WHY ARE THERE JUST A FEW DOCTORS PERFORMING THIS PROCEDURE?
This is the most common and one of the most important frequently asked questions. It deserves it’s own page because my answer to this question will also describe that current state and attitude toward treating eye floaters in the professional eye care community.
There are just a few doctors with any significant experience using the YAG laser because:
FLOATERS ARE CONSIDERED BENIGN AND UNIMPORTANT
Most vitreous eye floaters are not associated with progressive, degenerative eye conditions like cataract, glaucoma, and macular degeneration. Those conditions can certainly affect visual acuity and quality of vision, but they are usually more diffuse and don’t have the movement of shadows associated with floaters. There are rarer causes of floaters such as autoimmune conditions, infection, hemorrhage, foreign bodies, and parasites. These are indeed rare. So let’s face it, eye floaters are not sexy, or dramatic, and they are rarely a cause of diminished function of capacity for the patient. They often continue to work, read, and drive even if perpetually annoyed and distracted by the moving shadows. Now if we consider the psychological effects of floaters, then we can argue that they are not so benign. So within the eye care profession, floaters commonly just don’t register as anything important. Here is a scan of a portion of the official patient education brochure from the American Academy of Ophthalmology on the topic of floaters:
As you can see, the traditional dogma in the profession is that eye floaters are nothing to be concerned about as long as the retina is OK. They don’t even answer the question of whether they can be removed. To be fair, it should at least mention the possibility of a vitrectomy procedure which is the gold standard for removing floaters. If you are having trouble convincing your doctor of the importance of the floaters in your eye, this will explain why they may appear dismissive.
DIFFERENT GOALS AT THE TIME OF THE INITIAL EVALUATION FOR FLOATERS
A patient may go to the doctor with a recent onset floater. They will want to know 1.) What is it?, 2.) Is it going to blind or visually disable me?, and 3.) What can be done to get rid of it? The eye doctor, on the other hand, really just needs to 1.) Ascertain that it is not part of a retina (or other serious) problem, and 2.) Issue some platitudes of reassurance and find their our of the exam room and on to the next patient.
EXAMS (ON PAPER) ARE USUALLY QUITE NORMAL
Most of our patients could pass any rigorous eye examination, and many could easily pass an FAA flight physical eye exam or a military flight surgeon’s eye exam. Eye floaters generally do not decrease the visual acuity, decrease measured peripheral vision, change depth perception, or affect the health of the cornea, lens, retina or affect the eye pressure. Larger eye floaters may be noted on the exam chart, but usually not much fuss are attention to the floater ensues. Physician discussion is usually limited to “you’ll just have to learn to live with it”, or some variation.
PIONEERING EYE DOCTORS HAVE FOSTERED AN EXCLUSIVITY TO THE TREATMENT
I give a lot of credit to Dr. Scott Geller for being the first in the US to seriously pursue the laser treatment. Dr. John Karickhoff had his floater treated by Dr. Geller and then pursued further skills and added it to his own practice. Dr. Karickhoff further distilled the basic science knowledge of the physic and interaction of the laser with the vitreous and wrote a book for physicians on the topic.
Where I think they have made a mistake is in keeping it so exclusive and closely held. I understand the temptation, though. Since the skills needed to treat with the laser are not taught anywhere, there is a long and arduous learning curve if you are going to learn the needed skills. We believe you need to fire the laser around 100,000 times to get comfortable with the treatment skill set. After that difficult learning curve, we are also initially reluctant to just “give away” the tips and tricks and skills we have had to develop on our own.
For this procedure to become more well known, more legitimate and accepted among the profession, we do need to teach and train others. It will be better for humanity.
THOSE WHO HAVE TRIED WILL OFTEN INITIALLY FAIL OR BECOME FRUSTRATED
I will sometimes have a patient tell me that their doctor tried to treat their floater with the YAG Laser. What I can glean and surmise is that the doctor probably used the wrong treatment contact lenses and more importantly, inadequate energy settings. They get frustrated, don’t see any progress, and declare that the laser procedure just doesn’t work and probably never try ti again.
SPARSE PUBLISHED STUDIES AND RESULTS UNIMPRESSIVE
There are only a few published articles on the laser treatment procedure. They were not well designed with vague definitions of success, and I believe, used inadequate energy settings to achieve plasma formation and vaporization of the floaters. They did conclude that it appeared to be safe, with no vision-affecting complications. Want to read them? You can find them in PDF format here.
NO FORMAL OR INFORMAL TEACHING / TRAINING OF THE PROCEDURE
Currently, there is no training of this procedure within the formal residency education programs, and no formal or informal courses at conferences, meetings, etc. There is no established institutional teaching / training / or exposure to this procedure. We have all had to learn the procedure on our own. Gently, gently at first and then expanding on our learned skills.
IT IS TECHNICALLY A VERY DIFFICULT PROCEDURE TO DO WELL
The laser we use is normally designed for use in the front part of the eye to create openings in the lens posterior capsule and create a hole in the iris to treat glaucoma. When the focus is pushed further back in the vitreous chamber there are many optical factors conspiring to decrease visibility and lighting as well as reduce the efficiency of the laser energy. It takes a lot of practice to overcome some of these technical and optical challenges. Something that can’t be effectively taught in an 8 hour course.
THE PROCEDURE DOESN’T FIT WELL INTO A BUSY, GENERAL OPHTHALMOLOGY PRACTICE
One the important factors contributing to Dr. Johnson’s success with the procedure is a single-focused approach without the distractions associated with a general ophthalmology practice. We have a small and low overhead practice that allows us to see only 3-6 patients per day. We will typically spend 1-2 hours per patients. Much of that time may be spend discussing the procedure, answering questions, examining the eye, discussing risks and putting them into statistical perspective, and of course the treatment it self which can be time consuming, tedious, and laborious. We block off enough time for each patient and rarely have someone waiting to be seen. This unique practice style works well for us and makes for an unhurried, very focused visit. It is a style that will not easily assimilate into other established practices. Other treating doctors may be able to get in and out of the office, but this practice model works well for us and we believe it makes a big difference in the end results.
In a nutshell, the ophthalmologist’s comments and attitude were: Floaters are not a medical problem. Surgery is the only means to remove them but I will not do the surgery as you otherwise have good vision, your insurance company will not pay for the surgery and as you have retinal tears there is some risk of a retinal detachment. Surgery could lead to blindness and I do not want to risk a law suit. Your mental state is not my business. Get used to the floaters. Get a life.
That’s a pretty hard line stance on the part of your doctor, but I’m sure it is not uncommon. This anecdote underscores much of what I have said before. Thanks for your contribution. Dr. Johnson