THE EVALUATION AND CONSULTATION EXAM: Even if you recently had an eye exam, an evaluation and consultation with Dr. Johnson prior to any treatment is mandatory.

The goal of the exam is establish:

• Pretreatment baseline visual acuity and eye pressure
• Thoroughly examine the front of the eye and more importantly, the retina and periphery
• Rule out any condition responsible for or contributing to the eye floaters
• Identify the floaters in light of the three important questions above
• Identify any complicating anatomy or conditions that might make treatment more difficult or contraindicate treatment altogether (as described above)
• Engage in conversation to set appropriate expectations and establish informed consent for the procedure and answer specific questions with the authority of experience in performing many procedures.

FLOATER DEMOGRAPHICS: Based on our exam experience, we have divided floater sufferers into three age-based demographic groups:

1. Teens and twenties
2. Thirties
3. Forty and older

The youngest group of teens and twenties are the least likely to be treatable. An entire page is devoted to this group HERE. The group in the thirties are treatable about half of the time and tend to have one or just a few isolated strands or small glass bead-like globules. Their floaters tend to be close to the retina with less free movement of the floaters. The forty and older group makes up most of our treatable patients. For younger people considering treatment, especially if they must travel a distance to our office, we proceed cautiously making every effort to get the local eye doctor to visually confirm and describe the floater (and not just "assume" or "infer" the diagnosis of eye floaters).

THE THREE QUESTIONS: For eligibility for treatment, all must be answered as "Yes".

1. Can I see the floater? This sounds self-evident and obvious but some younger patients have floater-like moving shadows, but the material responsible can not be seen despite vigorous concentrated effort.
2. Is the floater that I see the one responsible for the patient's symptoms? A very important question. We can treat densities floating around in the vitreous chamber, but if it is not the floater that responsible for the patient's symptoms they will not improve. One of Doctor Johnson's first patients illustrated that point and made an important learning lesson. This patient drew a very detailed and accurate sketch of their floater. On examination, we saw a soft cloudlike thickening of vitreous in the middle of the vitreous which was then treated successfully. Unfortunately, the floater material that was treated was not the responsible material. In retrospect it made sense that a soft cloudlike thickening could NOT form a hard-edged, distinct shadow. There was no harm done, but the patient was not relieved of his floaters. (By the way, the patient was not charged for the procedure if your are curious).
3. Is the floater located in a safe region to treat and is it technically and optically possible? Generally the floater should be more than 2mm from the lens in the front of the eye and 3mm from the retina. These distances are difficult to assess unless a special diagnostic contact lens is applied at the slit lamp. Generally, centrally located floaters toward the front of the eye are more efficiently treated than posterior, peripherally located floaters.

Questions #2 and #3 are difficult to answer without professional experience in treating eye floaters with the YAG laser.

FACTORS WHICH MAKE TREATMENT MORE DIFFICULT OR LESS EFFICIENT: None of the following anatomical challenges will prevent or contraindicate laser treatment but they may make it more challenging. These features do make the treatment less efficient, possibly requiring more attempted laser shots and/or more treatment sessions to get to the same treatment endpoint.

• Highly Myopic: Very nearsighted people usually have larger, longer eyeballs. It means trying to get the laser energy further back with a drop off of energy levels
• Small pupils: restrict the amount of light and laser energy. We try to counteract with an aggressive dilation, but some people just do not dilate well.
• LASIK/PRK: cornea refractive surgery causes changes to the central cornea that flattens or steepens the curvature compared to the untouched peripheral cornea. When the pupil is dilated well, it appears as if there are two competing optical regions of the cornea. The effect is that the laser energy is not coherently focused into one precise spot. The effect is much less efficiency in treatment especially the further posterior (toward the back) the floater resides.
• Cataract surgery / artificial lens implant: The artificial lens implant is usually smaller than the pupil size. This creates two different optical zones. This is a similar optical change seen with LASIK. We can generally only work through the lens opening which restricts the amount of energy that can be delivered.
• Small posterior capsule opening: A common result of cataract surgery and implant lens shown above is the gradual clouding of the posterior capsule (described HERE). The opening in the capsule (shown in blue here) created by the laser is even smaller than the lens implant which is smaller than the pupil (here in red).
• Peripheral or posterior location makes it more difficult to illuminate, more difficult to see, and decreases the energy delivered.
• Highly mobile floaters a moving target is more of a challenge than a stable one.

THE TYPICAL EXPERIENCE OF THE PROCEDURE

• After pupil dilation, a few drops of anesthetic are placed into the eye
• The patient is positioned at the laser. They are awake and sitting upright.
• The head is gently, but firmly strapped into position to stabilize it
• A thick, clear viscous solution is placed into the contact lens and Dr. Johnson positions the lens onto the anesthetized eye. This further stabilizes and controls eye movement.
• The laser energy levels are set to start with and each laser shot is individually aimed, assessed, re-checked for focus and activated. The patient and the doctor hear a "click-snap" sound which is a combination of the electronic shutter of the laser as well as the microscopic plasma cavitation bubble being formed when the vitreous material is directly hit and vaporized.
• The patient and doctor may see a very brief small flash of light from the plasma bubble.
• The patient does not feel the laser. There are no nerves or blood vessels in the vitreous.
• We may ask the patient to look in certain directions or to quickly move the eye in certain directions to "stir the pot" and move the floater into a better position.
• The patient may see some black specks "falling". These are usually micro bubbles floating upwards. (Remember that the image is flipped and inverted in the eye as well as cameras).
• In a short time the patient will become quite accustomed to the sensations and sounds and will likely be quite bored with the procedure.
• Because of the level of intense concentration needed, Dr. Johnson might take 1 or 2 short rests to take a break during the procedure or to change to a different treatment contact lens.
• The treatment session is stopped when the endpoint is achieved, or when Dr. Johnson has delivered a predetermined amount of energy.

IMMEDIATELY AFTER THE PROCEDURE:

• After the contact lens is removed, the vision brightness and acuity will be a bit dim or dark in the treated eye due to the bright light used to illuminate the eye for treatment. It will take several or more minutes to "dark adapt" again.
• The patient may also notice dark spots in the lower part of vision due to the gas bubbles that have floated to the top of the eye. These will usually only last for minutes to less than an hour or so.
• The pupils will remain dilated for a few to several hours after the procedure. Because of the dilation, the residual floaters may not be immediately visible until the pupils return to normal and the improvement may not be immediately noticeable

THE TYPICAL AFTER-PROCEDURE EXPERIENCE

• There should be no discomfort
• The pupil dilation may last several hours
• By the late evening and certainly by the following morning the improvement will be noticeable
• Each eye and floaters type is different, but it is not unreasonable to expect a 60-80% improvement with each treatment. This is a subjective assessment and difficult to objectively measure.

NEED FOR MORE TREATMENT

• It is unusual to be able to achieve a treatment endpoint with a single treatment. For those living local we may choose to allow a few or several days in between treatments. For those traveling into the area, we don't have that luxury and we may need to do consecutive day treatments over 2-4 days.
• We often describe the treatment progress as "3 or 4 steps forward and 1 step back". We believe that laser does vaporize the immediately targeted floaters but that there is also the fracturing and breaking up of some of the adjacent collagen. Those fractured strands of collagen are "sticky" and may clump up again.
• In spite of some of the mild setbacks, each treatment typically moves the progress forward.

WHAT IS THE TREATMENT ENDPOINT?

• Most patients come to us with very reasonable expectations and goals for treatment. It is a rare person that truly expects a 100% improvement and complete elimination of all floaters. Most just want to get the big chunk or strand out of the way. In essence, to return to "normal" floaters.
• We usually try to set a lower expectation initially and try to exceed that expectation. We might suggest that we can achieve a 60% improvement just to throw a number out there, and then after treatment, we actually achieve 70-80 plus percent. Because the treatment was painless, with rapid recovery and nearly immediate gratification, the patient will be pleased, but will also want more of their floaters eliminated.
• As long as the eye tolerates the procedure well, we can usually continue. When the treatments do not seem to continue to improve than that may be the time to stop treatment. Typically, it is the last 10% or so that is the most difficult to eliminate usually due to their location or small size.

By now you probably have questions. It is a good time to read through our Frequently Asked Questions (FAQs') section HERE. If you have a question that is not answered there and you think it might help others go ahead and ask Dr. Johnson on the contact form HERE