Efficacy and safety of early YAG laser vitreolysis for symptomatic vitreous floaters: the study protocol for a randomized clinical trial

BACKGROUND

Vitreous floaters are a common ocular condition that affects individuals of all ages. Although vitreous floaters are typically benign, they can significantly impair visual acuity and quality of life. Laser vitreolysis, which uses an Nd: YAG laser to vaporize collagenous vitreous opacities, is increasingly being used as a treatment option. However, there is currently a lack of evidence regarding its efficacy and the appropriate timing of its application. This study aims to evaluate the efficacy and safety of early intervention with YAG laser vitreolysis in treating symptomatic vitreous floaters.

METHODS

The present study is a randomized, controlled, double-blind clinical trial. A total of 70 participants with symptomatic floaters for 1 month were prospectively recruited. These participants will be randomly assigned to two groups, with 35 individuals in each group: the early treatment group and the delayed treatment group. Participants assigned to the early treatment group will undergo YAG laser vitreolysis immediately, followed by a sham laser treatment 3 months later. On the other hand, participants assigned to the delayed treatment group will receive a sham laser treatment and then undergo YAG laser vitreolysis 3 months later. The follow-up time points will be 1, 3, 6, and 12 months from randomization. Primary outcomes will be participants' self-reported improvement in visual disturbance on a scale of 1 to 10 and their scores on the National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25). Secondary outcomes will be an objective evaluation of the effectiveness of the treatment in reducing vitreous floaters through OCT and fundus photography and tracking any adverse events related to the eyes or overall health.

DISCUSSION

This clinical trial aims to evaluate the effectiveness of YAG laser vitreolysis in treating symptomatic vitreous floaters and assess the safety of performing early intervention with YAG laser vitreolysis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05800353 . Registered on 10 March 2023.

Choroidal vascularity index changes in different treatments for vitreomacular traction

INTRODUCTION

The aim of this study was to examine if choroidal vascularity index (CVI) is different in eyes with unilateral vitreomacular traction (VMT) from their healthy fellow eyes; and whether different treatments affect the CVI.

METHODS

The baseline and 8-week post treatment CVIs of 56 unilateral VMT patients that underwent spontaneous resolution (n = 30), vitreoretinal surgery (n = 16) or pneumatic vitreolysis (n = 10) were compared with fellow eyes using paired samples t-test. Partial correlation analyses correcting age and gender was used for calculations between treatment groups. P values < 0.05 were considered statistically significant.

RESULTS

The mean baseline CVI for VMT and control eyes had no statistically significant difference (p = 0.81, r= -0.38). The post traction release follow-up CVI of VMT eyes and contralateral eyes had no significant difference (p = 0.12, r = 0.49). In spontaneous resolution group, vitreoretinal surgery group and pneumatic vitreolysis group the baseline and follow up CVIs of VMT eyes were statistically similar (p = 0.72, p = 0.32 and p = 0.79 respectively).Spontaneous detachment patients' CVIs showed a 0.57±5.81% increase, vitreoretinal surgery group had a reduction of 1.098±4.76%, and the pneumatic vitreolysis patients showed a CVI reduction of 0.307±4.24%. However, none of these changes was found to be statistically significant when compared between the groups (p = 0.21, r = 0.02).

DISCUSSION

Previous studies have argued that vitreomacular traction might have a role on the choroidal changes seen in the vitreoretinal interface disorders. This study has shown that VMT alone does not cause any significant changes in choroidal vascular index pre or post traction release.

Practical applications of vitreous imaging for the treatment of vitreous opacities with YAG vitreolysis

PURPOSE

To demonstrate the methodology and efficacy of using scanning laser ophthalmoscopy (SLO) and dynamic optical coherence tomography (OCT) to identify and treat symptomatic vitreous floaters using yttrium-aluminum garnet laser vitreolysis (YLV).

METHODS

This is a case series highlighted from a cross sectional retrospective study conducted at the Vitreous Retina Macula Specialists of Toronto. Forty eyes from thirty-five patients were treated with YLV between November 2018 and December 2020 for symptomatic floaters and imaged with SLO and dynamic OCT. Patients were re-treated with YLV if they reported ongoing significant vision symptoms during follow-up which correlated to visible opacities on exam and or imaging. Three cases will be highlighted to present the practical applications of SLO and dynamic OCT imaging for YLV treatment.

RESULTS

Forty treated eyes were enrolled in this study, with twenty-six eyes (65%) requiring at least one repeat YLV treatment following the first treatment due to ongoing symptomatic floaters. Following the first YLV, there was a significant improvement in overall mean best corrected visual acuity compared to before treatment (0.11 ± 0.20 LogMAR units vs. 0.14 ± 0.20 LogMAR units, p = 0.02 (paired t test)). Case 1 demonstrates a dense, solitary vitreous opacity that has been localized with dynamic OCT imaging to track its movements and retinal shadowing with the patient's eye movements. Case 2 shows the utility of adjusting the fixation target to monitor the movement of vitreous opacities in real-time. Case 3 exhibits an association between decreased symptom burden and vitreous opacity density after YLV.

CONCLUSION

Image-guided YLV facilitates the localization and confirmation of vitreous opacities. SLO and dynamic OCT of the vitreous can provide a real-time evaluation of floater size, movement, and morphology, to help clinicians target treatment and monitoring of symptomatic floaters.

Application of Nd:YAG laser to the anterior vitreous in malignant glaucoma - a systemic review and meta-analysis

PURPOSE

The study aims to review the efficacy, safety, and technique of Nd:YAG laser vitreolysis for the management of malignant glaucoma (MG).

METHODS

We performed a search of electronic databases for all published studies which included technical specifications of Nd:YAG laser application for MG. Individual patient data was extracted and evaluated in a weighted pooled analysis.

RESULTS

Thirty eyes were reported on from seven studies worldwide. Age of affected patients ranged between 37 and 82 years. Nd:YAG vitreolysis was performed either through an iritodomy (66.7%, 18/27 eyes), transpupillary (18.5%, 5/27 eyes), or through both simultaneously (14.8%, 4/27 eyes). Treatment intensity ranged between 1.0 and 11.00 mJ with 75.9% (22/29 eyes) of treatments being 3.0 mJ or lower. Between 1 and 41 pulses per session were applied. Rates of both anatomical and intraocular pressure resolution were examined. Overall, in a pooled analysis, 77% of eyes demonstrated MG resolution with no further treatment required after Nd:YAG vitreolysis (95% CI: 58.1 to 91.4%). A trend for lower need of additional interventions was seen with transpupillary application (11.1% versus 42.1%). No complications were reported.

CONCLUSIONS

Nd:YAG laser vitreolysis is a safe procedure, associated with MG resolution in the majority of reported cases, regardless of treatment intensity. Transpupillary treatment may be associated with lower risk of re-intervention.

The Efficacy and Safety of YAG Laser Vitreolysis for Symptomatic Vitreous Floaters of Complete PVD or Non-PVD

INTRODUCTION

To evaluate and compare the efficacy and safety of YAG laser vitreolysis in treating symptomatic vitreous floaters of complete posterior vitreous detachment (PVD) and non-PVD.

METHODS

In this prospective cohort study, 51 eyes with symptomatic floaters were treated with YAG laser vitreolysis. Participants were divided into complete PVD and non-PVD groups. Objective visual quality measures including the Strehl ratio (SR), internal spherical aberration (SA), internal comatic aberration (CA), internal high-order aberration (HOA), area ratio of modulation transfer function (MTFa) and Vitreous Floaters Symptom Questionnaire (VFSQ-13) scores were used to compare the efficacy of YAG laser vitreolysis treatment between two groups.

RESULTS

The mean age of all patients was 56.80 ± 10.82 years old. In total, 36 of 51 (70.59%; 95% CI 58.10-83.10) patients reported their symptoms as significant or complete improvement after YAG laser vitreolysis treatment. Post-treatment MTFa, internal SA and internal HOA were significantly better compared to baseline (26.19 ± 14.73 vs. 29.19 ± 17.98, p = 0.013; 0.05 ± 0.05 vs. 0.04 ± 0.04, p = 0.031 and 0.23 ± 0.22 vs. 0.16 ± 0.07, p = 0.044; respectively) in all eyes. Twenty-nine of 51 (56.86%) eyes had floaters of non-PVD type. Significant or complete subjective improvements in the PVD group and non-PVD group were 72.73% and 68.97% (p = 0.344), respectively.

CONCLUSIONS

Improved subjective and objective visual quality in participants with symptomatic floaters following YAG laser vitreolysis was found in both groups. The efficacy of YAG laser vitreolysis was comparable in floaters of complete PVD and non-PVD types.

Safety and Efficacy of YAG Laser Vitreolysis for the Treatment of Vitreous Floaters: An Overview

Emerging evidence has suggested that the entoptic phenomena associated with vitreous opacities (i.e. vitreous floaters) are more bothersome than previously believed. In addition, the prevalence of vitreous floaters is likely increasing due to the evolving global pandemic of myopia. The use of YAG laser vitreolysis for the treatment of annoying vitreous floaters has attracted significant attention in recent years as the technique offers a number of potential advantages. Unfortunately, the currently available evidence that is needed to guide clinical practice is both very limited and contradictory. As a consequence, the technique remains highly controversial. A review of the existing literature sheds light on patient- and treatment-related factors that may significantly affect both the effectiveness and the safety of the procedure. The current article discusses important aspects of key publications on the topic, offers suggestions for clinical practice, and highlights unmet needs that should be addressed by future research.

Objective assessment of YAG laser vitreolysis in patients with symptomatic vitreous floaters

Background

To objectively evaluate YAG laser vitreolysis for symptomatic vitreous floaters using color photo imaging.

Methods

In this interventional and prospective study, 32 eyes of 32 patients with symptomatic vitreous floaters secondary to posterior vitreous detachment (PVD) were treated with a single session of yttrium aluminum garnet (YAG) laser. Primary outcomes were objective and subjective changes measured by masked grading of color fundus photographs and National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25), respectively. Secondary outcomes included Early Treatment Diabetic Retinopathy Study (ETDRS), best-corrected visual acuity (BCVA) and adverse events. Wilcoxon signed-rank test was used to analyze the results of the objective and subjective assessments at each time point. P < 0.05 was considered statistically significant.

Results

Thirty-two patients (32 eyes; 13 men and 19 women) with symptomatic vitreous floaters were enrolled in this study (mean age: 59.4 years). All study patients were followed up for 6 months. Following the laser vitreolysis, there was a statistically significant improvement in both the near visual function (z = - 2.97; p = 0.003; r = 0.633) and visual disturbance rate (z = - 3.97; p < 0.001; r = 0.84). Distance visual function did not show statistically significant difference after the laser procedure (p = 1.00). Color fundus photograph did reveal vitreous opacity improvement over time in 93.7% of study eyes (partial improvement in 37.5% and total improvement in 56.2% of study eyes). During the follow-up period, recurrence of vitreous floaters, BCVA deterioration and adverse events were not observed.

Conclusions

YAG laser vitreolysis decreased the amount of vitreous floaters opacities seen on color fundus imaging and improved related symptoms according to the NEI VFQ-25 responses.

Long-Term Results of Vitrectomy for Macular Holes after Failure of Vitreolysis

PURPOSE

Ocriplasmin injection may close some small-to-medium macular holes associated with vitreoretinal traction. If the treatment fails, does vitrectomy and gas injection yield the same results as primary surgery?

MATERIAL AND METHODS

We report a retrospective case series study of 3 eyes of 3 consecutive patients operated on a few months after initial intravitreal injection of ocriplasmin and enlargement of the macular hole. The minimal follow-up period after surgery was 18 months.

RESULTS

Surgery was uneventful in all cases. Vitrectomy, internal limiting membrane peeling, and gas injection allowed closing of the 3 macular holes with a progressive improvement in visual acuity over time. Before ocriplasmin injection, visual acuity ranged from 20/60 to 20/32, after failed ocriplasmin injection from 20/80 to 20/40, and at the final follow-up after 18 months from 20/32 to 20/25.

CONCLUSION

Vitrectomy with internal limiting membrane peeling leads to closure of macular holes even in cases of prior failure to close them by ocriplasmin injection.

[Ocriplasmin as a treatment option for symptomatic vitreomacular traction with and without macular hole. First clinical experiences]

PURPOSE

To evaluate the resolution rate in patients with symptomatic vitreomacular traction (≤ 1500 μm) with or without macular holes (≤ 400 μm) after therapy with intravitreal ocriplasmin (Jetrea®) injection in a clinical setting.

METHODS

Until now we have prospectively examined 21 eyes of 21 consecutive patients with symptomatic vitreomacular traction with or without macular holes who underwent intravitreal operative injection of 0.1 ml ocriplasmin. The best corrected visual acuity and high-resolution optical coherence tomography (SD-OCT) ultrastructural parameters were measured before injection and again 1, 3 and 4 months after treatment. The numbers of resolved vitreomacular traction and closed macular holes were documented.

RESULTS

Vitreomacular traction was resolved in 15 out of 21 (71 %) eyes. Of the five eyes which initially presented with vitreomacular traction with macular holes, all showed resolution of vitreomacular traction but only two of the macular holes were closed. The average best corrected visual acuity was 0.38 logMAR (± 0.23) at baseline and 0.43 logMAR (± 0.28), 0.38 logMAR (± 0.27) and 0.36 logMAR (± 0.24) 1, 3 and 4 months after injection, respectively. The average foveal thickness was 355.95 μm (± 114.53 μm) at baseline, reducing to 304.61 μm (± 100.91 μm), 308.00 μm (±76.17 μm) and 277.50 μm (± 26.24 μm) after 1, 3 and 4 months, respectively.

CONCLUSION

In this ongoing study there was a high percentage of resolution of vitreomacular traction (71 %) 1 month after intravitreal operative injection of Jetrea® and closure of two out of five macular holes. This was further associated with stabilization of visual acuity and reduction of foveal thickness. Further investigations are necessary to document the effectiveness of the pharmacological vitreolysis in a clinical setting.

Treatment of vitreomacular traction syndrome with autologous plasmin enzyme

PURPOSE

To determine whether intravitreal injection of autologous plasmin enzyme (APE) is effective in vitreomacular traction syndrome (VMTS) by improving visual acuity and restoring macular morphology.

METHODS

A prospective study of 11 consecutive patients diagnosed with VMTS in the Ophthalmology Department from January to May, 2011.

INCLUSION CRITERIA

best corrected visual acuity (BCVA) less than 0.5, and vitreomacular attachment in foveal area resulting in macular thickness>250 microns diagnosed by optical coherence tomography (Cirrus OCT, Carl Zeiss Meditec, Inc, Oberkochen, Germany).

EXCLUSION CRITERIA

active proliferative diabetic retinopathy, axial myopia>26mm, vitrectomy, glaucoma, previous intravitreal injections and previous rhegmatogenous detachment. One to 3 monthly intravitreal injections of 0.2ml of APE were applied, interrupting if posterior vitreous detachment was attained. Wilcoxon's test was used for statistical analysis.

RESULTS

A total of 12 eyes of 11 patients were treated. A complete posterior vitreous detachment was achieved in 4 (33%) eyes at the end of the study, 2 of them with one injection, and 2 with 3 monthly injections. Improvement of BCVA was statistically significant (P=.017) and the decrease in central macular thickness also was statistically significant (P=.016). There was only one complication: intraocular hypertension after injection that subsided with a new paracentesis.

CONCLUSIONS

Intravitreal APE injections avoided vitrectomy in VMTS in one in every 3 patients.

Incomplete vitreomacular traction release using intravitreal ocriplasmin

Purpose

To report the clinical course of our first 7 consecutive patients treated with intravitreal ocriplasmin (Jetrea^®).

Methods

Retrospective case series of the first 7 patients treated with ocriplasmin between January and December 2013 at an academic tertiary care center.

Results

The average age was 78.4 years (range: 63–92). Five patients were pseudophakic and 2 patients were phakic in the injected eye. The median baseline visual acuity (VA) was 20/60 (range: 20/25 to 20/200). The median 1-month postinjection VA was 20/70, with a mean loss of 2 lines of VA among all patients. None of the patients had complete resolution of their vitreomacular traction or macular hole at 1 month of follow-up. Three patients had subsequent pars plana vitrectomy and membrane peeling surgery. The mean follow-up period for those who did not undergo vitrectomy was 9 months (range: 1–13). One patient with known ocular hypertension had an increase in intraocular pressure requiring topical pressure-lowering eyedrops. There were no cases of postinjection uveitis, endophthalmitis, retinal tears, or retinal detachment.

Conclusions

While ocriplasmin may be a viable pharmacological agent for vitreolysis, we present a series of patients that all had incomplete resolution of vitreomacular traction with and without full-thickness macular hole. There was an associated reduction in VA after ocriplasmin treatment at 1 month of follow-up. Careful analysis of the vitreoretinal interface and comorbid eye conditions is required to optimize outcome success with ocriplasmin.