will be greatly appreciated.

    Regards,

    Martin

    • Without examining your particular condition, I can only discuss in general, but I do not agree that you have the eyes of a 50 year old. The floaters that younger people have are not the same as those of the older age group. The older age group often has had a posterior vitreous detachment with or without more widespread and diffuse degeneration of the vitreous. The floaters in younger people are microscopic little condensations of the collagen proteins and often located very close to the retina. I do not agree that there is any shrinking of the eyes going on here. I don’t even agree with the restriction on bungee jumping. So we differ on a few important points. There is no specific recommendation that I can make as far as activities to avoid or supplements to take.

  6. Peggy says:

    Why do my floaters appear like white clouds instead of dark shadows? I have had my eyes examined by an opthalmologist who says I have a lot of floaters. I am 61 years old and these things make it hard to drive. I would love it if your treatment could help me.

    • Dense floaters appear as darker, well-defined shapes. Cloud-like floaters appear subjectively as, well, cloud-like shapes. They can be just about anything. They run the spectrum.

  7. Kathy says:

    I am 56 years old and within the last year I had cataract surgery with lens replacement in both eyes. 3 months post surgery I had a posterior vitreous detachment in my right eye and retinal “tugging”. The Doctor was able to see and confirm Weiss Ring. The ring is extremely dark and slightly to the right of my central line of sight. There is also another larger, opaque floater positioned in the bottom right. He told me the body would eventually break it down and absorb it. I was to return in a year. Monday I had a PVD in my left eye. The ring is centrally located and more opaque than the other. Again there is another centrally located floater near it. Two questions: will the body break down Weiss Ring and absorb it? If the ring in the right eye is darker than the fringe in the other does that mean it is closer to the back of the eye and therefore untreatable?

    • You are describing a really classic example of what is probably a posterior vitreous detachment: 1) Sudden-onset, 2) Correct age demographic, 3) shape and relative position, and 4) Your doctor confirmed its presence and appearance. Because the vitreous “detached” or separates from the underlying retina, it moves forward and away from the retina. I have seen PVD’s very early – within a few days of onset and these can be situated relatively closer to the retina, but given a few weeks time they almost always move to a position either in the middle of the globe or in the anterior (front) half of the globe where they are quite treatable. The darker/more opaque appearance of the left eye’s floater may reflect its not quite stable positioning.
      You also describe a second, different kind of floater associated with what appear to be the Weiss ring floater. This is not uncommon and might be a more diffusely cloudy type of floater. Usually treatable, but not as much fun.
      As far as the body/eye’s ability to break it down? No. It doesn’t. I would be curious to hear your doctor’s explanation as to the putative mechanism of that action. More likely it is something he heard during his/her residency and it became a rote reassuring explanation.
      Give the left eye more time – at least a month to stabilize. It may become less bothersome if it moves a little further from the retina. Maybe.

  8. Penny Riley says:

    How expensive is this laser procedure and does innsurance cover it?

  9. Sam Lombardi says:

    Hi,You keep referring to the floaters being in the right place to do this laser surgery. COuld I tell if they are in the right place. Mine are more concentrated on the side of my eyes,not in the direct center but swiftly move to the center and even to the other side of the eye when I move my eyes but they seem to be basically stationed and stuck on the outside of the center of vision.. Is this a good position to have this done?

    • vitreousfloaters says:

      I am more concerned with the front-to-back position (antero-posterior position) and how it related to the proximity to the retina or lens. You are describing the central versus peripheral position which is technically and safety-wise, nit as important. There is no simple set of questions or ways that you could concern the floater’s floaters location. The best prognosticator for likely treatability is based on patient age.

  10. I am a 59 years old and I started to see my floaters on a trip to Colorado. I live in Puerto Rico. I have 1 floater in each eye(na dark spot) and a web floating in the middle. I went to my ophthalmologist and everything in my eyes seems to be perfect I asked the doctor about the yag laser to eliminate my floaters and he told me not to do this procedure because its dangerous because YAG laser is like over cooking the eye and I could lose me eye sight or have cataracts. Please tell me if this is true and how dangerous is this procedure. He also told me that ill get use to floaters and they will eventually go away.


    reply: That response from your doctor does not reveal a very sophisticated understanding of the optics and physics of the YAG laser interacting with the eye. The duration of the YAG laser, when activated, is measured in nanoseconds (0.00000003 seconds). It is not a thermal laser and that short duration is not long enough to allow for any transfer or dissipation of heat to other areas of the eye.
    More practically, physics aside, I could not stay in business if the procedure was inherently damaging and dangerous. That is not to say that there are no risks. There are risks with any procedure in medicine. I have described the main associated risks on my web site HERE. If many of the treated patients were commonly visually disabled, we could no longer offer the procedure as
    medico-legal Darwinism would eliminate us from the medical gene pool, so to speak. Your doctor’s admonitions and warning are simply not accurate. This procedure is not experimental, it has been around for two decades, and for it there is a Common Procedural Terminology (CPT) code used by the insurance industry and defined by the American Medical Association.

  11. Ulrich Sommer says:

    Hi, I am 67 and since 3 months I am suffering from a large amount of floaters on my left eye, the right one is fine. I had a few on both eyes since 2006, which annoyed me occasionally but over the time I got used to it. Now I constantly have a brown cloud in the middle of my vision have my attention on it all the time. Even in a darker environment. Having read about your method gives me hope that something can be done about it. I used a lot of otherwise highly effective supplements, antioxidants, anti-inflammatories etc. Nothing improved the condition. My body is otherwise in great shape, I eat right, I am very healthy and energetic. Never had any eye issue, except conjunctivitis about a year ago. Please let me know if I should get a treatment now or wait in cause it would get worse and then get a treatment?


    Ulrich, sorry to hear about the shadows in your vision. You age and sudden-onset of symptoms suggests a posterior vitreous detachment. I can safely treat most of those with success. Typically, these stabilize in their behaviour pretty quickly – like in the first few days. It is not likely to get worse, nor is it likely to get better. One nice thing about floaters is you can wait as long as you want (or can) do do something about them. There is no penalty for delay in treatment as there is with so many other medical conditions and pathologies. If and when you decide that having that junk moving around in your vision is ultimately unacceptable, I’ll be here with the laser all warmed up for you.

  12. JACK R MIRSKY says:

    Dr. Johnson I’, a 65 year old male that is diabetic with what I believe to be a Vitreous Floater. I have had Cataract Surgery in both eyes in the last 4-5 years ago at Jules Stein in Los Angeles. I saw my Dr. there last week and was told your eyes look good see you in 1 year. (get used to this condition) I was told laser is not a good option.
    He said it was a good chance that the large Vitreous Floater could break into many smaller pieces. The second option if things get worst is to see a Retina Specialist and have the fluid in the eye replaced. Dangerous? not sure.


    The laser is not for every floater type, but for those that are good candidates, it can be a great alternative to the vitrectomy. Regarding the suggestion that a large floater will break into smaller pieces, I beg to differ. That would not be an expected behaviour of the floater if left alone. The vitreous collagen proteins are “sticky” and prefer to remain clumped up. There is no naturally occurring mechanism for floater to break up on their own. I think that is a false reassurance or expectation to dispense to those suffering these very bothersome floaters. -Dr. J

  13. martha reaper says:

    Can you treat floaters associated with retinal tears that have been corrected with cryo-surgery?


    answer: yes, assuming that the floaters(s) is/are in a treatable location (not too close to the retina or lens). I have treated many patients with previous retinal holes/tears, or detachments that were repaired. It doesn’t really change the technique or strategy at all. After cryo-pexy or laser retino-pexy, the retina is attached to the eye globe better that original equipment. In addition, the laser treatment does not appear to cause any traction or stress to those areas. So as long as it has been a few months and things are deemed stable by your retinologist, it should not be any problem. – Dr. Johnson

  14. Cindy L Thomas says:

    I’m 52 years old. I used to have a -9.5 to -10.0 prescription until I got LASIK in 2004. I’ve enjoyed good vision until last Saturday, 4/28. All of a sudden there was a cloudy gray web in the center of my right eye and another floater that looks like a bat flying right next to the center. I see bits of floaters along the right side and flashes there in the dark. I went to the eye doctor yesterday. He says my retina looks fine. He says I have posterior vitreous detachment. He says to wait 2-3 months to see how my body handles the floaters. If they are still affecting my vision then, I could get a surgery that pumps out the floaters with part of the fluid in the back of my eyeball, replaced with synthetic fluid. I think I’d prefer getting zapped with a laser. I’m telling you these floaters look like gnats flying around my right eye all the time. It wouldn’t be so bad if they stayed put, but they keep zipping around whenever I move my eyes. I love to read, and it’s just about impossible now. Do you agreed with waiting for a few months? And does it sound like I’d be a candidate for this procedure with my eye prescription and having had LASIK?


    answer: Cindy,
    I have treated people with various degrees of myopia as well as with prior corneal refractive surgery such as LASIK or even lens surgery like cataract surgery. I am currently treating a gentleman with a -17 dpt myopia. These conditions present some optical and technical challenges, but they rarely will prevent a successful treatment assuming that the floaters are in a good position to treat to begin with. There really is no harm in waiting, and you can wait as long as you wish until you’re convinced that it is not something that you will become accustomed to. The surgical vitrectomy procedure is an option although in reality I believe it is a theoretical option for most people. The doctors that perform that surgical procedure really take some convincing to be willing to do it on somebody with “just floaters”. BTW the fluid they use to replace the vitreous is just a saline solution. Nothing exotic.
    I generally recommend waiting about one month after the onset of eye floaters and then I can usually treat anytime after that.

    • Cindy L Thomas says:

      Thank you for your quick response.

      One more question: How long you have been doing this procedure?


      answer: as of May, 2012 I have been using the laser for floaters for about 4.5 years.

  15. I recently saw what I thought was a cobweb or spider web attached to the right side
    of my right eyeylash. Then I used some celluvisic eye drops over night and the webb-like structure seems to be a “foater” resembling a fine web floating in the right side inside my eye. I am 73 years old and need to know if this spider-web type of floater is indicative of anything more serious than a nuisance. Do I need to see an eye
    doctor for an evaluation and is there a qualified doctor in the Tampa Bay area?
    I am a 100% Disabled American Veteran with PTSD-Psyneurotic Phobic Reaction and I
    need to know if the Veteran’s Hospital in St Petersburg, Florida, where I go for other
    treatment for dental, orthopaedic, and neuropsychiatric meds, have a qualified
    eye dotor who can evaluate and treat these “webs” which do not block my vision and
    often just seem like something resembling a spide web outside that I automatically
    try to brush away sensing that it’s exterior, but it’s really not.


    answer: although what you describe sure sounds like a simple floater, it is always good advice to get it checked out to make sure that it is not something more serious.
    There are just a few of us in the US treating floaters on a regular basis. None in the VA system. There is a doctor in Ft. Myers who is certainly closer to you. I have all the other floater treating doctors listed on my web site page: http://vitreousfloatersolutions.com/choosing-a-doctor/

  16. John Brownridge says:

    I am age 72 and I had cataract surgery in my right eye at age 43 but I did not receive an intro-ocular lens implant. I have 20-20 vision in my right eye with a contact lens. My left eye is amblyopic and I have 20-8- vision in that eye. I have had a large C-shaped floater in my right eye for a few years. Does the fact that I had cataract surgery have any bearing on laser treatment for the floater?


    answer: In general, there is little difference between treating through a biological crystaline lens or through an artificial implant lens. If someone has a moderate cataract that has developed, I’ll prefer to treat through a perfectly clear artificial lens. If the biological lens is clear, then I’ll usually prefer to go through it because the treatment opening aperture is larger. A dilated pupil may be in the 7-9mm range, whereas an implant lens has a diameter of about 5.5mm, a bit more challenging. Your is a rarer situation where the lens has been removed but no implant lens replaced so there should be a nice big clear opening to work through. BTW, a “C”-shaped floaters sounds suspiciously like a partial Weiss ring – my favorite to treat.- Dr. Johnson

  17. Liza Bennett says:

    I live in Calgary, Alberta, Canada – any chance this procedure is done here?


    I’m not aware of anyone in Canada. The floater discussion forums can be helpful in that sense because the forum members are always looking for someone closer to them. I have listed the few doctors worldwide who do claim to have experience with this procedure here: Cheers, Dr. Johnson

  18. Laura McDonough says:

    Can my Opthimologist tell me via exam if I’ve had a posterior vitreous detachment? Seems I had a “ring” floater a few years back that is now gone. I have cobweb type floaters in both eyes now at 67 yrs old. I live in dothan Ala and there is a eye surgery center with about 8 Drs with sub specialties in Opth.



    Posterior Vitreous Detachments should be diagnose-able by your doctor, but it is not always so straightforward. Sometimes difficult. It may take a diagnostic contact lens examination. Regards, Dr. Johnson

  19. Paula Worstell says:

    Do pre-existing retinal tears make the laser treatment of floaters more risky?


    As long as the previous retinal tear has been stabilized (either spontaneous healing or more likely “spot welding” with and argon laser) and have been stable for a few months, then I can treat. The laser and its immediate or delayed effects do not increase traction on the retina and laser for floaters does not increase the risk of retinal detachment. Most of the time in mature adults, the bad floaters (and likely in your case, retinal tears and holes) are usually caused by a posterior vitreous detachment whereby the vitreous has separated from the retina. That is a one-time event. After a posterior vitreous detachment, the risk of retinal tears IS MUCH LOWER than before. – Dr. Johnson

    • Adam says:

      a few weeks ago I started noticing my floaters and had an eye exam. Fortunately i had no retinal tear but these buggers are so annoying. I can learn too live with the transparent ones, but their is this one floater that seems to be clumped together with another floater. The problem with this is that the overlap creates a dark line that is extremely noticeable when i move my eye. Also, because of this it makes all my over floaters a lot more noticeable . Is their any hope for them too unclump?

      • I think the local molecular “stickiness” is stronger than any tendency or force that may promote them to “unclump” or disperse. They can move possible to a less bothersome location, but I do not think the will un-clump.

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