FLOATERECTOMY DEBATE

Thomas Wolfensberger MD

Floaterectomy in an otherwise healthy eye remains a highly controversial topic in vitreoretinal surgery. What is considered by some surgeons to be a legitimate medical procedure that improves patients’ quality of life, is for others simply a cosmetic procedure with high risks of serious complications.

It was within this context that Thomas Wolfensberger MD, of Jules Gonin Eye Hospital, Lausanne, Switzerland and Alistair Laidlaw MD, of the London Eye Clinic, battled it out in the Amsterdam Retina Debate at the 14th EURETINA Congress in London.

Dr Wolfensberger made the case for floaterectomy while Dr Laidlaw argued against the procedure.

“Many of these patients with vitreous floaters are desperate, pleading for help. We as vitreoretinal surgeons can provide the only floater treatment that has actually been proven to work,” stated Dr Wolfensberger.

He reviewed the published evidence in support of floaterectomy, pointing out the high levels of patient satisfaction and low incidence of complications.

“An overwhelming majority of patients who are treated view the operation as very successful, both in terms of improvement of visual symptoms and the limited peri- and postoperative pain,” he added.

In the spirit of a classic British debate tinged with humour, Dr Wolfensberger then outlined in increasing order of importance “The top five reasons why I do floaterectomies”.

Reason No 5: “Patients with floaters suffer more than you will ever know, unless you have floaters yourself.”

Reason No 4: “Decades of surgical experience have honed the technique of floaterectomy.”

Reason No 3: “Risk is part of life! Its evaluation is a very personal matter. The absence of floaters may mean a new life for some patients.”

Reason No 2: “An overwhelming majority of patients, up to 95 per cent, view the operation as very successful.”

And finally, the No 1 reason to do floaterectomies: “Apart from enucleation, floaterectomy is the only surgical procedure in ophthalmology that has a guaranteed 100 per cent anatomical success rate.”

This facetious comment was greeted with muffled murmuring and chuckling throughout the crowded auditorium. “Of course, if you want to avoid all risks, then you shouldn’t operate,” concluded Dr Wolfensberger.

NUANCED APPROACH

Dr Laidlaw began on the offensive: “My opponent’s Reason No 1 is simply not true. Nothing in medicine is 100 per cent.”

He then took a more nuanced approach. “I realise that this side of the argument is nearly unwinnable, so I decided to change my tactic. I will argue that floaterectomy is rarely justified,”
he said.

“Floaterectomy is undoubtedly effective if uncomplicated, but I believe the risks to be underestimated. The studies often fail to consider the long-term complications, which can include RD in up to 10 per cent at five years postoperatively. Even with this underestimation, less than 10 per cent of patients complaining of floaters elect to
undergo surgery.”

Dr Laidlaw emphasised the proper selection of eyes to operate, in particular regarding the status of the posterior vitreous. The treatment is particularly suited in cases of syneretic clumping, as opposed to posterior vitreous detachment-related floaters (PVD). The symptoms in patients with a PVD will usually remit spontaneously.

“Of course, you always have to exclude uveitis as a potential cause of the floaters and screen for retinal pathology,” he said.

Dr Laidlaw also warned against the potential large discrepancy between patients’ symptoms and the intraocular signs.

“Somatization is not infrequent. Anxiety depressive disorder is common within this patient population, so look out for patients in whom the vitreous changes are not as marked as their symptoms.

“When I suspect it, I refer to a psychiatrist as the primary pathology can be psychological, not vitreal. When I see a patient with recent onset floaters I assess for serious pathology, reassure them, and provided all is well, advise them that help is at hand if required. I then discharge them.”

Pointing to his own data, he explained: “A PVD is present in 75 per cent of patients that I see with floaters and about one in 20 of them will eventually want surgery . The other 25 per cent of patients have syneretic floaters, and about one in three of them will want an operation. I only operate after a very extensive discussion of the risks.”

The debate ended in a perfect draw, with each debater earning exactly 50 per cent of the votes cast by the audience.

Thomas J Wolfensberger: thomas.wolfensberger@fa2.ch

Alistair Laidlaw: a.laidlaw@thelondonclinic.co.uk