Eye Floaters

There are two categories of eye floater causes or etiology: benign and pathological.

• The benign category is by far the most common,
• while the possibility of a pathologic cause must be evaluated by an eye-care professional, such as your ophthalmologist or optometrist.

Benign etiology: The vitreous gel occupies the bulk of the interior of the eye, containing approximately 5 cc or milliliters of clear jelly. The vitreous gel performs no essential functions other than to occupy a space and to clearly transmit light from the cornea and lens in the front of the eye to the retina in the back of the eye. The gel itself is merely a vestige or non-functioning remnant of embryogenesis or fetal development of the eye. During the very early stages of embryogenesis, the central cavity of the eye contains blood vessels vital to the normal development of the eye structures. These vessels form during the first trimester of pregnancy. By the end of the second trimester, the vitreous cavity vessels shrink or regress, then disappear completely. The remaining vitreous gel consists of 99% water and 1% protein and resembles clear Jell-O.

The vitreous gel is normally attached to the wall of the eye in two places: the optic nerve head and the front or anterior edge of the retina toward the front of the eye cavity.

In many people, these attachments remain in place throughout life, but separation from these vitreous attachments are extremely common. A vitreous separation may occur for any number of reasons, including

• trauma or injury to the eye,
• routine ocular surgery,
• strenuous athletic activity, or
• simply for no obvious reason at all.

Spontaneous vitreous separation from its normal attachment to the optic nerve, in fact, is the most common cause of vitreous or eye floaters.

• When the vitreous gel separates from the optic nerve head in the back of the eye, it is termed a vitreous separation, a vitreous detachment, or a posterior vitreous detachment, usually abbreviated PVD. After the posterior attachment separates from the optic nerve, the vitreous, now free to move around within the eye, may bump into or touch the retina, causing flashes of photopsia.
• Once the separation or detachment process has been completed and the entire back face of the gel is removed from the optic nerve attachment, the flashes generally stop. At this juncture, the now collapsed posterior face of the jelly has become somewhat less transparent and it is these aggregations of protein that we call vitreous syneresis or floaters.
• Occasionally, a small wisp of blood may be seen on the optic nerve or in the vitreous just after the detachment has occurred. These tiny hemorrhages are generally benign and resolve spontaneously. Nevertheless, such a finding should be followed until full resolution by a qualified eye-care professional.

Benign eye floaters occur at all ages. Over half of humanity eventually develops an eye floater, syneresis, or PVD.

• A traumatic birth delivery due to malpresentation,
• breech presentation,
• prolonged labor,
• inadequate birth canal, or
• forceps delivery may compress the very elastic eyes of the newborn and cause a benign vitreous separation.
• Benign floaters may occur with even normal vaginal delivery as well.

Pathologic etiology: Similarly, the anterior vitreous attachment or vitreous base toward the front of the eye can exert tractional forces on the underlying peripheral retina. A similar cascade of events can occur as seen posteriorly or in the back of the eye.

However, anterior vitreous traction will usually not result in a separation or detachment of the vitreous, since the attachment of the vitreous to the underlying retina at the vitreous base is much stronger. This vitreoretinal traction may pull on the thin anterior retinal tissues strongly enough to create a small hole in the retina.

• These holes are often associated with a flap of elevated retina still attached to the vitreous base.
• These holes often create a horseshoe shape around the elevated flap of retinal tissue.
• These peripheral retinal holes may cause a small amount of blood to escape into the vitreous cavity, which to the patient looks exactly like a benign posterior detachment floater.
• These small anterior vitreous hemorrhages produce unmistakable signs for the examining eye doctor and frequently necessitate a punctual repair of the retinal hole.

Left unattended, an anterior retinal hole or horseshoe tear can allow vitreous cavity fluid to accumulate under the retina. As this fluid progresses into the retinal tissues surrounding the hole, a retinal detachment can occur.

• This serious complication may require major surgery to restore the retina to its normal attached configuration.
• Left to its own devices, a retinal detachment can lead to certain blindness.
• Some patients are more at risk for anterior retinal hole formation and subsequent detachment. These patients include
  • those with previous eye trauma or injury,
  • previous eye surgery,
  • high myopia or nearsightedness beyond 6 diopters,
  • certain degenerative retinal conditions,
  • diabetes, bleeding or clotting disorders,
  • some systemic inflammatory diseases such as rheumatoid arthritis, and
  • patients with other ocular diseases such as glaucoma.

Bleeding into the vitreous cavity may also result from conditions other than anterior retinal holes. The most common cause of vitreous hemorrhage is

• proliferative diabetic retinopathy or PDR. This condition usually follows a long course of poorly controlled diabetes which allows abnormal blood vessels to grow in the retina.
• Eventually, when left undetected or untreated, these abnormal fragile vessels actually grow into the vitreous cavity and bleed spontaneously.
• PDR must be treated by a qualified ophthalmologist with a wide variety of sophisticated measures, including injections, lasers, and surgery.
• Untreated PDR inevitably leads to blinding complications.
• A diabetic vitreous hemorrhage may absorb or regress of its own accord, or remain persistently in the vitreous cavity, obscuring the view of the abnormal underlying retina.
• Persistent vitreous hemorrhage may necessitate surgical removal by a technique called pars plana vitrectomy (PPV) or simply vitrectomy.
  • This advanced procedure is accomplished by a vitreoretinal surgeon using an operating microscope and 3 microincisions into the vitreous cavity through the pars plana.
  • The pars plana is a circular band of tissue about 3 to 4 millimeters behind the cornea.
  • Because the pars plana contain no major blood vessels and no retinal tissue, safe access is available to the surgeon.

A number of other conditions can less commonly produce vitreous floaters, including

• hemorrhagic macular degeneration,
• retained foreign bodies,
• postoperative matter, or
• rare parasitic infections, more common in third-world nations.

Patients may describe a wide variety of symptoms, including

• spiders or insects darting across their vision,
• cobwebs,
• dirt on the windshield,
• spots,
• strands,
• black spots in their vision,
• squiggly lines, and of course,
• floaters.

There is a wide variety of presentations. Floaters are generally more noticeable to patients in bright lighting conditions such as outdoor activity or brightly illuminated computer screens, binoculars, or microscopes. This is because the bright illumination increases the contrast between the darkness of the floater and the surrounding light, making the floaters more apparent. Floaters generally jiggle or move when the eye moves. This is because the vitreous gel is a dynamic structure and compresses slightly with eye movements. Thus, when the patient looks to the right, for example, the floater may first dart to the right and then re-center as the vitreous gel returns to its normal resting position.

Patients with other conditions causing some loss of vision, such as cataracts or macular degeneration, may not notice their floaters as much.

• Some patients with large or numerous floaters upon examination may have few complaints and minimize their symptoms. One fascinating condition known as asteroid hyalinosis is characterized by dozens or even hundreds of small yellowish floaters throughout the vitreous cavity in one or both eyes.
• Patients with asteroid hyalinosis are often remarkably unaware or unperturbed by their vitreous opacities.
• Other patients with demanding jobs or hobbies, such as professional truck drivers or outdoor athletes, may have more complaints and the presence of floaters may have a more profound impact upon their daily living.

It is impossible to determine whether or not a new onset floater is benign or pathologic based solely upon the symptoms. Thus patients with new-onset floaters should seek the care of their eye-care professional, their ophthalmologist, or optometrist. A visit to an internist, pediatrician, primary-care doctor, urgent-care doctor, emergency-room doctor, or other non-eye-care professional is simply inadequate to ascertain a proper diagnosis. Only eye-care professionals have the expensive and complex complement of diagnostic equipment and the expertise to provide a diagnosis. In some instances, healthcare plans create barriers to specialists and a referral must be obtained prior to visiting the appropriate eye-care professional. These hurdles must be engaged and overcome.

Patients with a longstanding history of floaters that are familiar in character to the patient need not suddenly panic and seek care unless there is an obvious change in the size, shape, intensity, or density of the floaters. Other alarming symptoms include blurred vision, red-eye, pain in the eye, tenderness, a severe discharge from the eye, photophobia or aversion to bright lights, new onset of flashes, and of course loss of vision.

Some patients have a higher risk for pathologic causation of their floaters and should seek professional care immediately. These at-risk patients include those with known retinal diseases, diabetes, previous eye surgery, previous eye trauma, recent eye trauma, previous eye inflammation or uveitis, bleeding disorders, chemotherapy, and anticoagulation therapy. Anticoagulants are commonly used for a wide variety of conditions such as deep vein thrombosis, pulmonary embolism, stroke, heart attack, or coronary stents. Anticoagulant therapy includes warfarin (Coumadin), clopidogrel (Plavix), and aspirin (Bayer).

Patients with arthritis or joint pain from athletic injury very frequently take oral NSAIDs or nonsteroidal anti-inflammatory drugs. These medications thin the blood and may also increase the risk of a vitreous hemorrhage. Many over-the-counter (OTC) cold and sinus medications also include low doses of an NSAID. Just as these medications can cause an increased risk of bruising under the skin, there may be an associated increased risk of vitreous hemorrhage from otherwise benign events. NSAIDs include naproxen (Naprosyn, Aleve), ibuprofen (Motrin), and aspirin.

If your doctor is not an ophthalmologist or optometrist, ask for a referral. If you have been examined by an eye-care professional, then be sure you understand the diagnosis, the potential complications, and the required treatment or follow-up care. Generally, even a benign PVD or syneresis diagnosis requires a follow-up visit within the subsequent two to 12 weeks to ascertain the benign nature of the condition and look once again for hemorrhage or retinal tears.

If treatment is recommended or referral to a retinal specialist is made, be certain that you understand the advice and have a referral appointment made at the earliest advised time. If a change in your medications is advised, then be sure you understand the recommendation, which may require additional consultation, at least by telephone, with your medical doctor prior to discontinuation of a given medication such as Coumadin.

A chief complaint of eye floater, particularly of recent onset, requires a full eye evaluation and examination, including dilation of the pupils in one or both eyes. The evaluation includes

• a vision check (visual acuity),
• an eye pressure measurement (tonometry),
• examination under the slit lamp or biomicroscope, and
• examination of the vitreous and retina after dilation.

The vitreous and retina comprise the posterior segment or back of the eye.

• Highly specialized polished and coated lenses are used to view the posterior segment through the slit lamp and with the indirect ophthalmoscope. The indirect is worn on the head of the eye doctor and strongly resembles a coal miner's hat. Many of the lenses used to view the posterior segment are simply handheld without contacting the eye. At times, a full view cannot be afforded by non-contact means, and a lens that touches the eye is required.
• In order to accomplish this diagnostic contact lens examination, a drop of anesthetic is first placed in the eye, the removable contact lens is sterilized and a thick lubricant is placed on the lens. This same type of lens is often used during laser surgery of a retinal tear.

Additional testing may be recommended by your eye-care professional. These tests may include

• photography of the posterior segment,
• visual field testing to assess loss of central or peripheral vision,
• retinal tomography imaging to determine the thickness of the retina or optic nerve or fluorescein angiography to assess blood vessel leakage.
• Complete evaluation and treatment of pathologic causes of eye floaters may require several visits to your eye doctor.

Benign eye floaters caused by vitreous syneresis and posterior vitreous separation or detachment (PVD) do not require specific treatment. Additional observation may be required. Patients are generally cautioned to watch for more serious symptoms suggestive of retinal disease, including:

1. the onset of new or more dense floaters,
2. onset or worsening of flashes or photopsia,
3. worsening of visual acuity,
4. the appearance of a curtain of lost vision emanating from any direction.

Pathologic floaters may necessitate a wide variety of therapeutic interventions. The treatment of a retinal hole is accomplished most readily by a laser surrounding the hole and thus sealing the retina from ingress of fluid that could cause a detachment. The repair of a retinal hole will not in itself decrease the symptom of floaters. Sometimes a retinal hole may require more aggressive intervention, including the injection of gas into the vitreous cavity (pneumatic retinopexy), freezing therapy (cryotherapy), or even a vitrectomy.

A retinal detachment is far more serious than a retinal hole, especially when a large portion of the retina is detached or when the detachment involves the macula or center of vision. The earlier the intervention, the better the results, generally speaking. This timing judgment can only be made by a qualified ophthalmologist with expertise in retinal and vitreous disorders. Retinal detachments can occasionally be accomplished in an office setting utilizing the pneumatic retinopexy technique. More serious detachments require a trip to the operating room, the injection of anesthetic agents around the eye, and extensive repairs using sclera buckles, pars plana vitrectomy, cryotherapy, or intraocular endolaser. Operative detachment techniques may also require the infusion of specialized gases or oil into the vitreous to accomplish a reattachment.

Diabetic retinopathy presents a growing challenge to eye-care specialists due to the burgeoning population of patients with both types I childhood-onset and type II adult-onset diabetes mellitus. If diabetic retinopathy is allowed to progress to the proliferative stage (PDR) wherein abnormal friable new vessels appear, the risk of blindness is markedly increased. The treatment of PDR involves a wide variety of treatment modalities customized by the retinal specialist to the individual patient's needs. Treatments may include laser therapy with pan-retinal photocoagulation (PRP) to deter the impetus to new blood vessel formation. Newer injection techniques with highly advanced biotechnology medications have also been used successfully for PDR. Recalcitrant or progressive PDR often requires surgical intervention utilizing modern vitrectomy techniques. When PDR advances to a scarring stage, also called fibrotic or cicatricial, the surgery becomes far more difficult and the prognosis deteriorates.

Thus, every stage of diabetic retinopathy requires close observation and intervention. Every diabetic patient should have at least an annual dilated eye examination by their eye-care professional. If this simple recommendation was actually fully executed, the morbidity, costs, and blindness due to diabetic retinopathy would be markedly reduced. Central to the avoidance and control of diabetic retinopathy is the aggressive control of blood sugar, weight, blood pressure, and other parameters essential to good health. Additional measures also should include immediate cessation of all tobacco use, regular exercise, and dietary consultation with reduction of glycemic load.

Benign eye floaters require no additional care, other than a follow-up examination as recommended.

• Pathologic eye floaters require exquisite cooperation with the eye doctor to take all prescribed oral and eye drop medications,
• make all scheduled follow-up and treatment visits, and restrict an activity if necessary.
• Collaboration with the family doctor, internist, or endocrinologist may be essential as well.

• There are no specific medications for eye floaters, benign or pathologic.
• There are no medicinal means to dissolve or remove eye floaters, despite what some less reputable Internet marketers may persuade.

Medications recommended by your eye-care professional may be necessary to control underlying conditions leading to vitreous hemorrhage or retinal disease. These medications may be taken in conjunction with a laser, cryotherapy, pneumatic retinopexy, vitrectomy, or retinal detachment surgery.

Furthermore, some medications may be discontinued to optimize the treatment of pathologic floaters. Follow only the recommendations of your eye-care professional in conjunction with your medical doctors.

Surgery is almost always not recommended for benign eye floaters. Some patients are annoyed by the floaters and are best advised to avoid those circumstances in which the floaters are most bothersome. The classic advice is that the treatment is worse than the disease.

• Pars plana vitrectomy (PPV) is a remarkable modern technique that can remove most of the vitreous contents, including virtually all the noticeable central floaters.
  • Due to the significant effort and cost entailed by PPV, its use for minor conditions is not warranted or recommended.
  • There are approximately one in 1,000 risks of serious complications following PPV, including infection.
  • This admirably low rate nevertheless does not justify major surgery for a benign nuisance condition.

Some patients by nature of their profession are significantly hindered by larger or very central floaters. After careful consultation with the retino-vitreal surgeon, a PPV may be recommended in very specific and unusual cases. These professions might include

• pilots,
• truck drivers,
• athletes, or
• jobs where continuous outdoor work in bright sunlight renders the floaters severely symptomatic.

Because the most common side effect of a PPV is cataract formation, the patient must be fully aware of a decision to move forward with elective PPV surgery for floaters. PPV for serious pathologic conditions such as PDR or vitreous hemorrhage is clearly warranted despite the risks.

Some eye-care providers recommend laser therapy to dissolve or remove vitreous floaters. Unfortunately, this is not standard therapy, and efficacy is not generally accepted by most eye-care practitioners. There are no prospective randomized clinical trials to demonstrate the safety of the efficacy of laser therapy for benign vitreous floaters. Until such trials are accomplished, or a laser specifically designed to efficiently and safely dissolve floaters is developed, laser treatment for floaters is not considered by any means a standard or acceptable practice.

Hyaluronic acid is a very common protein in many tissues throughout the body. It is also present in the vitreous cavity. An enzyme capable of dissolving hyaluronic acid called hyaluronidase is available for vitreous injection.

• It has been investigated for the treatment of vitreous disorders and may be appropriate for some pathologic conditions.
• It is not recommended for routine benign vitreous floaters.
• Consult your eye-care professional if you have questions about treatments for your floaters.

Benign eye floaters cannot be prevented. They occur at all ages and most frequently for no apparent reason. Because some floaters follow ocular injury, prevention of eye trauma is a wise strategy.

• Projectile sports such as baseball, squash, racketball, and lacrosse should always incorporate an eye-protection regimen.
• Competitive combat sports such as karate should also require eye protection.

Pathologic floaters due to diabetic disease can be prevented by regular examinations and exquisite control of blood sugar.

• Highly myopic patients who are also at increased risk of retinal detachment should also have regular at least yearly eye examinations.

• If you have stable longstanding floaters, be sure to mention them at your next eye examination.
• If you have the onset of new eye floaters, with or without flashes or photopsia, make an appointment with your ophthalmologist or optometrist as soon as possible.
• If you have the onset of new eye floaters, with or without flashes or photopsia, and have diabetes, previous ocular surgery or trauma, recent eye trauma, take anticoagulants, or have other at-risk conditions, make an appointment with your ophthalmologist or optometrist immediately.
• If you have the onset of new eye floaters, with or without flashes or photopsia, and the loss of vision or ocular pain, make an appointment with your ophthalmologist or optometrist immediately.

Follow-up recommendations can only be made by your eye-care professional, and only after an examination in their office. Recommendations cannot be made over the telephone other than the timeliness of your appointment.

The outlook for benign floaters is highly positive. For pathologic floaters, early detection and appropriate treatment with the highly sophisticated tools available to modern medicine also portend a generally favorable prognosis in uncomplicated cases.

Benign eye floaters generally do not disappear completely. The vitreous gel and its protein remain within the eye for life.

• However, the density of floaters often decreases with time and decreases more rapidly with the separation or if PVD is complete and the posterior vitreous face has been completely removed from the optic nerve.
• In addition, some patients only notice their floaters in bright lighting conditions or in situations where there is a bright homogenous white background, such as looking out an airplane window or into a microscope.
• Some PVD patients notice extra "microbes swimming around" when looking at a microscope slide from a routine clinical specimen for example.
• Furthermore, the brain becomes accommodated to the presence of floaters and learns to ignore them in everyday life.
• This adaptation to the presence of the floaters renders the condition less bothersome or annoying.