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Safer eye floater treatments come with a burst of nanobubbles

Between invasive surgery or risky laser therapy, people suffering from severe eye floaters have no great treatment options. now, with the development of a safer and less invasive nanoparticle-based therapy, people with floaters may finally get their vision and quality of life back..

Stephanie joined Drug Discovery News as an Assistant Editor in 2021. She earned her PhD from the University of California Los Angeles in 2019 and has written for Discover Magazine,...

Sometimes they sit just out of sight in the corner of your eye. Other times they waft across your vision, and when you shift your gaze to look at them, they fly out of sight. These pesky obstructions, commonly referred to as floaters, are a visual phenomenon caused by small clumps of collagen in the eye called vitreous opacities. 

While floaters are very common, they are typically unobtrusive enough that people ignore them. Sometimes, however, floaters can be so dark and numerous that they obscure large swaths of a person’s vision. These severe floaters impair people’s ability to drive, work, and simply enjoy their lives, often leading to depression (1).

“There are millions of people in the world suffering from floaters,” said Yannis Paulus, a vitreoretinal surgeon and clinician scientist at the University of Michigan. “Currently, they’re stuck with bad options,” he added. The only available treatments have a significant number of risks.

These treatments include vitrectomy, the surgical removal of the clear gel-like vitreous of the eye that contains the collagen clumps, and laser vitreolysis, shining high-energy light pulses directed at the fibers to break them apart. Vitrectomy is more effective than laser vitreolysis, but patients have experienced retinal tears, detached retinas, and vitreous hemorrhage with both treatments.

While investigating how to make vitrectomy and laser vitreolysis safer and more effective, scientists are also developing new nanobubble-based technologies that may prove even safer and less invasive than the current treatments, improving the quality of life for the many people around the world suffering from disruptive floaters.

Clumps of collagen

The most common cause of floaters is simply getting older. In young eyes, collagen fibers bound to hyaluronan molecules hold together the gel-like structure of the vitreous. As people age, the collagen and hyaluronan begin to dissociate, and the gel becomes more liquid-like, causing the collagen fibers in the vitreous to collapse onto each other and form clumps, which are perceived as floaters.

People over 60 years old often begin to see more floaters due to their vitreous pulling away from the back of the eye in a phenomenon called posterior vitreous detachment. But because this de-gelling process happens faster in people with nearsightedness, nearsighted people in their 20s, 30s, and 40s can also experience floaters.

For people who notice a sudden burst of many new floaters, ophthalmologists first check for any signs of retinal detachments or injuries to the eye. But after ruling out an acute cause, doctors usually suggest that people wait a few weeks or months to see if their floaters seem to fade or become less noticeable. Usually, people experience some neuroadaptation, and the brain tunes out the floaters. But if the floaters don’t get better and they continue to detrimentally affect daily life, people return to their doctors seeking help.

“Unfortunately, the most common form of treatment is to dismiss them and ignore them and send the patient home frustrated and unhappy,” said Jerry Sebag, a vitreoretinal surgeon and floaters researcher at the Vitreous Macula Retina (VMR) Institute. “I started to realize that these patients are being dismissed because we had no way of identifying if they really have a problem, or if they're just overreacting to something that we all experience.”

Sebag and his colleagues developed quantitative assessments to measure how floaters affect people’s vision. They demonstrated that they could use quantitative ultrasound to characterize the density of the entire vitreous with floaters showing up as points and lines of increased density (2). Sebag’s team also reported that floaters decreased a person’s contrast sensitivity , meaning that people with floaters were less able to distinguish between differences in shading and patterns (3).

“With a quantitative component, it enables you to classify conditions as mild, moderate, and severe,” said Sebag. “It enabled me to select patients for treatment.”

Surgical incisions clear out floaters

The most effective way to treat floaters is to physically remove them. By performing a surgery called a vitrectomy, surgeons remove the vitreous from the eye and replace it with a clear gel.

While there are risks of retinal tears and detachments during vitrectomy, “you can usually identify those problems during the surgery. If you see a torn retina, you can laser it during the operation,” said Jason Hsu, a vitreoretinal surgeon and researcher at Thomas Jefferson University.

Vitreoretinal surgeons have recently made improvements to vitrectomies to make these retinal tears less likely. For example, they now use smaller gauge instruments to perform the surgery, meaning that they can make smaller incisions. Sebag has adapted his vitrectomy procedure with this modification and improved the method so that it doesn’t induce a posterior vitreous detachment during the surgery. With these safety modifications, Sebag’s team reported in a clinical study of 195 eyes from 145 patients that vitrectomy led to a 94.1% reduction in vitreous echodensity, indicating successful removal of the vitreous opacities that cause the appearance of floaters (4). The patient’s contrast sensitivity also improved to the level of healthy control eyes after surgery. Out of the 195 eyes operated on, there were three retinal tears and three retinal detachments, but these were successfully repaired during the surgery.

While vitrectomy is relatively safe and effective at treating severe floaters, it does lead to an increased risk for developing cataracts (5). Because of this and because other long-term risks of vitrectomy are unknown, Sebag and other vitreoretinal surgeons hesitate to operate on younger patients.

“I just haven't followed people for 30 years, so I can't answer that question,” said Sebag. As an alternative to vitrectomy, some ophthalmologists turned to a risky and somewhat controversial treatment: laser vitreolysis.

An explosion in the eye

Rather than physically removing the vitreous opacities that cause floaters, some ophthalmologists have tried blasting them apart with pulses of a yttrium-aluminum-garnet (YAG) laser.

“It's not like a typical laser beam that we think of like in Star Wars or something where it's burning tissue. The YAG laser is like a little explosion in the eye,” said Hsu. “It’s almost like evaporating some of the tissue with this high concentrated energy.” This process breaks up large aggregates of collagen into smaller pieces, reducing the appearance of floaters.

Ophthalmologists have used YAG lasers for decades to remove cloudy layers of scar tissue that form after cataract surgery and in the treatment of specific kinds of glaucoma, but their use to treat floaters is relatively new and somewhat controversial.

In the only clinical trial so far investigating the effectiveness of YAG laser vitreolysis for floaters, 54% of the patients who received the YAG treatment reported improvement in the appearance of floaters (6). None of the patients in the trial experienced any adverse effects.

There are, however, substantial risks associated with YAG laser treatment. The laser energies needed to blast apart the fibers that cause floaters are double or triple that of the energies used for the other more routine uses of YAG lasers. Even with the higher energy laser pulses, a person may need to sit through multiple sessions of YAG laser treatment to effectively break up a bothersome floater. In some instances, surgeons have focused the laser too close to the front or back of the eye, causing direct damage to the lens or the retina.

Citing these concerns, Inder Paul Singh, an ophthalmologist at the Eye Centers of Racine and Kenosha, explained that newer YAG lasers allow for better illumination of the vitreous, which helps ophthalmologists more easily orient themselves in the eye, decreasing the risks of damaging vital structures.

“Not every floater is a good candidate for YAG laser vitreolysis,” he said, but for example, if “the floater is in the middle of the vitreous where you can correlate signs and symptoms well, this can be a fantastic opportunity to avoid something like a vitrectomy and not to make [the patient] suffer living with it.”

While Singh has had much success treating floaters with YAG vitreolysis in his practice, that has not been the case for many other doctors.

“There is no protocol to guide the use of YAG laser, either in terms of which patients to select or in terms of how to really do the treatment in a reproducible scientific fashion,” Sebag said. He is organizing a study on how to make YAG vitreolysis more reproducible and safer using quantitative ultrasonography, among other methods, to measure outcomes.

Singh agreed that proper training on how to perform YAG vitreolysis is integral to successful floater treatment.

“The laser is not unsafe. It’s we as doctors who can be unsafe,” he said. “It's important for doctors to feel comfortable understanding where they are in the vitreous and learning how to maximize that view.”

He and others are investigating the use of systems to track floaters more accurately in the vitreous and the use of the more efficient femtosecond laser rather than a YAG laser for floater treatment, which would decrease the number of laser sessions needed to destroy floaters.

With the current risks associated with both vitrectomy and laser vitreolysis, researchers are looking for new strategies to treat floaters.

Nanobubbles bust up floaters

Before presenting his research at the Academy of Medicine in Belgium years ago, Stefaan De Smedt, a drug delivery researcher at Ghent University, had never considered nanobubbles as the next frontier in eye floater treatment. He and his team were interested in using vapor nanobubbles, which are produced by shining a laser at nanoparticles, as a method to deliver nucleic acids into cells.

When scientists shine a laser of a certain frequency at nanoparticles that are close together, the nanoparticles absorb the energy from the laser, which heats up the solution surrounding the nanoparticles, causing the liquid to evaporate and create nanobubbles. These nanobubbles expand and then pop tens to hundreds of nanoseconds after they form (7), leading to the creation of a mechanical force that can poke a hole in a cell membrane.

“I was talking to an ophthalmologist, [and] he said maybe it could be useful as well to see whether this kind of nanobubbles could be valuable to destroy aggregates,” De Smedt said.

Intrigued by the possibility, De Smedt and his postdoctoral fellow Félix Sauvage began testing the ability of vapor nanobubbles produced by different kinds of nanoparticles to destroy the collagen aggregates that cause floaters. In a new study published in Nature Nanotechnology , De Smedt and Sauvage, working in collaboration with Sebag, Paulus, and others, reported the success of nanobubbles produced by gold nanoparticles and an ophthalmologic dye to destroy collagen aggregates in vivo for the first time (8).

The researchers demonstrated that both gold nanoparticles coated in hyaluronan and the ophthalmologic dye indocyanine green (ICG) preferentially bound to and destroyed human vitreous opacities that had been isolated from vitrectomy patients in Sebag’s practice. Because the particles specifically bound to the collagen aggregates, the creation of nanobubbles only occurred at the aggregates. This means that even if the laser shines on a place in the eye with no nanoparticles or dye, no nanobubbles will be created to potentially damage other structures in the eye.

“The threshold to generate bubbles is very high,” explained Sauvage. “We have a selective manner to trigger the generation of bubbles.”

Encouraged by how well their technology worked in an ex vivo system, De Smedt’s team searched for the best animal model to test it in vivo . This proved to be somewhat of a challenge, because, as Paulus quipped, “you don't have a mouse telling you that it has floaters in its vision.”

The team finally landed on rabbits with their relatively large eyes, which are closer in size to those of humans, making them ideal models.

De Smedt, Sauvage, and their colleagues injected rabbit eyes with collagen fibers to give the rabbits vitreous opacities, then they either injected the gold nanoparticles or ICG and shined laser pulses into the rabbits’ eyes. They found that they only needed to use an average of five laser pulses to completely remove the collagen aggregates.

“When we saw that data about how effective it was, it was pretty stunning to me,” said Paulus. When the team assessed the safety of their technique, they found that it had no adverse effects on the rabbits’ retinas.

Because the nanoparticles and dye bind directly to the collagen fibers, the researchers could remove the vitreous opacities from locations in the eye that would be impossible using a YAG laser, such as close to the retina. Similarly, the aggregation of the particles allowed the researchers to use a lower energy laser to induce nanobubbles than that required for a YAG laser to break up fibers, vastly improving safety. 

This technology also improves on vitrectomy because it does not require a risky surgery, rather simply an injection of nanoparticles or dye into the eye. Eye injections are a common procedure for vitreoretinal surgeons, Paulus added.

“It's taking two things that we do in essence almost independently — these eye injections and the laser — and combining them,” he said.

Moving forward, De Smedt and his team are interested in investigating the pharmacokinetics of their gold nanoparticles and ICG in humans. While both gold nanoparticles and ICG are biocompatible, only ICG is biodegradable, making it the more likely of the two to move forward into future human clinical trials.

“Certainly, there's additional work in terms of clinical trials that we need to do before this is readily available for everyone, but I think it would really be a game changer in terms of the ability to treat these floaters in a manner that's minimally invasive with low risk. And I think it would really transform our care for patients,” said Paulus.

Although De Smedt did not initially set out to develop new treatments for floaters, he now understands what a non-invasive and effective treatment would mean for people suffering from floaters. After his team published their first paper on nanoparticles and floaters (9), he and Sauvage received hundreds of questions from people all over the world asking about the potential of the technology to treat floaters.

“I try to imagine how it feels to open your eyes and to feel always depressed about the fact that you cannot really see,” De Smedt said. “It can contribute to giving vision back to people, which means to give quality of life.”

• Kim, Y-K. et al. Psychological Distress in Patients with Symptomatic Vitreous Floaters. Journal of Ophthalmology   2017 , 3191576 (2017).
• Mamou, J. et al. Ultrasound-Based Quantification of Vitreous Floaters Correlates with Contrast Sensitivity and Quality of Life. Investigative Ophthalmology & Visual Science  56 , 1611-1617 (2015).
• Garcia, G.A. et al. Degradation of Contrast Sensitivity Function Following Posterior Vitreous Detachment. American Journal of Ophthalmology  172 , 7-12 (2016).
• Sebag, J. et al. Long-Term Safety and Efficacy of Limited Vitrectomy for Vision Degrading Vitreopathy Resulting from Vitreous Floaters. Ophthalmology Retina   2 , 881-887 (2018).
• Yee, K.M.P. et al. Incidence of Cataract Surgery after Vitrectomy for Vitreous Opacities. Ophthalmology Retina   1 , 154-157 (2017).
• Shah, C.P. & Heier, J.S. YAG Laser Vitreolysis vs Sham YAG Vitreolysis for Symptomatic Vitreous Floaters: A Randomized Clinical Trial. JAMA Ophthalmol   135 , 918-923 (2017).
• Xiong, R. et al. Comparison of gold nanoparticle mediated photoporation: vapor nanobubbles outperform direct heating for delivering macromolecules in live cells. ACS Nano   8 , 6288-6296 (2014). 
• Sauvage, F. et al. Laser-induced nanobubbles safely ablate vitreous opacities in vivo. Nat Nanotechnol (2022).
• Sauvage, F. et al. Photoablation of Human Vitreous Opacities by Light-Induced Vapor Nanobubbles. ACS Nano   13 , 8401-8416 (2019).

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Optegra Leads the Way in Successful New Treatment for Floaters

3 June 2021

By Author: Alex J Shortt

Medically reviewed on 17-August-2023

Specialist eye hospital group, Optegra, is leading the way in developing a new method to treat floaters , an eye condition which mainly affects young adults whom to date have been told there is little or no treatment and whose distressing symptoms are frequently dismissed.

Symptoms of floaters include dots, shadows or long strands blocking everyday vision , caused by debris floating in the eye’s vitreous solution and which disturb clear sight at all times, often leading to a huge impact on confidence, attitude and outlook of the sufferer.

Niall Patton, Consultant Surgeon at the Optegra Manchester Eye Hospital , utilises micro-incision sutureless surgery, called vitrectomy (which involves removing the vitreous fluid behind the lens of the eye) for patients with floaters, with remarkable results.

He explains: “Floaters can torment people as these ‘clouds’ in their vision move as their eyes move, so sufferers will constantly have their vision affected. Whilst for many patients, floaters are an everyday part of life and do not bother them, in a significant percentage of individuals, this can lead to substantial detriment to a patient’s quality of life and can even result in depressive symptoms. Sufferers may become withdrawn, or seek psychiatric help. Some individuals can be concerned that they are imagining the symptoms, but they are real.

“The long standing view has been that little can be done for these sufferers, but by applying the very latest modern sutureless techniques to this condition, patients can often have their lives transformed with complete alleviation of their symptoms.

“We have now removed floaters on a number of patients, with excellent results. Because we largely use suture-free surgery, recovery can be very quick, often within a few days/weeks and the patients notice almost immediately that their floaters are gone. What once was a long, difficult and potentially hazardous operation is becoming as reliable and as routine as cataract surgery , usually taking less than an hour to complete. It is fantastic that we can make a dramatic impact on patients’ quality of life.”

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Caroline Broadley, 33, from the Wirral, started suffering from floaters when she was seven months pregnant. Describing a big black mark in her eye, constantly whizzing around, Caroline felt that the latter stages of pregnancy and early months with her daughter were spoilt with anxiety and depression.

She says: “This floater was not just affecting my vision, it was affecting my sanity. I felt like I was going mad as my doctor and my local hospital just told me I was hormonal, and I should go away and take some vitamin C!

“I knew it was so much more than that, but people don’t realise how serious floaters can be. I got to the point I was too anxious to leave the house, and would sit in a darkened room hour after hour – as natural daylight made my vision even worse. I just wanted to sleep to escape it.”

After six months, and having been put on anti-depressants, Caroline had the vitrectomy with Mr Patton. She says: “It was amazing. Having become almost agoraphobic for six months, my vision was suddenly crystal clear. I felt as though I got my life back – and could enjoy my daughter, enjoy the sunshine and start living again.”

Floaters are present in the vitreous behind the lens, and move with the eye to disrupt vision. The procedure takes up to one hour, and removes this fluid, taking the floaters with it. Results can be seen within a few days, and full impact within a matter of weeks.

Martin Baldwin, 56, managing director of a mobility aid company in Lancashire, suffered for three years with floaters, and became desperate to find a solution. He explains: “After previous emergency eye surgery for retinal problems, I was left with floaters and told I had to just put up with them. But it felt like a cloud over my central vision, and I would move my eyes around to shift the cloud, but it would pop straight back into the centre of my eye. It’s as though it was on a piece of elastic and would always ping back into place.

“Having always had great vision, it was incredibly frustrating to have this affecting my computer work, my driving, everything I did. I was even contemplating going to America to explore treatment options, when I discovered Niall Patton at Optegra. It was a life changing operation for me – these floaters were driving me mad, I could not escape them, and now thanks to this new procedure I can see as well as I could in my twenties!”

For information on this treatment, please contact us online to arrange a free consultation or call 0800 086 1064.

Notes to editors:

1) Optegra is committed to the world-wide development of eye sciences and championing the latest innovations in vision correction.

Optegra does this by partnering with leading UK universities in the research and development of the next generation of ophthalmic services and technologies.

Optegra operates five private eye hospitals: Surrey Eye Hospital (Guildford), Birmingham Eye Hospital (Aston), Yorkshire Eye Hospital (Apperley Bridge and Laser Eye Centre in Leeds City Centre); Solent Eye Hospital (Whiteley) and Optegra Manchester Eye Hospital, (Didsbury).

All are supported by over 60 consultant level ophthalmic surgeons who provide a wide range of ophthalmic procedures including: Clarivu (refractive lens exchange), laser vision correction, cataract removal, glaucoma, AMD and cosmetic procedures.

2) Floaters  are small pieces of debris that ‘float’ in the vitreous humour of the eye. They occur behind the lens (the transparent window through which light enters the eye), and in front of the retina (the light sensitive tissue that lines the back of the eye). Vitreous humour is a clear, jelly-like substance that fills the space in the middle of the eyeball. It is 99% water and 1% substances that help to maintain the shape of the vitreous. Floaters cast shadows on the retina, and it is these shadows which people can see.

3) Niall Patton MB ChB, MD, FRCOphth; Consultant Ophthalmologist, Cataract and Vitreoretinal Surgeon, Optegra Manchester Eye Hospital. Niall graduated in Medicine from the University of Manchester in 1996. He completed his ophthalmic surgical training at the Manchester Royal Eye Hospital and the Princess Alexandra Eye Pavilion, Edinburgh. In addition, he has undertaken four years of specialist Vitreoretinal surgical fellowship training at the Lions Eye Institute, Western Australia, Princess Alexandra Eye Pavilion, Edinburgh, Tennant Eye Institute, Glasgow and Moorfield’s Eye Hospital, London. In addition to his clinical expertise, Niall Patton has completed ophthalmic research in a variety of different ophthalmic fields and has been successful in procuring research grants from the Royal College of Surgeons, Edinburgh. His research culminated in the award of a Doctorate from the University of Manchester in 2006. He has spoken at national and international ophthalmology meetings, including the United States, Australia, and Europe. In addition to 49 peer-reviewed publications in ophthalmic journals, he has also co-authored a chapter of a textbook and has served as a reviewer for major international ophthalmology journals, including Investigative Ophthalmology & Visual Science, Ophthalmology, Archives of Ophthalmology & Journal of Applied Physiology.

Mr Shortt is a leading ophthalmic surgeon and an expert in the fields of cornea, cataract and refractive surgery.

Medically Reviewed Date: 17th August 2023

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• Article CME
• Published: 20 April 2020

Management of vitreous floaters: an international survey the European VitreoRetinal Society Floaters study report

• Ece Ozdemir Zeydanli   ORCID: orcid.org/0000-0001-6479-2228 1 ,
• Barbara Parolini 2 ,
• Sengul Ozdek 3 ,
• Silvia Bopp 4 ,
• Ron A. Adelman 5 ,
• Ferenc Kuhn 6 ,
• Giampaolo Gini 7 ,
• Ahmed B. Sallam 8 &
• Nur Aksakal 9

for the EVRS Floaters Study Group

Eye volume  34 ,  pages 825–834 ( 2020 ) Cite this article

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Metrics details

• Eye manifestations
• Vitreous detachment

Learning Objectives

Upon completion of this activity, participants will be able to:

Describe symptomatic improvement after PPV for symptomatic floaters, according to results from a retrospective survey study.

Determine safety outcomes after PPV for symptomatic floaters, according to results from a retrospective survey study.

Identify clinical implications of the efficacy and safety of PPV for symptomatic floaters, according to results from a retrospective survey study.

Accreditation statements

In support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Springer Nature. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit hours

Release date:

Expiration date: 19 April 2020

Authors/Editors disclosure information

Sobha Sivaprasad, MD, has disclosed the following relevant financial relationships: Served as an advisor or consultant for: Allergan, Inc.; Bayer AG; Boehringer Ingelheim Pharmaceuticals, Inc.; Heidelberg Pharma GmbH; Optos; Roche. Served as a speaker or a member of a speakers bureau for: Allergan, Inc.; Bayer AG; Novartis Pharmaceuticals Corporation; Optos. Received grants for clinical research from: Allergan, Inc.; Bayer AG; Boehringer Ingelheim Pharmaceuticals, Inc.; Novartis Pharmaceuticals Corporation; Optos. EOZ, MD, has disclosed no relevant financial relationships. BP, MD, has disclosed no relevant financial relationships. SO, MD, has disclosed no relevant financial relationships. SB, MD, has disclosed the following relevant financial relationships: served as a speaker or a member of a speakers bureau for: Allergan, Inc.; Bayer AG; Novartis Pharmaceuticals Corporation. RAA, MD, MPH, has disclosed no relevant financial relationships. FK, MD, has disclosed no relevant financial relationships. GG, MD, has disclosed no relevant financial relationships. AS, MD, has disclosed no relevant financial relationships. NA, MD, has disclosed no relevant financial relationships.

Journal CME author disclosure information

Laurie Barclay, MD, Freelance writer and reviewer, Medscape, LLC, and has disclosed no relevant financial relationships.

Background/objectives

To evaluate the efficacy and safety of pars plana vitrectomy for symptomatic floaters.

Subjects/methods

Forty-eight vitreoretinal surgeons from 16 countries provided information on 581 eyes who underwent vitrectomy for floaters in this retrospective survey study conducted by European VitreoRetinal Society. Percentage symptomatic improvement, incidence of retinal tears/detachment and post-vitrectomy cataract surgery, and the factors associated with satisfaction and complications were investigated.

Ninety-two percent were satisfied with the results, with 86.3% reporting complete resolution of daily-life symptoms. Overall satisfaction was lower in patients with smaller vitreous opacities at presentation (OR:0.4). Iatrogenic retinal breaks occurred in 29 eyes (5%). Core vitrectomy and cut rates of 1500–4000 or >4000 cuts/min were associated with lower risk of retinal breaks than complete vitrectomy (OR:0.05) and cut rates < 1500 cuts/min (OR: 0.03, 0.12, respectively). Fourteen eyes (2.4%) developed retinal detachment at a median of 3 months; and 84 (48.6%) developed cataract at a median of 16 months post-vitrectomy.

Conclusions

Pars plana vitrectomy resulted in high patient satisfaction with relatively low rate of severe complications in a large group of patients. The procedure may be safer when core vitrectomy and cut rates > 1500 cuts/min are favoured. Proper patient selection and informed consent are the most important aspects of surgery.

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Introduction

Vitreous floaters are caused by degenerative or pathologic alterations in the vitreous ultrastructure and perceived as shadows or fly-like obscurations to vision [ 1 , 2 , 3 ]. While patients with floaters often improve over time because of peripheral displacement of vitreous opacities or cognitive adaption [ 4 ], there remain a subgroup with persistent symptoms. Physicians often underestimate how much of an impact floaters may have on patients’ life; however, recent studies indicated that they can be highly debilitating [ 5 , 6 , 7 ]. In one study, the negative impact of the floaters was so severe that the patients were willing to accept a 7% risk of blindness to get rid of them [ 5 ].

Two treatment options have been advocated to date: Nd:YAG vitreolysis and pars plana vitrectomy (PPV) [ 8 , 9 , 10 , 11 , 12 ]. Nd:YAG vitreolysis appears to have limited efficacy, often leaving a significant amount of residues that cause persistence of the symptoms [ 8 ]. In addition, there is a potential risk of laser damage to the retina. Conversely, PPV is curative, since vitreous opacities can be permanently removed. Although reported complication rates are relatively low, vitrectomy is invasive and development of iatrogenic retinal breaks and cataract are concerns [ 9 , 10 ]. As floater treatment is mostly patient-driven with lack of objective signs to support the indication of the surgery, it is still a debate whether the symptoms of the patients justify the potential risks.

In this study, members of the European VitreoRetinal Society (EVRS) retrospectively reported the outcome and safety for treatment of vitreous floaters. This study aimed to investigate the post-treatment patient satisfaction levels and complications of PPV for vitreous floaters in a large set of patients.

The EVRS Floaters Study was a nonrandomized, retrospective, multicentre survey initiated in the autumn of 2015. Members of the society who wish to contribute were requested to fill out the study-specific data-entry forms for each patient through a web portal created on the EVRS website. Data included patient demographics, refraction error, lens status, duration of symptoms, floater severity, surgical details (vitrectomy quality/gauge/cutting speed/combined phacoemulsification), intraoperative and postoperative complications, preoperative and postoperative discomfort levels and patient satisfaction. Floaters were graded according to the severity of ophthalmoscopically visible vitreous opacities as huge, dense, small and almost invisible. Vitrectomy quality was reported as “complete vitrectomy” if peripheral vitreous was totally removed along with PVD induction unless there was a preexisting PVD; “subtotal vitrectomy” if PVD was induced but vitreous base not cleared extensively; “core vitrectomy” if the surgery was limited to the removal of central vitreous without PVD induction. Cutting speed was grouped into “<1500”, “1500–4000” and “>4000” cuts/min (cpm). Discomfort intensity in everyday life, in professional life and psychologically was graded as “no”, “light”, “moderate” and “high”. Patient satisfaction after surgery was graded as “worse”, “equal”, “satisfied” and “extremely satisfied”. Eyes with previous vitrectomy, <6 months of follow-up, or incomplete data were excluded. The results were analysed independently of the contributor surgeons. EVRS Ethics Committee approved the study design. Because this study involved 16 different countries and institutional review board regulations differed by location; each participant was responsible for following the specific requirements of their own institution.

Statistical analysis

Descriptive data were presented as frequencies, percentages, mean (±standard deviation) and median values (minimum, maximum). For categorical variables; Pearson χ 2 , χ 2 for trend, Yate’s corrected χ 2 , and Fisher’s exact tests were used for comparisons. For continuous data, depending on normality, Independent Samples t -test or Mann–Whitney U test; and for correlation analysis Spearman’s test was used. Multivariable logistic regression models were fitted to identify various factors that were thought to be correlated with complications and patient satisfaction. Age, sex and the factors that revealed a p value of ≤0.20 in univariate analyses were included in the models. Statistical analyses were performed using SPSS v22.0 and significance was set as two-tailed p value < 0.05.

A total of 678 eyes (645 patients) were reported by 48 experienced vitreoretinal surgeons from 16 countries. After excluding 90 eyes with <6 months of follow-up and 7 eyes with missing data, 581 eyes remained eligible for analyses. Patient demographics, ocular features and surgical details are summarized in Table  1 .

Complications

Combined phacovitrectomy was performed in 91 eyes, including 2 eyes that had inadvertent lens touch during surgery. Of 173 eyes that were phakic after PPV, 84 (48.6%) developed cataract requiring surgery at a median of 16 months (range, 1–67 months) post-vitrectomy. The mean age of this subgroup was 60 ± 12.5 years. There was no correlation between the age at which the vitrectomy was performed and the delay of cataract formation ( r  = −1.17, p  = 0.28). None of the potential risk factors we explored were associated with the cataract formation at multivariable analysis (Table  2 ).

Rhegmatogenous complications

Iatrogenic retinal breaks were reported in 29 eyes (4.99%); all were treated intraoperatively either with endolaser or cryopexy. Of these, 18 (62.1%) were 20-gauge cases; 10 (34.5%) were 23-gauge cases; 1 (3.4%) was a 25-gauge case. No patient developed retinal breaks among 27-gauge cases. Retinal breaks tended to occur more frequently as the gauge increased ( p  < 0.001). Twenty-five eyes (86.2%) complicated with a retinal break had complete vitrectomy; three eyes (10.3%) subtotal vitrectomy; and one core vitrectomy. Complete vitrectomy was associated with a higher incidence of retinal breaks than more limited vitrectomy ( p  < 0.001). Cut rates < 1500 cpm were associated with a higher incidence of retinal breaks than higher speeds (89.7 vs. 1.6%, p  < 0.001). Phakic eyes (7.2%) had a significantly higher incidence of retinal breaks than pseudophakic eyes (3.2%) ( p  = 0.03). Of the 19 phakic eyes that had iatrogenic retinal breaks, 15 (79%) had combined phacoemulsification. Retinal breaks tended to occur more frequently when combined phacovitrectomy was performed (16.5 vs. 2.9%, p  < 0.001). It is of note that complete vitrectomy had been performed in most of the combined surgeries that had an iatrogenic break; of the 15 eyes, 14 eyes had complete and only 1 eye had subtotal vitrectomy.

RD occurred in 14 (2.4%) eyes at a median of 3 months post-vitrectomy (range, 1–50 months). Of the seven eyes that developed RD later than 3 months postoperatively, two had cataract surgery 2 months prior to the development of RD. Having a cataract surgery in the postoperative period was not related with the postoperative RD development ( p  = 0.14). Except from one eye that developed RD 50 months post-vitrectomy, none had a history of iatrogenic break formation noticed during the surgery. There were 5 (4.7%) RDs in the 20-gauge; 5 (2.5%) RDs in 23-gauge; 4 (1.5%) RDs in the 25-gauge; and none in the 27-gauge group ( p  = 0.18). RD occurred in six eyes (3.6%) in which a complete vitrectomy was performed; in seven eyes (2.4%) that had subtotal vitrectomy; and in one eye (0.8%) that had core vitrectomy ( p  = 0.29). The mean age of the patients with a RD was 57.4 years, which was slightly younger than 63.2 years of the patients who did not develop a RD ( p  = 0.04).

Multivariable logistic regression analyses were conducted to assess the impact of a number of factors on the likelihood of development of rhegmatogenous complications. Potential risk factors investigated were refractive status, lens status, vitrectomy quality, gauge, cutting speed and combined phacoemulsification. In addition, presence of any intraoperative complication and postoperative cataract surgery were explored as potential risk factors in the postoperative RD development. The factors associated with rhegmatogenous complications at p value ≤ 0.20 were included in the fitted model, along with the forced covariates (age, sex). Initial screening of the factors is shown in Supplementary Material  1 and the results of the logistic regression in Table  2 . Based on the odds ratios, iatrogenic retinal breaks were less likely to occur in eyes where surgery was limited with core vitrectomy compared with those that had complete vitrectomy (OR 0.05, p  = 0.009), and when cut rates of 1500–4000 or >4000 were used rather than <1500 cpm (OR 0.03, 0.12; p  = 0.002, 0.03, respectively). Regarding the postoperative RD development, regression model yielded none of the potential factors as independently significant.

Other complications

Cystoid macular oedema occurred in eight eyes (1.4%). A macular pucker developed in 7 (1.2%) cases, four of which required a second PPV with membrane removal. Three eyes (0.5%) had transient vitreous haemorrhage; and one had choroidal haemorrhage. One eye developed chronic hypotony. Thirteen (2.2%) eyes developed an IOP rise; four were controlled with short-term medical therapy; nine (1.5%) resulted in glaucoma. Four eyes (0.7%), in which posterior hyaloid was left intact during the primary surgery, were reported to have PVD at an average of 21 months (range, 1–36 months) post-vitrectomy, which resulted in floaters, requiring repeat vitrectomy. No endophthalmitis case was reported.

Preoperative symptoms and postoperative patient satisfaction

Preoperative ophthalmoscopic evaluation revealed that most eyes had huge (22.2%) or dense vitreous floaters (61.6%); whereas a smaller portion had small (14.6%) or almost invisible (1.6%) floaters. Reported response rate, regarding preoperative and postoperative discomfort levels was 99.1% and 97.8%, respectively. Most patients (96.4%) described the subjective severity of daily symptoms as “moderate” or “high”. Floater symptoms diminished significantly after the operation compared with preoperative values ( p  < 0.001). Complete resolution of symptoms affecting everyday life, professional life and psychological condition was reported in 86.3, 92 and 91%; and only mild symptoms in 9.7, 5.7 and 7.6% of the cases, respectively (Fig.  1 ).

Preoperative (left column) and postoperative (right column) discomfort levels were reported by 99% and 98% of the patients, respectively. After vitrectomy, 86.3% of the patients were completely cured from their troublesome floaters affecting everyday life (upper row); 92% of the patients reported complete resolution of symptoms affecting professional life (middle row); and 91% reported complete resolution of psychological symptoms (lower row).

Overall satisfaction was reported by 476 patients. Four hundred forty patients (92.4%) were “satisfied” or “extremely satisfied” with the outcome. Twenty-six patients (5.5%) were neutral. Ten patients (2.1%) described their symptoms to be “worse” after the surgery. More than half of the dissatisfied cases had complications or persistent floaters.

Multivariable logistic regression analyses were conducted to assess the potential factors that may influence the postoperative symptomatic improvement and satisfaction. Given the sparsity of the observed categories of discomfort, symptomatic improvement was defined as the reduction of the preoperative discomfort from substantial (“moderate/high”) to low (“no/light”) after the operation. Likewise, since there are few unsatisfied patients, patients were aggregated into: satisfied (“satisfied/extremely satisfied”) and not satisfied (“equal/worse”). Predictors evaluated in the analyses were floater size, duration of symptoms, refractive status, lens status, vitrectomy quality, gauge, cutting speed, combined phacoemulsification and presence of any intraoperative or postoperative complications (Supplementary Material  2 ). We included in the fitted regression model, the factors to be independently associated with symptomatic improvement and satisfaction at p value ≤ 0.20, along with the forced covariates (age and sex). Regression analysis showed that the patients with almost invisible to small preoperative floaters were 2.5 times more likely not to be satisfied with the postoperative results than the patients with dense or huge floaters ( p  = 0.02). Regarding symptomatic improvement, patients with postoperative complications were found to be less likely to report improvement in their symptoms affecting everyday life and professional life (OR 0.31, p  = 0.01 and OR 0.15, p  = 0.02) (Table  3 ).

While there remains the debate among vitreoretinal surgeons whether the symptoms of patients justify the potential risks of a surgery, a significant number of patients demand getting rid of bothersome floaters [ 5 , 6 , 7 ]. The present large-scale multicentre study therefore sought to determine the outcomes of vitrectomy and identify possible risk factors responsible for the complications.

Given the invasive nature of the PPV, potential drawbacks in these patients are rhegmatogenous complications and cataract formation. Reported rates of iatrogenic retinal breaks during vitrectomy for other elective indications (e.g. macular hole/pucker) vary between 11 and 24% for 20-gauge systems [ 13 , 14 ], and between 3 and 16% for smaller-gauge procedures [ 14 , 15 , 16 ]. The overall rate of 5% in this study falls in the lower end of the spectrum. We observed a higher rate of retinal breaks with 20 gauge (17%) compared with smaller-gauge vitrectomy (5.4%); however, this difference failed to reach significance on multivariable analysis. One of the significant risk factors was the extensive vitrectomy with peripheral base shaving and PVD induction. Despite the limitation that the proportion of preexisting PVD was unknown in the complete vitrectomy group, extensive surgery was related with the increased risk of iatrogenic retinal breaks compared with core vitrectomy where no PVD was induced. Other risk factor significantly associated with the retinal break formation was the use of low cutting speeds. Even though no study to date discussed the role of cut rates in the development of iatrogenic breaks during floater vitrectomy, literature reports on other elective macular surgeries suggest that higher speed could reduce the incidence of retinal breaks, by minimizing the vitreous turbulence and dynamic traction [ 17 , 18 ]. Multivariable analysis showed that the use of cut rates ≥ 1500 cpm was safer than <1500 cpm. However, the use of cut rates >4000 cpm did not differ significantly from the use of 1500–4000 cpm.

Several authors proposed minimalistic surgical approaches in an attempt to prevent complications [ 19 , 20 ]. Sebag et al. [ 19 ] reported low complication rates by adopting a more limited surgery, involving core vitrectomy without the posterior hyaloid removal unless there is a preexisting PVD. Of 60 cases, they reported macular pucker formation in one eye and no cases of iatrogenic retinal breaks, postoperative RD, vitreous haemorrhage or endophthalmitis at an average follow-up of 17.5 months. Mason et al. [ 20 ] described a similar approach in their series of 168 eyes; with leaving posterior hyaloid in most eyes (85%), and shaving base only in the presence of retinal breaks. They reported iatrogenic retinal breaks in 12 eyes (7.1%), and no postoperative RD at an average follow-up of 18 months. They found no significant association between retinal breaks and PVD induction; however, as the authors also refer to, this may be due to the fact that only a small number of patients underwent PVD induction. Conversely, higher complication rates were reported by Schulz-Key et al. and De Nie et al. in two series with longer follow-ups of 37 and 26.4 months, respectively [ 6 , 10 ]. Schulz-Key et al. [ 10 ] performed mostly core vitrectomy, yet they reported postoperative RD in 6.8% of eyes. It is noteworthy that 5.5% of the RD occurred in the long-term, between 2 and 4 years post-vitrectomy. A possible explanation for this late incidence may be spontaneous and anomalous PVD development over time since the vitrectomy was limited to central vitreous. In the latter study by De Nie et al. [ 6 ], in which patients underwent 20- or 23-gauge vitrectomy with PVD induction, postoperative RD rates were found as high as 10.9%. As the authors commented, lack of routine search with scleral indentation to detect retinal breaks might be responsible for high incidence. In contrast, postoperative RD occurred rather early and infrequent in the present study. We observed RD in 2.4% of patients at a median of 3 months post-vitrectomy; and none except one case were in eyes where the retinal breaks noted intraoperatively. This may indicate the possibility of unrecognized retinal breaks at the time of surgery, and underscores the importance of searching for intraoperative breaks before concluding the surgery. The 20-month follow-up in this study is longer than the follow-ups in the studies by Sebag et al. [ 19 ] and Mason et al. [ 20 ], but less than 37-month-follow-up by Schulz-Key et al. [ 10 ]. RD may be expected to increase in the longer term due to a postoperative PVD development in eyes where posterior hyaloid was left intact. Another point that draws attention is that two patients developed RD only after having a cataract surgery. It is arguable that the RD in these cases may be related to cataract extraction with consecutive PVD rather than vitrectomy itself. However, this hypothesis was not supported statistically.

Cataract formation was frequent in our series, necessitating phacoemulsification in nearly half the phakic cases (48.6%) at an average of 16 months. This was comparable to the rates of 38–50% given by De Nie et al.[ 6 ] and Tan et al.[ 9 ] in series where full vitrectomy was performed. Reported rates of cataract formation was lower at 23.5 [ 19 ] and 22.5% [ 20 ] in two other studies where sparing of anterior vitreous were advocated to protect the lens against free oxygen radicals. However, the exact pathogenesis of post-vitrectomy cataract formation is not clear and many other factors have been proposed to play a role, including surgery duration, mechanical damage from instrumentation, intraoperative light toxicity, type and amount of irrigating solution and intraocular inflammation [ 21 , 22 ]. We failed to find any significant difference among the eyes to whom more limited or extensive surgery were performed; however, employment of heterogenous surgical approaches by different surgeons may be expected in this study and could affect the outcome.

Visual acuity in floaters is generally minimally affected and does not correlate with the symptoms. Therefore, patient selection as well as efficacy assessment have been addressed by evaluating the difficulty of performing daily tasks, the impact of the symptoms on patients’ lives, or patient satisfaction [ 6 , 8 , 10 ]. We separately assessed the symptoms affecting different aspects of life and overall satisfaction after surgery. Most patients stated that they had “moderate” to “high” level of discomfort before surgery; and complete resolution of the symptoms affecting everyday life, professional life and psychological condition was reported in about 90%. Overall, 92.4% of the patients were satisfied with the outcome. This is in accordance with earlier studies, reporting high patient satisfaction post-surgery, ranging from 88 to 96% [ 8 , 10 , 20 ]. The investigation of the potential factors that may negatively influence the symptomatic improvement and patient satisfaction yielded two significant results. The first one was the presence of complications as expected. However, the second one was more noteworthy. Patients with almost invisible/small preoperative vitreous opacities were more likely not to be satisfied with the results than the patients with dense/huge opacities. This indicates the possibility that psychological factors might be related with the discomfort severity. Some authors have shown that certain personality traits may be related with an increased awareness and perceived discomfort with floaters [ 23 , 24 , 25 ]. A recent study found a higher incidence of psychological problems, such as depression, anxiety and stress among symptomatic floater patients compared with the asymptomatic controls with vitreous opacities. In addition, the degree of floater-related discomfort and severity of the psychological distress was correlated [ 24 ]. The proportion of the patients reporting persistent symptoms post-treatment that affect their psychological condition was not significantly different between the groups with almost invisible/small preoperative vitreous opacities and with huge/dense opacities (3.3 vs. 1.1%, p  = 0.13). However, the dissatisfaction rate was significantly higher in the patients presenting with smaller opacities. These results raise the concern whether the severity of symptoms constitute enough of an indication especially when there is no corresponding opacity detected ophthalmoscopically. Several methods, including contrast sensitivity, straylight measurements, quantitative ultrasound and optical coherence tomography infrared video scans, have been proposed to define the target group more objectively [ 19 , 26 , 27 ]. Validation of these tests in large-scale prospective studies and better assessment of patients’ impairment level and expectations may help to reduce the concerns.

Limitations of this study include the retrospective design and evaluations based on self-reporting; which may both cause selection bias and affect the quality of the results. In addition, detailed information regarding preoperative PVD status was not available in all cases. Despite these pitfalls, considering that a large number of surgeons from 16 countries contributed to the study, the outcomes reported here are expected to be representative of a wide population globally and largely applicable.

In conclusion, this large-scale multicentre study demonstrated that the PPV was effective in alleviating the symptoms of floaters yet it is an invasive approach with risk of complications. Performing vitrectomy limited to central vitreous only and using cutting speeds >1500 cpm may increase the safety. The degree of impairment must be well understood, especially in patients whose distress level is out of proportion with the severity of the opacities. Further studies that may elucidate objective parameters to support the indication for surgery are thus warranted.

What was known before

Vitrectomy for floaters has remained controversial among vitreoretinal surgeons.

The reported complication rates of floater vitrectomy vary substantially and still lack sufficient peer-reviewed evidence in large series.

The effect of vitrectomy parameters on safety in floater vitrectomy has not been investigated.

What this study adds

Providing data on 581 cases from 16 countries undergoing floater vitrectomy, this study may be expected to be representative of a wide population globally.

Hence, the success as well as the complication rates may be largely applicable and guide counselling of patients on the efficacy and safety profiles of this intervention.

Vitrectomy parameters such as core vitrectomy and the use of cut rates above 1500 cuts/min have been found to increase the safety of the procedure.

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Zeydanli, E.O., Parolini, B., Ozdek, S. et al. Management of vitreous floaters: an international survey the European VitreoRetinal Society Floaters study report. Eye 34 , 825–834 (2020). https://doi.org/10.1038/s41433-020-0825-0

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Received : 18 August 2019

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Issue Date : May 2020

DOI : https://doi.org/10.1038/s41433-020-0825-0

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Pick virtually any ophthalmol­ogist’s practice and you’ll find patients who complain of vitre­ous floaters. When, if ever, should these patients receive treatment? Like most of his colleagues, Chirag P. Shah, MD, MPH, with Ophthalmic Consultants of Boston, prefers observation in 99.9% of these cases. “However,” he said, “I do think that paradigm is slowly changing.”

A combination of more sophisti­cated patient selection and enhanced technology and techniques may be diminishing some concerns about the risks of surgery for vitreous floaters. And although a recent study 1 conducted by Dr. Shah also suggested that YAG vit­reolysis may offer benefits for troublesome floaters, it also raises questions about its efficacy and safety, as well as the necessity for multiple costly sessions.

Three vitreoretinal surgeons offer their perspectives on whether, and how, to treat vitreous floaters.

Troublesome Vitreous Floaters

Vitreous floaters may occur following a retinal tear, retinopexy, scleral buckling, or vitreous hemorrhage associated with a tear, said Gaurav K. Shah, MD, with The Retina Institute in St. Louis, Mis­souri. But most patients who experi­ence vitreous floaters fall into 2 groups: those with a posterior vitreous detach­ment (PVD) or myopic vitreopathy.

PVD and myopic vitreopathy. People in their 50s, 60s, or 70s may develop a PVD and have more significant floaters, said Dr. Chirag Shah. “Most of the time, patients can cope with them because the brain neuroadapts. But a certain percentage of patients continue to be bothered by the floaters.” People in their 20s and 30s may also develop opacities in their vitreous as a result of myopia, said Jerry Sebag, MD, at VMR Institute for Vitreous Macula Retina in Huntington Beach, California.

Impact of light. “Because the impact is greater in bright light, individuals with floaters—often younger people—typically complain about the inability to work long hours on computers,” said Dr. Sebag. In addition, snow reflections, bright skies, and looking at the ocean may be bothersome. “I’ve had patients tell me they’ve stopped camping, fish­ing, or skiing because they no longer find these activities pleasurable. Some even tell me they can’t wait to go to sleep at night.”

Why worse for some? Why some people are more afflicted than others is not fully understood, said Dr. Sebag. It may be connected to more than 1 factor, he said, such as biochemistry and the effects of aging, genetics, hormones, and the ability to neuroadapt. “For example, some have a denser posterior vitreous cortex, and these people won’t be able to adapt well to their floaters.”

What is clear, he said, is that many of these patients feel ignored by the med­ical profession. “What they are com­plaining about may not fit neatly into our diagnostic boxes, but that doesn’t mean they don’t have a problem.”        

Evaluating Vitreous Floaters

Fewer than 5% of Dr. Chirag Shah’s patients complain of floaters. Given that not all floaters are created equally, he said, it’s important to demonstrate a correlation between what the patient is experiencing and what the physician is seeing. “Deciding who to treat ends up being the key to success.”

Basic exams. Why do physicians underestimate serious symptoms of vitreous floaters? “One reason is that we usually check patients’ visual acuity and visual fields,” said Dr. Chirag Shah, “but we don’t check contrast sensitivity, which can be degraded by significant floaters.” Also, floaters may move into the patient’s central vision, affecting their ability to read or drive, but doc­tors rarely check reading speed.

Dr. Sebag was the first to discover that patients with significant vitreous floaters are bothered with decreased contrast sensitivity function. 2-4  He coined the diagnostic term “vision-degrading vitreopathy” to help distin­guish debilitating floaters from those that are relatively benign. “Screening with vitreous-specific questionnaires, structural assessments with ultrasound, and contrast sensitivity functional (CSF) assessments give me the ability to diagnose vision-degrading vitreopathy and make me more comfortable about offering treatment,” he said.

Floaters questionnaire. Dr. Sebag and colleagues devised a screening tool called the Vitreous Floaters Functional Questionnaire (VFFQ) to help evalu­ate the impact of floaters on patients’ quality of life. “We’ve shown a statisti­cally significant correlation between the VFFQ and the National Eye Institute’s (NEI’s) Visual Function Questionnaire, a gold standard for assessing vision in more general terms,” he said. In addition, there is a high correlation among the results of the VFFQ and CSF and the density of the vitreous body as assessed by ultrasound.

Contrast sensitivity function. A CSF assessment provides a functional evaluation of the impact of vitreous (as well as cornea or lens) opacification on vision, by measuring the ability to distinguish shades of gray, said Dr. Sebag. One of his studies found that patients with bothersome floaters had a 67% reduction in CSF compared with age-matched controls. 2

“These days, I never operate on someone with normal CSF,” said Dr. Sebag. More than 140 patients with abnormal CSF on whom he has per­formed vitrectomy attained normal CSF within 1 week of surgery. 2-4 Dr. Sebag has followed these patients for an average of nearly 3 years; during this time, their CSF has remained normal.

Quantitative ultrasound (QUS). Dr. Sebag also advocates the use of quanti­tative ultrasound, which gives an index of the structure of the vitreous body. “The quantitative ultrasound measure­ments we perform clearly show that the greater the density of the vitreous, the more patients are bothered by their floaters,” he said. He added that QUS is also a useful way to show patients what’s going on inside their eyes and to assess the effectiveness of vitrectomy.

Wide-angle color photography. In his clinical study, Dr. Chirag Shah used wide-angle color photography to visualize floaters. “Oftentimes, patients would look at their color photographs and say, ‘That’s the bug-like floater that keeps going in and out of my vision,’” he said. “If a patient had significant symptoms but the photograph was crystal clear except for a few normal vitreous wisps, that patient may not be easy to satisfy.”

OCT. To assess floaters, Dr. Gaurav Shah takes optical coherence tomogra­phy (OCT) infrared video scans. “This allows us to see what the patients are seeing,” he said. “If I do a video scan and don’t see much, the patient’s symptoms are not from the eye, and I won’t treat them with vitrectomy. If patients truly have something, it is a very dramatic demonstration of their symptoms.”

Vitrectomy for Troublesome Floaters

“Vitrectomy is valuable for some pa­tients with floaters, but I tend to reserve it only for those with the most debili­tating floaters because of the potential side-effect profile,” said Dr. Chirag Shah. Vitrectomy is invasive, agreed Dr. Gaurav Shah. “But it has evolved and been vindicated by improvements in technology and technique. My patients have been ecstatic with the results, although it’s first critical to determine that they are truly symptomatic and have been given a chance to neuroadapt or to allow the floaters to resolve.”

Exclusion criteria. Dr. Sebag uses the VFFQ, CSF, and QUS to select the best candidates for vitrectomy. “I don’t take surgery lightly,” he said, explaining that he’s performed only about 200 surgical floater cases in over 8 years. “I rarely meet someone and say, ‘Let’s operate.’” In fact, he said the average time be­tween the first onset of symptoms and surgery is more than 30 months.

Dr. Gaurav Shah uses slightly differ­ent criteria for excluding patients.“I exclude patients who are phakic, who have 360 degrees of lattice or a lot of peripheral retinal problems, or who have expectations that are way beyond what the surgery can provide.” To help assess expectations, he asks his patients, “If you are driving on a road and the entire windshield is clear except for one little spot, does that bother you?” If the answer is “yes,” he is more concerned about the ability to please the patient with surgery.

Risks of vitrectomy. “With vitrecto­my, you are creating 3 holes in the eye,” said Dr. Chirag Shah, “which carries a small risk of infection.” Vitrectomy also accelerates cataract formation, because of increased oxygen concentration in the vitreous cavity following removal of the vitreous. “But for me, retinal detachment is the most concerning risk, with published reports as high as 10.9%,” he said.

Presenting vitrectomy findings from 151 eyes at the 2016 Academy annual meeting, Dr. Sebag reported no cases of endophthalmitis or hypotony; 1 case each of glaucoma, cystoid macular edema, and retinal break; 2 cases of retinal de­tachments that were surgically corrected; and 6 cases of vitreous hemorrhage, which all cleared spontaneously.

Reducing risks. Dr. Gaurav Shah has found that being discerning in choosing patients has resulted in fewer complications. Operating on 5 to 10 floaters patients last year, he has had no patients experience retinal tears or de­tachments. The key, he said, is 27-gauge topical vitrectomy, which minimizes complications with blocks and intraoperative issues. Dr. Sebag also credits the development of sutureless, small-gauge vitrectomy in reducing risks, as well as a couple of other techniques.

Reduce risk of endophthalmitis. To this end, Dr. Sebag creates highly beveled incisions and uses nonhollow probes for cannula extraction.

Leave a little vitreous. “I have modified my approach by leaving a few milli-meters of vitreous behind the lens. The antioxidants in the vitreous gel help mitigate cataract formation,” Dr. Sebag said. He and his colleagues compared the incidence of cataract using this modified approach with extensive vitrectomy, which is used at the Uni­versity of Amsterdam. At 24 months, the incidence of cataract was 35% with the modified approach and 87% with the extensive approach. The time until cataract formation was also 5 months longer with a limited vitrectomy. 5

Two philosophies on surgical PVD. Younger patients have vitreous floaters because of collagen cross-linking in the vitreous body, not because of PVD, said Dr. Sebag. To reduce the risk of tears in these patients, he recommends simply removing the central vitreous and not separating the posterior vitreous from the retina. By contrast, Dr. Gaurav Shah said that he always creates a complete PVD because he’s concerned that con­tracture of the residual cortical vitreous may cause problems in the future. That has not been the case in Dr. Sebag’s experience of 200 cases, where only 1% experienced retinal detachment.

YAG Laser Vitreolysis for Troublesome Floaters

Before conducting the first random­ized clinical trial of YAG vitreolysis for symptomatic Weiss ring floaters, Dr. Chirag Shah wondered whether lasers could provide a niche between perform­ing vitrectomy and doing nothing. “I was very skeptical going into the study, and I’m not currently performing this procedure,” he said, “but the study has shown me that YAG vitreolysis may have some value.”

Laser study results. In the trial, 54% of the laser group reported symptom improvement after 1 treatment. In ad­dition, no differences in adverse events were identified between the laser and sham groups. 1 “We need to do larger studies of longer duration to determine the best candidates and the number of treatments needed, as well as [the treat­ment’s] true risks and benefits,” said Dr. Chirag Shah.

Although more than half of the patients in Dr. Chirag Shah’s study reported significant or complete res­olution of their vitreous floaters, only about one-third of patients in an earlier study by Delaney et al. reported similar results. 6 “We used a higher laser power in our study, which may account for the differences in response,” said Dr. Chirag Shah. “At a lower power, you’re doing more fractionating, but when you turn the power up, you form plasma and can see the tissue vaporize into gas bubbles.”

Dr. Sebag, however, disputes this assertion, saying that YAG laser does not vaporize tissue. “YAG lasers are photodisruptors,” he said. “They take something large and break it into smaller pieces.”

Anomalous? In Dr. Chirag Shah’s trial, 8 patients self-reported zero im­provement out of a scale of 100 despite color photography showing significant or complete objective improvement. “Some patients recognized that the floater was virtually gone, but a little speck that was mobile, possibly more than previously, annoyed them to the same degree as their large floater did,” he said.

Exclusion criteria. In Dr. Chirag Shah’s study, the following patients were excluded: those with Snellen best-corrected visual acuity worse than 20/50 in the nonstudy eye; history of retinal tear, retinal detachment, uveitis, diabetic retinopathy, macular edema, retinal vein occlusion, or aphakia in the study eye; and history of glaucoma or high intraocular pressure.

Risks and costs of laser. “To my knowledge, just a handful of doctors are doing YAG vitreolysis, and with variable results,” said Dr. Chirag Shah. With no dedicated insurance code, the procedure is done off-label, he said. In his study, Dr. Chirag Shah only did 1 treatment session because he could not treat patients with 2 sham lasers without unmasking them. “In the real world, patients may require 2 or more laser sessions to vaporize the majority of their floaters.”

With YAG vitreolysis, there is a risk of glaucoma, retinal tear, retinal detachment, cataract if you hit the lens, and retinal damage if you hit the retina, said Dr. Chirag Shah. To minimize risks of lens or retinal damage, he recommends ensuring a safe distance between the focal point of the laser and the retina and crystalline lens. In the study, he required the Weiss ring floater to be 5 mm posterior to the posterior capsule of the crystalline lens and 3 mm anterior of the retina, as measured by B-scan ultrasonography.

Dr. Gaurav Shah has not personally used laser for floaters but is concerned that it may be a time-consuming procedure, and he noted, “Although laser appeared quite safe in this recent laser study, it may have potential drawbacks.”

He added, “It’s important to remem­ber that the vast majority of patients don’t require intervention. However, there are those who are truly symptom­atic and might require a procedure—and, even more importantly, [who may benefit from] a conversation that acknowledges their pathology.”

 ___________________________

1 Shah CP, Heier JS . JAMA Ophthalmol. 2017;135(9):918-923.

2 Sebag J et al. Retina . 2014;34(6):1062-1068.

3 Garcia GA et al. Am J Ophthalmol. 2016;172:7-12.

4 Milston R et al. Surv Ophthalmol. 2016;61(2):211-227.

5 Yee KMP et al. Ophthalmol Retina. 2017;1(2):154-157.

6 Delaney YM et al. Eye (Lond). 2002;16(1):21-26.

___________________________

Dr. Sebag is a vitreo-retinal specialist at the VMRInstitute for Vitreous Macula Retina in Hun­tington Beach, Calif., and professor of clinical ophthalmology at the Doheny Eye Institute in Los Angeles. Relevant financial disclosures: Abbott Labs: C; Johnson & Johnson: C.

Dr. Chirag Shah is a retina specialist at the Ophthalmic Consultants of Boston; fellowship codirector of the combined Tufts New England Medical Center/Ophthalmic Consultants ofBoston vitreoretinal surgery fellowship; and assistant professor at Tufts University School of Medicine, all in Boston. Relevant financial disclosures: Ellex: L.

Dr. Gaurav Shah is a retina specialist and codirec­tor of the retina fellowship at The Retina Institute in St. Louis, Mo. Relevant financial disclosures: None.

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Design of a Functional Eye Dressing for Treatment of the Vitreous Floater

Wen-shuang fan.

1 Department of Ophthalmology, Dalin Tzu Chi General Hospital, 2, Min-Sheng Rd., Dalin Town, Chia-Yi 62247, Taiwan

Shuan-Yu Huang

2 Department of Optometry, Central Taiwan University of Science and Technology, No.666, Buzih Road, Beitun District, Taichung City 406053, Taiwan

Hong-Thai Nguyen

3 Department of Mechanical Engineering, Advanced Institute of Manufacturing with High Tech Innovations (AIM-HI) and Center for Innovative Research on Aging Society (CIRAS), National Chung Cheng University, 168, University Rd., Min Hsiung, Chia Yi 62102, Taiwan

Wen-Tsung Ho

4 Master’s Program in Wellbeing Technology and Biomedical Engineering, Yuanpei University of Medical Technology, No.306, Yuanpei Street, Hsinchu 30015, Taiwan

5 TO2M Corporation, 5F., No. 2, Kedong 3rd Rd., Zhunan Township, Miaoli County 35053, Taiwan

Wen-Hung Chao

Fen-chi lin.

6 Department of Ophthalmology, Kaohsiung Armed Forces General Hospital, 2, Zhongzheng 1st.Rd., Lingya District, Kaohsiung City 80284, Taiwan

Hsiang-Chen Wang

Associated data.

The data presented in this study are available in this article.

With the rapid development of display technology, related diseases of the human eye are also increasing day by day. Eye floaters are one of the diseases that affect humans. Herein, we present a functional ophthalmic dressing that can permeate the skin tissues of the eyes through oxygen and hydrogen to improve the symptoms of floaters. In clinical tests, the symptoms of sensory floaters improved in 28 patients, and the recovery rates of mild, moderate, and severe floaters were about 70%, 66.7%, and 83.3%, respectively.

1. Introduction

In the past, 90% of vitreous floaters were caused by aging [ 1 ]. With the development of 3C (computer, consumer electronics, and communication) products and the increase in myopia, 15% of people aged 20–29 years will develop lymphadenopathy, indicating the gradual acceleration of the eye-aging rate. Lymphadenopathy refers to the presence of floating objects in the eye caused by thickened clumps of vitreous jelly [ 2 , 3 , 4 , 5 , 6 , 7 ]. After the age of 40, the vitreous will become dense and gel-like, in which some denser bundles of collagen fibers form. For people with high myopia, the anterior–posterior diameter of the eye axis is stretched, destroying the dense structure of the vitreous and leading to vitreous degeneration and turbidity. When light is projected to the eyeball, it passes through the interface of the thicker fiber bundle. The vitreous jelly blocks light coming from the front of the eye and casts shadows on the retina. This phenomenon is called degenerative floaters [ 8 , 9 , 10 , 11 , 12 , 13 , 14 ].

Pathological floaters are another type of vitreous floater. Pathological floaters occur when there is a sudden increase in floaters or when the light and shadow of lightning can be observed. Although pathological floaters only account for 5% of floaters, they may seriously harm eyesight. The causes include retinal tears, accompanying retinal detachment, bleeding caused by retinal vein vascular occlusion, diabetic retinopathy, and macular degeneration, which causes blood to flow into the vitreous. At present, the diagnosis of pathological floaters depends on the experience of ophthalmologists. Primary vitreous floaters are mainly produced by the intrinsic structure of the vitreous, and the stacked collagen fiber bundles form visible fibers, which first appear in the central vitreous, where they have a linear structure. With age, they become more and more thick and irregular and are common in young axial myopia. In old age, the glass body liquefies and forms a cavity, and light scattering from the glass cavity wall may cause a floating phenomenon [ 15 , 16 , 17 , 18 , 19 ]. Secondary floaters are exogenous turbidity in the vitreous that is usually composed of protein, amyloids, or cells. However, the most common cause of secondary vitreous floaters is anterior or vitreous hemorrhage, which can cause a sudden onset of floaters and blurred vision [ 20 , 21 ]. Inflammatory diseases (infectious or non-infectious) or malignant tumors (such as lymphoma) can cause an increase in vitreous cells. If the number is large, it may also cause symptomatic vitreous floaters.

The currently available treatments for floaters include vitrectomy and Nd: YAG laser vitrectomy. Many studies have evaluated the success and potential risks of vitrectomy for vitreous floaters [ 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. Although vitrectomy is an effective treatment method, it may affect the lens and accelerate the occurrence or deterioration of postoperative cataracts. On the other hand, Nd: YAG laser vitreous dissolution is used to destroy the vitreous collagen fiber bundles. It only treats the fiber bundles that are relatively far from the retina. However, it only destroys the aggregation and cannot remove the aging cells from the body. It is better for larger aggregations. Nd: YAG laser vitreous dissolution using newer technology has been proven to be safe and effective in treating symptomatic Weiss ring vitreous floaters. The primary outcome measures were the percentage of symptom improvement after treatment and the rate of postoperative complications. In the study, Delaney et al. [ 23 ] reported that the Nd: YAG vitreous improved symptoms in only one-third of patients. Furthermore, clinical improvement was only moderate, subjectively graded to no greater than 50% among 93.3% of patients. Only 38% of the 39 eyes with vitreous floaters showed symptomatic improvement moderately after Nd: YAG laser treatment; not only that, the symptoms could not be improved in terms of complete vision resolution. Moreover, this method of laser therapy also causes complications that are not completely reported. Specifically, complications after surgery can be mentioned as complications of retinal detachment, focal lens opacities, and minor retinal hemorrhages. The exact pathogenesis of this complication is unknown but may involve shock wave generation, vitreous disturbances, or the formation of cellular debris or inclusions. A study by Nguyen et al. [ 25 ] proposed a method to evaluate the recovery of patients with vitreous floaters after treatment with Nd: YAG. Evaluation methods are based on visual function questionnaires, comparative statistical methods are based on quantitative ultrasonography index and contrast sensitivity. There were 38 eyes with vitreous floaters status examined after performing Nd: YAG treatment. Of these, 13 cases showed improvement in symptoms after surgery. However, there were still 25 cases who feel unsatisfied with the results of vision therapy. Another study by Souza et al. [ 26 ] reported no side effects or a recurrence of vitreous floaters. The study used color photo imaging to evaluate YAG laser vitreolysis for symptomatic vitreous floaters. A total of 32 patients were participating in the survey based on the visual function questionnaire. After 6 months of follow-ups, color imaging showed improvement in vitreous opacity over time in 93.7% of study eyes. In trials, symptomatic amorphous posterior clinical vitreous floaters were detected by a novel optical coherence tomography (OCT) [ 27 ] and successfully treated with a YAG laser optimized for vitreous dissolution. A study by Landa et al. [ 27 ] has shown that the spectral domain OCT can assist in the diagnosis of retinal detachment that cannot be excluded only on clinical examination. In general, laser therapy, particularly Nd: YAG, was found to be more effective and safer in the treatment of vitreous floaters. OCT is one method to evaluate the results after treatment is relatively effective. However, the limitation of laser therapy is that it brings many complications and the success rate of vision recovery is not high. The reason may be that this is an invasive method to the vitreous in the retina, causing disturbances in the retinal environment after treatment, and leading to complications. This means that laser treatment is considered when used as a method of vitrectomy.

In this study, we propose a functional dressing for eye floaters as a non-surgical, semi-invasive treatment with no direct impact on vitreous humor. We demonstrate a functional dressing, which has a structure that effectively allows oxygen and hydrogen to penetrate the skin. After the dressing is attached to the skin, it can generate hydrogen and oxygen through moisture. The function of oxygen is to increase blood oxygen, and the function of hydrogen is to fight inflammation and cell apoptosis in the eye and inhibit the production of excessive active oxygen. The dressing uses hydrogen and oxygen to penetrate tissues, and protect wounds from infections, creating a favorable environment for the recovery of lesions around the eye area. We propose a technique to evaluate post-treatment outcomes by analyzing OCT images, providing a more advanced visual assessment than traditional assessment methods through the visual functioning questionnaire system or other measures such as quantitative ultrasonography or contrast sensitivity.

2. Materials and Methods

2.1. oxygen therapy.

The purpose of oxygen therapy is to treat hypoxia and reduce the clinical symptoms caused by hypoxia. Reactive oxygen species (ROS) are small molecules derived from oxygen and are a by-product of biological aerobic metabolism. They can be used as oxidants or are easily converted into oxygen-free radicals, which are one of the most important elements in oxygen therapy. They react with a variety of molecules, including other small organic molecules such as carbohydrates, lipids, proteins, and nucleic acids. However, excessively high levels of ROS can cause damage to the cell and gene structure. Usually, cells pass enzymes (e.g., superoxide dismutase) to reduce the damaging effect of ROS on cells. Oxygen therapy is also used to treat some patients with chronic oxygen deficiency, such as patients with chronic obstructive pulmonary disease or cystic fibrosis. On the other hand, oxygen is needed in every synthetic action of wound repair, including the synthesis of adenosine triphosphate, collagen, protein, and phagocytes, as shown in Figure 1 a. Nitrogen oxides (NOx) enzyme is the main source of ROS. The production of ROS during wound healing is essential for cell-signal transduction, angiogenesis, and wound disinfection. Oxygen generates superoxide anions through the catalysis of NOx to generate hydrogen peroxide and, subsequently, undergoes the action of redox signals until angiogenesis, as shown in Figure 1 b. In addition, as shown in Figure 1 c, hyperbaric oxygen therapy can increase the level of vascular endothelial growth factor in the wound and monoxide and enzymes in the bone, allowing vascular endothelial stem cells to return to the wound. The ischemic site merges into new blood vessels [ 29 ]. After receiving oxygen, nitric oxide (NO) and enzymes will be affected by enzyme catalysis to synthesize NO and help regulate blood vessel tension and angiogenesis, as shown in Figure 1 d. In the human eye, supersaturated oxygen emulsion can also be used for the local treatment of ocular trauma. Oxygen therapy can improve limbal ischemia, accelerate the formation of corneal epithelium, increase corneal transparency, and reduce corneal blood vessel formation [ 30 ].

Oxygen repair cell derivation process. ( a ) Synthesis of adenosine triphosphate (ATP), collagen, protein, phagocytes, and oxygen. ( b ) Enzyme-catalyzed redox repair in the cell. ( c ) Hyperbaric oxygen therapeutic cell repair. ( d ) Synthesis of nitric oxide (NO) angiogenesis. Vascular endothelial growth factor (VEGF).

2.2. Hydrogen Therapy

Hydrogen is one of the most common substances in nature. It can selectively neutralize cytotoxic ROS and reduce inflammation. Hydrogen is used in a variety of medical applications. At present, the concentration of H 2 in the air does not exceed 4%. Low-H 2 concentrations exhibit therapeutic effects on local inflammation of the eyes, ears, nose, and liver, as well as pancreatitis, systemic inflammatory syndrome, sepsis, and neurodegenerative diseases. In 1975, high concentrations of H 2 were found to inhibit tumor growth [ 31 ]. Hydrogen can play a protective role in various ROS-related diseases, including reducing bowel transplant damage in organ transplantation, treating chronic inflammation, and reducing ischemia-reperfusion injury. Hydrogen is also used to treat various ocular diseases, especially in the retina, which is a place where oxygen is highly needed. However, if excessive free radicals accumulate and increase oxidative pressure, they will peroxidize the lipids in the retina, causing retinal hypoxia. Once hypoxia will cause the production of new blood vessels, hydrogen molecules play a very important role at this time. H 2 is a perfect anti-free radical, and it can protect the retina from vascular proliferation. Oxidative stress triggers the development of a variety of human diseases and injuries, including eye diseases. The human body will induce an oxidative stress response due to excessive production of ROS or reduced production of antioxidants. In order to replace these weakened antioxidants, substances with effective antioxidant properties are needed to inhibit oxidative stress and promote healing. Molecular hydrogen (H 2 ) is very suitable for this purpose due to its unique properties. H 2 is the only antioxidant that crosses the blood–brain barrier and the blood–eye barrier. Due to its small molecular weight, it can quickly penetrate tissues and effectively remove active oxygen. H 2 mainly removes hydroxyl free radicals and peroxynitrite. In addition to its antioxidant effect, H 2 also has anti-inflammatory, anti-apoptotic, cell protection, and mitosis effects. Even when used at high concentrations, H 2 still maintains its non-toxic properties. Figure 2 shows the biological effect mechanism of hydrogen. The main molecular target of the biological effect of H 2 is ROS. The effects on chronic inflammation, signal transduction, genes, immunity, and metabolism (mitochondria) are essentially exerted through ROS. Exogenous damage caused by radiation and other factors induces excessive cellular ROS production [ 31 ]. H 2 penetrates the biomembrane and effectively reaches the cell nucleus. H 2 will selectively remove OH and ONOO−, thereby, preventing DNA damage, as shown in Figure 2 a. H 2 reduces the number of apoptotic factors such as caspase-3, caspase-12, caspase-8, and Bax. Some regulatory apoptosis factors such as Bcl-2 and Bcl-xL exhibit an increasing trend, making human cells have anti-apoptotic effects, as shown in Figure 2 b. In addition, H 2 reduces the number of inflammatory cytokines such as interleukin (IL)-1β, IL-6, tumor necrosis factor-α, intercellular adhesion molecule-1, and high mobility group protein-1, leading to anti-inflammatory effects in human cells, as shown in Figure 2 c. H 2 also regulates the signal transduction within and between many pathways, but the exact target and molecular mechanism need to be further studied, as shown in Figure 2 d. In general, H 2 reduces the risk of oxidative stress related to lifestyle and environment by reacting with strong ROS in a cell-free reaction.

Biological effect mechanism of hydrogen. ( a ) H 2 selective removal of -OH and ONOO−. ( b ) H 2 stimulating human apoptosis factor cell regulation. ( c ) H 2 promoting human inflammatory factor cell regulation. ( d ) Unknown molecular mechanism of H 2 regulation.

2.3. Functional Dressing

Oxygen is a vital source of energy necessary for cell repair and renewal. Once in the lungs, oxygen is carried to the cells through the blood in the capillaries. Due to hypoxia, epidermal cells appear inactive and hibernate, leading to the appearance of grayish-yellow and dark black oxidation marks and dryness, roughness, wrinkles, and sagging of the skin. Air pollution, dust, various toxic substances, and computer radiation are the most likely to cause cell hypoxia, which will cause skin cells to repair themselves, store water, and decrease their defenses. With the exception of supplemental oxygen, all other treatments are nearly futile as they only correct the symptoms but do not treat the root cause. Oxygen not only plays an important role in maintaining the health of our skin but also in wound healing and preventing infection. Oxygen can effectively increase the speed of wound healing. In a low-oxygen environment, healing might be delayed. By contrast, healing is accelerated and the risk of infection is greatly reduced in a high-oxygen environment. In addition to wound healing and infection prevention, oxygen can also be in the form of active oxygen, which can effectively reduce the production of melanin and scars and improve skin tone. Figure 3 shows the structure of the functional dressing used in the study. The functional dressing is from TO2M Co. (Miaoli County, Taiwan), model BXX01. This dressing contains sodium peroxide, sodium hydroxide, aluminum powder, and oxalic acid. It generates hydrogen by adding water [ 32 , 33 ]. It can not only protect the wound but also combine oxygen (O 2 ) and hydrogen (H 2 ) to provide an ideal environment for the affected area, block foreign bodies, and reduce the chance of infection.

Structure of the functional dressing. The outer film layer has a structure that allows the penetration of H 2 O easily, the middle layer consists of chemical compounds that generate hydrogen and oxygen, and sequentially escape through the inner film layer.

2.4. Type B Ultrasonic Scanner (Nidek RS-3000)

Type B ultrasonic scanner includes choroidal mode, which provides a comprehensive evaluation for choroid, retina, and glaucoma analysis. The principle of OCT scanning is to use the spectral domain of OCT with a scan range X axis is 3–12 mm, the Y axis is 3–9 mm, and the Z axis is 2.1 mm, using an 880 nm Super-Luminescent Diode light source. Scan speed can achieve up to 85,000 A-scans/s with averaging 120 images. The device can perform retina analysis, glaucoma analysis, angio-scan, or real-time compensation for eye movements which ensures higher image quality and maximum reproducibility. The advanced mode of RS-3000 can be used for measurement with ultra-low sensitivity depending on the pathology to be evaluated. The 9 mm × 9 mm wide-area scan ensures excellent coverage of the entire retinal structure. The unique Eye Tracer technology can use fundus information obtained from high-definition images for precise measurement. The Eye Tracer technology combines positioning, tracking, and automatic shooting functions for convenient and rapid measurement. During the macular line scan, micro-tracking and other involuntary eye movements can be compensated by the “Tracking HD” function. This function ensures that up to 120 macular scan images are aligned to enhance image averaging. Subsequent images are precisely aligned with the baseline data to achieve high reproducibility. The automatic registration function can compensate for the knob in the image acquisition process, thereby, improving the quality of subsequent data. The B-mode ultrasound scanner is an important diagnostic and predictive tool to determine diseases at the back of the eyeball when obvious vitreous opacity is present. There have been many research trials using Scan-B Ultrasound to detect vitreous floaters. Oksala et al. [ 34 ] used ultrasound to detect echoes from vitreous collagens. Mamou et al. [ 35 ] effectuated similar experiments by analyzing the contrast sensitivity obtained from this ultrasound device. Hence, ultrasound is typically used to assess the diagnosis of vitreous floaters.

2.5. Symptoms of Vitreous Floaters

In the imaging of the B-mode ultrasound scanner, vertical and horizontal analysis diagrams inside the vitreous body and OCT assist the doctor to make more accurate judgments and treatments. Patients with mild clinical symptoms will see black lines floating and occasional flashes of tiny spots of light that may not affect vision. Under the analysis of the B-mode ultrasonic scanner, the turbid part of the vitreous is not obvious, but a slight shadow and blackness can still be seen on the vitreous. Patients with moderate clinical symptoms have increased dark shadows and light spots in front of their eyes ( Figure 4 a). In the imaging of the B-mode ultrasound scanner, local shadows begin to appear inside the vitreous, as shown in Figure 4 b. When this symptom persists, the condition is worsening, and the patient must seek a medical facility for treatment. Finally, patients with severe and more significant turbidity have a large number of black shadows in front of their eyes, and their vision may even be reduced by varying degrees. Dust or thick flocculent blocks floating may be present near the vitreous body and the macula. As shown in Figure 4 c, when the vision is severely affected, surgical treatment should be considered. Clinical symptoms and details of pathological signs diagnosed and consulted by doctors represented in OCT images are shown in Table 1 .

Measurement results of B-type ultrasound scanner. ( a – c ) Imaging analysis of mild, moderate, and severe floaters, respectively. The figure on the right is the OCT in the horizontal and vertical directions.

The clinical symptoms and pathological sign details are shown on OCT images for levels of vitreous floater.

3. Results and Discussions

Figure 5 a–c show the measurement results of the ultrasound scan of patient A before and after treatment. In Figure 5 a, before treatment, patient A has a darker shade in the center of the macula in the middle of the vitreous, and many tiny floating objects can be observed in the vitreous. In Figure 5 b, the shadow of the fovea gradually fades after 2 months of treatment, and the floating objects are also reduced and lighter. In Figure 5 c, 4 months after treatment, the shadow of the fovea is lighter, and the floating objects are almost disappeared. Figure 5 d–f show the results of the ultrasound scanner measurement of patient B before and after treatment. In Figure 5 d, the shadow covers almost the entire macula and is even more severe than the symptoms of patient A. The vitreous body is also full of many tiny floating objects. After 2 months of treatment, the shadow of the macula is significantly lighter, the treatment effect has not decreased due to more serious symptoms, and the number of floating objects is reduced (see Figure 5 e). After 4 months of treatment, the macular shadows and floating objects almost completely disappear, as shown in Figure 5 f. The diagnosis of vitreous floaters through ultrasound scanners provides a fairly reliable basis. Type-B ultrasound systems are capable of assessing changes from the wave at interfaces of tissues with different densities, i.e., interfaces between liquid and gel vitreous or echoes from vitreous collagens. This was confirmed in some references that found that vitreous opacity in the vitreous vestibule was most correlated with diminishing contrast. When the amount of echoes from gel-liquid interfaces tend to decrease, it shows that the environment in the retina is gradually returning to equilibrium [ 24 , 34 , 35 ].

Comparative analysis of clinical treatment effects. Results showed improvement of eye floaters symptoms through fading of macular shadows and floating objects compared to baseline disease ( a , d ), after 2 months of treatment ( b , e ), and after 4 months of treatment ( c , f ) of 2 patients A and B.

Recently, due to aging or excessive use of 3C products, glass floaters have continued to increase. When the vitreous body of the eye is chaotic, vitreous floaters cast shadows on the retina, making it seem like something is floating in front of the eyes [ 36 ]. In a previous clinical trial, 10, 12, and 6 subjects had mild, moderate, and severe floaters, respectively. After 2 months of treatment for patients with mild floaters, seven patients almost no longer had symptoms of floaters. However, some patients had bad eye habits. Three patients with mild symptoms had improper eye habits, such as using mobile phones in dark places, staying up late, and overuse of eyes, resulting in symptoms of floaters. After 2 months of treatment for patients with moderate floaters, eight patients had mild symptoms, and the other 4 are due to complications such as recurrent vitreous hemorrhage and corneal edema. As well as poor healing of the corneal epithelium, postoperative intraocular pressure increase, retinal tears, etc., continuous regular follow-up and treatment are required to achieve the therapeutic effect. However, new complications may continue to occur in the acute phase. Thus, 1 week after diagnosis, close follow-up visits are required within 3 months. If patients remain stable, regular visits will be made for 3–6 months. However, patients with severe floaters usually have pathological floaters, which are more likely to occur over 50 years of age. People with high myopia, diabetes, high blood pressure, cataract surgery, eye injury, and eye inflammation. Due to the rupture of blood vessels in the retina, retinal tears or detachment of the retina result in inflammation of the tissues around the vitreous body, causing a large amount of white blood cell suspension to leak out from the vitreous body. Usually, the flying mosquitoes seen by the patient are a thick black shadow, which seriously affects the vision and needs immediate treatment. After 2 months of clinical trial treatment, six patients had moderate symptoms of floaters. Among the six patients with severe floaters, the use of functional dressings can improve the treatment effect due to the relatively large volume of floating objects. Among these patients, five had obvious treatment effects. The floating objects were not only greatly reduced, but the poor vision was also slightly improved. However, floating objects may not be removed by a single treatment. Multiple treatments and continuous follow-ups are required, and the other one is due to the usual and continuous improper use of the eyes, which results in the lack of effectiveness of the treatment. Taken together, when patients see floaters in front of their eyes, they should visit the ophthalmology department for a thorough retinal examination of the fundus. Patients with mild symptoms of floaters may have these symptoms throughout their lives, but they still need to be monitored regularly by an ophthalmologist. After a period of adaptation, floaters usually leave the field of vision and gradually disappear. Patients can also try to move their eyes (looking up and down) to make the fluid in the eyes form fluctuations, which can temporarily make floaters disappear. However, pathological floaters caused by vitreous hemorrhage, peripheral retinal tears, and retinal detachment require more aggressive treatment to avoid further deterioration. The number of patients who recovered positively after 2 months of therapy is shown in Table 2 .

The number of patients participating in clinical trials and the number of patients recovering actively after 2 months of treatment.

4. Conclusions

The treatment of vitreous floaters is currently attracting doctors’ and researchers’ attention. There are many advanced solutions to this problem. Our method has shown the patient’s recovery effect in more than 4 months of intensive treatment. Compared with laser therapy, using a functional eye dressing has more potential treatment results and does not cause side effects with the ingredients in the device. Functional eye dressing offers a novel solution for semi-invasive therapy, providing potential therapeutic results and no side effects with ingredients in the device. Our method is portable, compact, and suitable for treatment in the eye and face area. The treatment results achieved for the three grades of vitreous floaters disease were 70%, 66.7%, and 83.3%, respectively. Moreover, the evaluation of treatment results visualized by analyzing through OCT images will bring essential assistance to doctors in the diagnosis and conclusion of treatment regimens. We hope that the use of functional eye dressing will be a new solution in the treatment of vitreous floaters.

Funding Statement

This research was supported by the National Science and Technology Council, China under the grants NSTC111-2221-E-194-007. This work was financially/partially supported by the Advanced Institute of Manufacturing with High-tech Innovations (AIM-HI) and the Center for Innovative Research on Aging Society (CIRAS) from The Featured Areas Research Center Program within the frame-work of the Higher Education Sprout Project by the Ministry of Education (MOE), and Kaohsiung Armed Forces General Hospital research project MAB107-097 in Taiwan.

Author Contributions

Conceptualization, W.-S.F. and S.-Y.H.; methodology, H.-T.N.; software, H.-T.N.; validation, W.-T.H. and H.-C.W.; formal analysis, W.-S.F.; investigation, W.-T.H.; resources, W.-H.C.; data curation, W.-S.F. and S.-Y.H.; writing—Original draft preparation, H.-T.N.; writing—Review and editing, F.-C.L. and H.-C.W.; supervision, H.-C.W.; project administration, H.-C.W. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of Dalin Tzu Chi General Hospital (B11001017).

Informed Consent Statement

Written informed consent was waived in this study because of the retrospective anonymized nature of study design.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

RESEARCH PLANS

Research overview: our tri-project proposal.

A safe and effective cure for eye floaters is our goal – as soon as possible. While scientific research is the solution, it’s essential that we lay the foundation to have this disease recognized as a serious issue by the medical community – meaning a cure can be developed faster. We have outlined our Tri-Project Proposal below with details on how we can greatly accelerate scientific research and help us pressure the pharmaceutical industry to cure eye floaters. The VDM Project is exploring ways to receive governmental grants, but this won’t be possible without eye floaters being recognized as a serious problem first. We can only complete the program with funding, and we need your help.

Funding objectives

We are aiming to raise $10,000 per month to achieve our goals.

With the results of these vital projects, we will have the quantifiable research to present to medical institutes who will understand the serious impact of eye floaters – which will help us to develop a safe and effective cure sooner.

Our Objectives

A safe and effective cure for eye floaters is our goal – as soon as possible.

While scientific research is the solution, it’s also essential that we have this disease recognized as a serious issue by the medical community and society at large. This way, a cure can be developed faster.

We have outlined with the VMR Research Foundation and Dr. J. Sebag a Tri-Project Proposal below with details on how we can greatly accelerate scientific research and help put pressure on the pharmaceutical industry to cure eye floaters.

The VDM Project is exploring ways to receive government grants, but this won’t be possible without eye floaters being recognized as a serious problem first. We can only complete the program with funding, and we need your help.

What is the VDM Project?

We are a team of eye floater sufferers from around the world, united to find a safe and effective cure for this disease. We support the VMR Research Foundation and work with other international institutes. The VDM Project is committed to scientific research that will result in clear vision – but we need your help. Find out more information at: www.vdmresearch.org

Project One – Discovering the Origin of Eye Floaters

Our short-term goal is to cure this disease, and our long-term goal is to prevent it.

To do this, our researchers need to gain a better knowledge of eye floaters at a molecular level. For a cure to be found, a better understanding of eye floaters is essential. As a combined effort between the VMR Research Foundation and university laboratories in Belgium, Germany, Poland, Spain, and the United States , this project is fundamental to understanding how eye floaters develop, and how they can be treated safely today, as well as prevented tomorrow.

Project Two – Myopia and Eye Floaters

Near-sightedness (myopia) has a strong correlation with eye floaters, but the reason is currently unknown.

Project Two will assess the changes in the eyes of patients with eye floaters to better understand how and why this condition occurs. Due to myopia levels increasing dramatically worldwide (estimated to affect 5 billion people per year by 2050), this project is necessary to gain the attention of governments and medical institutes globally. Once we have sufficient data, funding toward a cure is much more likely, meaning a floater-free future for sufferers.

Project Three – Vitreous Floaters Functional Questionnaire

One of our key strategies in having this disease recognized by Governments, Medical Institutes and Researchers is to show the widespread prevalence of eye floaters.

Currently, a questionnaire frequently used by the U.S. National Eye Institute does not adequately show how eye floaters negatively impact the lives of sufferers. We aim to change this. A new questionnaire created by the VMR Research Foundation specifically measures the negative impact of eye floaters with quantifiable metrics, so we can accurately measure the magnitude of this problem for individuals as well as populations. This vital questionnaire will greatly strengthen our ability to apply for medical research funding and is a key step to curing eye floaters. We also anticipate that this questionnaire will provide sufferers with feedback on the severity of their disease.

Only with the necessary funding can we complete these essential projects and gain real-time data that shows how debilitating eye floaters can be.

All donations will be allocated to the Tri-Project Proposal accordingly, maximising our ability to complete them as soon as possible – meaning we’ll be closer to finding a cure.

Alternate Ways to Donate

If you wish to donate but are unable to via this platform, you are welcome to via Wire Transfer:

• Chase Bank Account Number: 531765581
• Routing Number for wire transfers: 021000021
• Routing number for direct deposits and ACH: 322271627
• SWIFT code for international wire transfers: CHASUS33

Research Team

J. Sebag, MD, FACS, FRCOphth, FARVO

Senior Research Scientist, Doheny Eye Institute/UCLA; Professor of Clinical Ophthalmology, Geffen School of Medicine, UCLA; Founding Director, VMR Institute for Vitreous Macula Retina

Considered a leading authority on the vitreous, Dr. Sebag has authored 233 academic publications, as of October 2020.

A fellow of the American College of Surgeons and the Royal College of Ophthalmologists (UK), Dr. Sebag has delivered named lectures throughout the world, most recently the Inaugural Robert Machemer Lecture to the European Society of Ophthalmology (2019). In 2006 Dr. Sebag was inducted as a member of the American Ophthalmological Society, chairing the program committee in 2016. In 2010 he was selected as a Fellow of ARVO, the world’s premier eye research organization.In 2018 the American Academy of Ophthalmology accorded Dr. Sebag the Senior Career Achievement Award.

In the past decade Dr. Sebag has championed the cause of people suffering from vitreous floaters sufficiently severe to merit the diagnosis of Vision Degrading Myodesopsia, a condition that can be cured today with vitrectomy, but tomorrow with less invasive approaches and even prevention, the ultimate goal of modern Medicine.

Supporting the VDM Project will make tomorrow happen sooner.

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• Patient Care & Health Information
• Diseases & Conditions
• Eye floaters

As you age, the vitreous — a jelly-like material inside your eyes — liquifies and contracts. When this happens, microscopic collagen fibers in the vitreous tend to clump together. These scattered pieces cast tiny shadows onto your retina. The shadows you see are called floaters.

Eye floaters are spots in your vision. They may look to you like black or gray specks, strings, or cobwebs. They may drift about when you move your eyes. Floaters appear to dart away when you try to look at them directly.

Most eye floaters are caused by age-related changes that occur as the jelly-like substance (vitreous) inside your eyes liquifies and contracts. Scattered clumps of collagen fibers form within the vitreous and can cast tiny shadows on your retina. The shadows you see are called floaters.

If you notice a sudden increase in eye floaters, contact an eye specialist immediately — especially if you also see light flashes or lose your vision. These can be symptoms of an emergency that requires prompt attention.

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Symptoms of eye floaters may include:

• Small shapes in your vision that appear as dark specks or knobby, transparent strings of floating material
• Spots that move when you move your eyes, so when you try to look at them, they move quickly out of your line of vision
• Spots that are most noticeable when you look at a plain bright background, such as a blue sky or a white wall
• Small shapes or strings that eventually settle down and drift out of the line of vision

When to see a doctor

Contact an eye specialist immediately if you notice:

• Many more eye floaters than usual
• A sudden onset of new floaters
• Flashes of light in the same eye as the floaters
• A gray curtain or blurry area that blocks part of your vision
• Darkness on a side or sides of your vision (peripheral vision loss)

These painless symptoms could be caused by a retinal tear, with or without a retinal detachment. This is a sight-threatening condition that requires immediate attention.

• Mayo Clinic Minute: What are eye floaters?

Jason Howland: Having vision problems? Do you see black or gray specks, strings or cobwebs that drift about when you move your eyes? It could be eye floaters.

Amir Khan, M.D., Consultant, Ophthalmology, Mayo Clinic: In the back of our eyes, we have a substance called "the vitreous." When we're young, it's a firm clump of jelly. As we age, this firm clump of jelly can liquefy and break up into smaller pieces. Those smaller pieces are what you may notice as floater.

Mr. Howland: Eye floaters are more common as you get older and if you're nearsighted. The biggest concern – they can cause retinal tears.

Dr. Khan: If a tear develops in the retina, fluid can get in underneath that tear and just lift the retina off like wallpaper off a wall and that's a retinal detachment.

Mr. Howland: And that can cause blindness, which is why it's especially important to have a dilated eye exam within days of noticing new floaters or changes in vision. Most eye floaters don't require treatment, but your eye doctor likely will recommend regular eye exams to ensure the condition doesn't worsen.

For the Mayo Clinic Newsnetwork, I'm Jason Howland.

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Retinal detachment

Retinal detachment describes an emergency situation in which a thin layer of tissue (the retina) at the back of the eye pulls away from the layer of blood vessels that provides it with oxygen and nutrients. Retinal detachment is often accompanied by flashes and floaters in your vision.

Eye floaters may be caused by vitreous changes related to aging or from other diseases or conditions:

Age-related eye changes. The vitreous is a jelly-like substance made primarily of water, collagen (a type of protein) and hyaluronan (a type of carbohydrate). The vitreous fills the space in your eye between the lens and retina and helps the eye maintain its round shape.

As you age, the vitreous changes. Over time, it liquifies and contracts — a process that causes it to pull away from the eyeball's inside surface.

As the vitreous changes, collagen fibers within the vitreous form clumps and strings. These scattered pieces block some of the light passing through the eye. This casts tiny shadows on your retina that are seen as floaters.

• Inflammation in the back of the eye. Uveitis is inflammation in the middle layer of tissue in the eye wall (uvea). Posterior uveitis affects the back of the eye, which includes the retina and an eye layer called the choroid. The inflammation causes floaters in the vitreous. Causes of posterior uveitis include infection, autoimmune disorders and inflammatory diseases.
• Bleeding in the eye. Bleeding into the vitreous can have many causes, including retinal tears and detachments, diabetes, high blood pressure (hypertension), blocked blood vessels, and injury. Blood cells are seen as floaters.
• Torn retina. Retinal tears can happen when a contracting vitreous tugs on the retina with enough force to tear it. Without treatment, a retinal tear may lead to retinal detachment. If fluid leaks behind the tear, it can cause the retina to separate from the back of your eye. Untreated retinal detachment can cause permanent vision loss.
• Eye surgeries and eye medications. Certain medications that are injected into the vitreous can cause air bubbles to form. These bubbles are seen as shadows until your eye absorbs them. Silicone oil bubbles added during certain surgeries on the vitreous and retina also can be seen as floaters.

Risk factors

Factors that can increase your risk of eye floaters include:

• Age over 50 years
• Nearsightedness
• Complications from cataract surgery
• Diabetes complication that causes damage to the blood vessels of the retina (diabetic retinopathy)
• Eye inflammation
• What are floaters and flashes? American Academy of Ophthalmology. https://www.aao.org/eye-health/diseases/what-are-floaters-flashes. Accessed May 26, 2022.
• Floaters. National Eye Institute. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/floaters. Accessed May 26, 2022.
• Floaters. Merck Manual Professional Version. https://www.merckmanuals.com/professional/eye-disorders/symptoms-of-ophthalmologic-disorders/floaters. Accessed May 26, 2022.
• Buttaravoli P, et al., eds. Floaters. In: Minor Emergencies. 4th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 26, 2022.
• Uveitis. National Eye Institute. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/uveitishttps://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/uveitishttps://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/uveitis. Accessed May 26, 2022.
• What is a vitrectomy. American Academy of Ophthalmologists. https://www.aao.org/eye-health/treatments/what-is-vitrectomy. Accessed May 26, 2022.
• Lin T, et al. The efficacy and safety of YAG laser vitreolysis for symptomatic vitreous floaters of complete PVD or non-PVD. Ophthalmology and Therapy. 2022; doi:10.1007/s40123-021-00422-6.
• Charles S. Vitreous. In: Vaughan & Asbury's General Ophthalmology. 19th ed. The McGraw-Hill Companies; 2018. http://accessmedicine.mhmedical.com. Accessed May 27, 2022.
• Chodnicki K (expert opinion). Mayo Clinic. June 6, 2022.

News from Mayo Clinic

• Mayo Clinic Minute: What are eye floaters? Jan. 16, 2023, 03:30 p.m. CDT
• Mayo Clinic Q and A: Most eye floaters caused by age-related changes Nov. 13, 2022, 12:00 p.m. CDT
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Managing eye floaters and navigating the latest research

Don't let eye floaters get the best of you - discover the latest advancements in managing this condition, from surgical treatments to home remedies.

A few years ago, my mother started to experience eye problems and was later diagnosed with cataracts. However, after undergoing a successful surgery, she started to notice dark spots that appeared like flies or bugs and would come and go. These spots were eye floaters.

In an effort to find if there was anything that could help with the eye floaters, I researched the topic to see what the latest understanding and treatment options were. In this blog post, I will share the information I gathered about eye floaters, including their causes, symptoms, and potential treatments. I will also discuss several studies on non-surgical alternative remedies I have come across. And lastly, my thoughts on what this information means for my mother’s eye conditions.

Causes of eye floaters 

Eye floaters are spots in your field of vision that appear as black or gray specks, strings, or cobwebs. They may drift about as you move your eyes and appear to dart away when you try to look at them directly. Eye floaters are commonly associated with aging, and middle to late-aged adults are more likely to experience them as the vitreous gel in the eye changes and becomes more liquid or shrinks. This change in the vitreous causes small particles to float down through the fluid, creating the appearance of floaters. They eventually settle toward the bottom of your eye, where you won't notice them anymore.

In addition to aging, other factors that can increase the risk of developing eye floaters include nearsightedness, ocular inflammation, bleeding in the eye, a torn retina, eye injury, eye injections for macular degeneration, or cataract surgery. If you have any of these risk factors, it's important to closely monitor your vision and seek medical attention promptly if you notice any changes.

Eye floater symptoms and when to see a doctor

Eye floater symptoms may include small shapes in your vision appearing as dark specks or transparent strings that move when you move your eyes and are most noticeable when looking at a plain, bright background. These small shapes or strings eventually settle and drift out of the line of vision.

Eye floaters, while commonly harmless, can sometimes indicate more serious underlying eye conditions, such as retinal detachment, retinal tear, or macular degeneration. If you notice an increase in the number of floaters, a sudden appearance of new floaters, flashes of light in one eye, a gray curtain or blurriness that obstructs part of your vision, or darkness in the peripheral vision, it is essential to see an eye specialist right away. These painless symptoms could indicate a retinal tear or detachment, which is a severe and sight-threatening condition that requires immediate medical attention. Do not wait to seek help if you experience any of these symptoms.

Eye floater treatments

Eye floaters are a common condition that can be frustrating and take time to adjust to, but most of the time, they do not require treatment. However, in rare cases, when they get in the way of your vision, you and your eye care specialist may consider treatment options. There are two main treatments for eye floaters: vitrectomy surgery and laser vitreolysis.

Vitrectomy Surgery: This is a surgical procedure to remove the vitreous gel through a small incision and then replace it with a solution that mimics the vitreous to help the eye maintain its shape. The procedure is performed by an ophthalmologist who specializes in retina and vitreous surgery. While this surgery can remove some of the eye floaters, it may not remove all of them and new floaters can still develop after surgery. Additionally, there are several risks associated with this procedure, including infection, bleeding, retinal detachment, retinal tears, and cataracts.

Laser Vitreolysis:  This is a minimally invasive procedure that aims to eliminate the visual disturbance caused by eye floaters. An ophthalmologist uses a special laser to break up the floaters, making them less noticeable. The goal of this treatment is to achieve a "functional improvement," allowing you to return to your normal day-to-day activities without the hindrance of floaters. Some people report improved vision after the treatment, while others notice little to no difference. However, there is a risk of damaging the retina if the laser is aimed incorrectly.

In my mother's case, in addition to having eye floaters, she was also diagnosed with macular pucker. If either condition worsens to the point where it significantly affects her vision and daily activities, we would consider vitrectomy surgery to treat both the macular pucker and eye floaters.

Eye floater relief or remedies

During my research, I found some small studies exploring alternative treatments for eye floaters. 

Pineapple (bromelain): A pilot study published in the American Science journal in 2019 showed that consuming pineapples could reduce the persistence of floaters. The study involved 388 participants, who consumed 100 to 300 g of pineapple daily for three months. Results showed that the percentage decrease of floaters ranged from 30% to 45%, depending on the amount of pineapple consumed. The researchers also suggested that the special chemicals in pineapples, called bromelain, might help break down substances that create tiny fibers or the eye floaters, and get rid of harmful particles called free radicals. 

Bromelain based supplement:  Another study published in 2020 involved 280 participants who took a supplement containing bromelain, papain, and ficin. The study found that 70% to 72% of participants reported a reduction in their eye floaters. The authors believed that the supplement works by breaking down the substances that cause floaters and removing harmful particles in the eye, similar to the pineapple study.

L-lysine based supplement: A study published in 2021 looked at the effects of a supplement containing L-lysine, grape seed extract, vitamin C, zinc, and citrus fruit extract on eye floater patients. Out of 61 participants, 77% reported a reduction in their floaters after taking the supplement daily for six months. However, it's worth noting that 29% of the participants in the placebo group also reported improvement. (Note: The authors of the study have a patent on the formula and funded the research.)

Atropine eye drops: During my research, I also came across research indicating that atropine eye drops may help relief symptoms of eye floaters. Atropine is more commonly known as an eye dilution eye drop used during eye exams or treatment to prevent myopia progression in children. For eye floaters, an abstract of a study submitted by Dr. Kaymak from Germany to the European Society of Cataract and Refractive Surgery in 2017 indicated that atropine improved floater symptoms when used in diluted concentrations of 0.01% or 0.005%. However, this study was not published and is no longer available on the society's website. 

Before finishing, it is important to note that the current standard of care for eye floaters is vitrectomy or laser vitreolysis. The alternative treatments discussed were based on small studies and didn’t work for everyone. And the use of atropine for eye floaters relief was not widely studied and not approved by the FDA.

Additionally, nutritional supplements may interact with medications or have potential side effects that may impact your health. Therefore, always consult with your eye care specialist before trying any new remedies or treatments for your eye floaters.

Our plan forward

Macula pucker and eye floaters are conditions that can develop with age. Although my mother experienced some symptoms of eye floaters and was diagnosed with macula pucker, these conditions do not significantly impact her vision or daily life now. As surgery comes with potential risks and complications, we have decided to treat these conditions if they worsen.

However, we will remain proactive and schedule regular check-ups with her eye doctor to monitor both of her conditions. If one of the conditions progresses and starts to significantly affect her vision and daily life, we will consider the surgical option, such as a vitrectomy.

In the meantime, we plan to add pineapple to the grocery list. Despite our skepticism about its potential benefits for eye floaters, it is convenient and one of my father’s favorite fruits. We are also considering supplements and atropine eye drops, but will consult with here eye doctor first.

And if atropine is appropriate, I can imagine a future scenario where my ten-year-old son asks his grandmother if her myopia is worsening too and that they can be myopia control buddies.

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At a glance: Floaters

Small dark spots or squiggly lines that float across your vision

Dilated eye exam

None (in most cases), surgery

What are floaters?

Floaters are small dark shapes that float across your vision. They can look like spots, threads, squiggly lines, or even little cobwebs.

Most people have floaters that come and go, and they often don’t need treatment. But sometimes floaters can be a sign of a more serious eye condition. So if you notice new floaters that appear suddenly and don’t go away, it’s important to tell your eye doctor.

What are the symptoms of floaters?

Floaters move as your eyes move — so when you try to look at them directly, they seem to move away. When your eyes stop moving, floaters keep drifting across your vision.

You may notice floaters more when you look at something bright, like white paper or a blue sky.

Am I at risk for floaters?

Almost everyone develops floaters as they get older, but some people are at higher risk. You’re at higher risk if you:

• Are very nearsighted
• Have diabetes
• Have had surgery to treat cataracts

What causes floaters?

Floaters usually happen because of normal changes in your eyes. As you age, tiny strands of your vitreous (the gel-like fluid that fills your eye) stick together and cast shadows on your retina (the light-sensitive layer of tissue at the back of the eye). Those shadows appear as floaters.

Sometimes floaters have more serious causes, including:

• Eye infections
• Eye injuries
• Uveitis (inflammation in the eye)
• Bleeding in the eye
• Vitreous detachment (when the vitreous pulls away from the retina)
• Retinal tear (when vitreous detachment tears a hole in the retina)
• Retinal detachment (when the retina gets pulled away from the back of the eye)

When to get help right away

Sometimes new floaters can be a sign of a retinal tear or retinal detachment — when the retina gets torn or pulled from its normal position at the back of the eye.

Symptoms can include:

• A lot of new floaters that appear suddenly, sometimes with flashes of light 
• A dark shadow (like a curtain) or blurry area in your side or central vision

Retinal tear or detachment can be a medical emergency . If you have these symptoms, it’s important to go to your eye doctor or the emergency room right away.

How will my eye doctor check for floaters?

Your eye doctor can check for floaters as part of a dilated eye exam. Your doctor will give you some eye drops to dilate (widen) your pupil and then check your eyes for floaters and other eye problems.

This exam is usually painless. The doctor may press on your eyelids to check for retinal tears, which may be uncomfortable for some people.

What’s the treatment for floaters?

Treatment for floaters depends on the cause. If your floaters are caused by another eye condition, you may need treatment for that condition.

If your floaters are caused by aging and they don’t bother you, then you probably won’t need any treatment.

If your floaters make it hard to see clearly and interfere with your daily life, your eye doctor might suggest a surgery called a vitrectomy to remove the floaters. Talk with your doctor about the risks and benefits of this surgery.  

Last updated: November 15, 2023

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• Félix Sauvage Department of Pharmaceutics, Universiteit Gent, Gent, Belgium
• Van Phuc Nguyen Kellog Eye Center, University of Michigan Michigan Medicine, Ann Arbor, Michigan, United States
• J Sebag VMR Institute, Huntington Beach, California, United States
• Juan Fraire Department of Pharmaceutics, Universiteit Gent, Gent, Belgium
• Katrien Remaut Department of Pharmaceutics, Universiteit Gent, Gent, Belgium
• Kevin Braeckmans Department of Pharmaceutics, Universiteit Gent, Gent, Belgium
• Yannis Mantas Paulus Kellog Eye Center, University of Michigan Michigan Medicine, Ann Arbor, Michigan, United States
• Stefaan De Smedt Department of Pharmaceutics, Universiteit Gent, Gent, Belgium
• Footnotes Commercial Relationships   Félix Sauvage , None; Van Phuc Nguyen , None; J Sebag , None; Juan Fraire , None; Katrien Remaut , None; Kevin Braeckmans , None; Yannis Paulus , None; Stefaan De Smedt , None
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Félix Sauvage , Van Phuc Nguyen , J Sebag , Juan Fraire , Katrien Remaut , Kevin Braeckmans , Yannis Mantas Paulus , Stefaan De Smedt; Gold nanoparticles for the treatment of eye floaters by light-induced vapor nanobubbles. Invest. Ophthalmol. Vis. Sci. 2021;62(8):3307.

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Purpose : Vitreous opacities are collagen aggregates that form in the vitreous body due to myopia and/or age-related structural changes (i.e. fibrous liquefaction) which cast shadows on the retina, impacting vision. Current therapies are based on laser treatment with an yttrium garnet laser (YAG) or vitrectomy The efficacy of YAG laser vitreolysis is unproven and vitrectomy remains invasive with associated side effects). We propose a nanotechnology-based treatment of floaters using the plasmon properties of gold nanoparticles (AuNPs). AuNPs bind to vitreous opacities, and when exposed to pulsed-laser light (typically a nanosecond laser), heat up and generate vapour nanobubbles (VNBs) due to the evaporation of the surrounding water. These VNBs then burst, providing sufficient mechanical energy to fragment and destroy the opacities.

Methods : In Vitro : Type I collagen fibers were prepared as artificial floaters and human vitreous opacities were obtained from patients after vitrectomy. Samples were mixed with Hyaluronic (HA) coated AuNPs (10 nm) and irradiated with a pulsed laser (<7ns; 561 nm) at different fluences. Dark field imaging was performed to assess effects. In Vivo : Type I collagen fibers were injected intravitreally in rabbits so that they were located close to the retina (<500 µm). 5 days later, HA-AuNPs were injected. Three days after the injection of AuNPs, fibers were irradiated with a nanosecond laser (<7ns; 530 nm). Photoacoustic imaging was performed to assess binding of gold on the injected fibers, and optical coherence tomography was performed to assess destruction of the fibers.

Results : HA-AuNPs can diffuse in the vitreous and bind to collagen fibers and vitreous opacities. Type I collagen fibers and vitreous opacities could be completely destroyed in vitro and ex vivo at a fluence of 4.5 J/cm 2 . In vivo , collagen fibers could be destroyed after 7 scans at a fluence of 1.9 J/cm 2 . Preliminary retinal toxicity assesment (TUNEL and H&E staining) did not reveal significant changes compared to untreated rabbits.

Conclusions : This approach can effectively and rapidly destroy vitreous opacities ex vivo and collagen fibers in vivo , using lower energy levels than YAG therapy and paves the way for the vitreolysis with pulsed-lasers and nanotechnologies

This is a 2021 ARVO Annual Meeting abstract.

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New Research Could Mean Less Invasive Eye Floater Treatment

A non-invasive method of treating eye floaters has yet to be devised, forcing patients to either undergo surgery or learn to live with the ailment. However, a pair of doctors at Ophthalmic Consultants of Boston may have discovered a solution involving the use of YAG lasers. These lasers are typically used for surgeries involving cataracts. After testing over thirty patients, over fifty percent of the patients that received treatment saw a decrease in floaters over a six month period compared to the nine percent that received a placebo.

The results of the testing have yet to show any side effects and the treatment appears to be safe, but it remains to be seen if any issues will arise in the long term. The future bodes well for using YAG lasers to one day treat floaters in a less invasive way.

This information is presented by Retina Macula Specialists of Miami, the largest private retina practice in the city. We are a nationally acclaimed retina practice dedicated to the medical and surgical management of vitreoretinal diseases. Each of our extensively trained doctors are Diplomates of the American Board of Ophthalmology and are highly qualified to treat a wide variety of retinal conditions including but not limited to diabetic retinopathy, retinal detachment, vitreous hemorrhage treatment macular problems, age-related macular degeneration , and CSR. We have three convenient locations in Miami, Coral Gables, and North Miami Beach. For contact information or to request an appointment, please visit https://www.retinamaculamiami.com .

Tags: retina macula specialists , vitreous hemorrhage treatment

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Mayo Clinic Q and A: Most eye floaters caused by age-related changes

Cynthia Weiss

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DEAR MAYO CLINIC:  My dad mentioned to me that he has several dark spots and cobweblike strings that interfere with his vision. Is this something to be concerned about? What is needed to fix this condition?

ANSWER:  Dark spots, such as those you describe, may be eye floaters . These black or gray specks, strings, or cobwebs typically drift about when you move your eyes and appear to dart away when you look at them directly. They may be most noticeable when you look at a plain, bright background, like the blue sky or a white wall.

People who need glasses to see distance, called being nearsighted , are more likely to get floaters. They also are more common in adults older than 50, as well as in people who’ve experienced eye trauma or inflammation inside the eye.

The presence of a few long-standing floaters usually is not a cause for concern. Most are caused by age-related changes that occur as the jellylike substance inside the eye, called vitreous, becomes more liquid. When this happens, tiny fibers within the vitreous tend to clump and can cast tiny shadows on the retina.

Although usually harmless, not all floaters are nonthreatening clumps of vitreous, so it is a good idea to have any new floaters examined with a dilated eye exam by an optometrist or an ophthalmologist. If he has not already done so, you should suggest to your father that he see a local eye specialist.

In the event that your father notices a sudden increase in floaters in one eye, he should seek immediate medical attention. In particular, prompt attention is needed if he sees light flashes or experiences a loss of peripheral vision. These changes may signal the presence of a retinal tear or a retinal detachment. If caught early, a retinal tear may be able to be treated with laser. If the tear has progressed to a retinal detachment , then surgery in the operating room is needed to repair the detachment. If left untreated, full detachment can lead to vision loss in the affected eye.

In rare situations an eye care professional may recommend surgical treatment. That can involve surgery to remove the vitreous, which is called a vitrectomy. However, there are risks, including bleeding and retinal tears, and the surgery may not remove all the floaters. Another treatment used infrequently for impaired vision caused by eye floaters is laser therapy. This treatment uses a laser to break up the floaters, making them less noticeable. Laser therapy risks still are not completely known.

As with any eye problem, if you are concerned about eye floaters, it is best to discuss your situation with an eye care professional, who will conduct a complete eye exam. By examining the back of the eyes and the vitreous, your eye care professional can determine the cause of the floaters. — Dr. Amir Khan , Ophthalmology, Mayo Clinic, Rochester, Minnesota

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EnVision Summit 2023: Surgically addressing floaters: Choose patients carefully

In addition to observation, laser-assisted vitreolysis and pars plana vitrectomy (PPV) are options, all of which deserve careful consideration.

Floaters are a huge and common annoyance for patients that can occur in a number of scenarios (Image courtesy stock.adobe.com)

Floaters are a huge and common annoyance for patients that can occur in a number of scenarios, such as posterior vitreous detachments, retinal tears/detachment, asteroid hyalosis, trauma, hemorrhage (diabetes, hypertension, macroaneurysms), uveitis (inflammatory, infectious, idiopathic), and lymphoma/malignancy according to Laxmi Devisetty, MD, who shared her pearls for dealing with floaters at the Envision Summit in Puerto Rico. She is in private practice in Savannah, GA.

Devisetty cited a prospective observational study 1 that reported how common subclinical floaters are, even in nonsymptomatic subjects. The number of perceived floaters also was correlated only weakly with floater-related discomfort. Visual disturbances resulting from floaters can affect quality of life despite the absence of a correlation with visual acuity.

Treatments for floaters

In addition to observation, laser-assisted vitreolysis and pars plana vitrectomy (PPV) are options, all of which deserve careful consideration, according to Devisetty.

If opting to observe the patient, the considerations are the time limit of the observation, the explanation to the patient, and when to make the decision to actively treat the floaters.

If laser-assisted vitreolysis is chosen, 1 study reported that 35.8% of patients have moderate improvement and only 2.5% have significant improvement. 2

Those investigators also found that compared to sham treatment, vitreolysis resulted in improvement, but the visual acuity remained the same. No change was seen in the functional measures between the control and treated subjects despite change in echodensity on ultrasound.

However, the procedure is associated with risks such as retinal detachment, which occurred in 2% of patients and glaucoma and cataract formation with posterior capsular disruption.

If PPV is the treatment of choice, Devisetty advised the use of small-gauge instrumentation. While PPV is more effective than YAG vitreolysis, 3 the associated risks include retinal detachment in 2% to 10%, cataract progression in 25% to 60%, epiretinal membrane formation and cystoid macular edema in less than 5% each, and infection or loss of vision in less than 1%.

The overriding question for these patients that remains is whether or not to treat the floaters.

“Choose your patients carefully and document their symptoms,” Devisetty explained. “Have a thorough discussion regarding the risks and benefits with the patient before actively treating floaters.

Devisetty advised waiting 3 to 6 months for patients so they are confident that treatment is the right choice for them. In her hands, small-gauge vitrectomy is her treatment of choice because it has made it possible to decrease the risks associated with vitrectomies.

“Although small-gauge vitrectomy is not benign, it is my first and only choice for treating floaters,” she concluded.

Tassignon M-J, Dhubhghaill SN, Hidalgo IR, Rozema JJ. Subjective grading of subclinical vitreous floaters. Asia Pac J Ophthalmol. 2016;5(2):104-109. doi: 10.1097/APO.0000000000000189.

Delaney ym, oyinloye a, benjamin l. nd:yag vitreolysis and pars plana vitrectomy: surgical treatment for vitreous floaters. eye (lond) 2002;16:21–26. , broadhead gk, hong t, chang aa. to treat or not treat: management options for symptomatic vitreous floater. asia pac j ophthalmol. 2020; 9(2): 96-103..

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Eye's 'Microbiome' Could Give Clues to Better Dry Eye Treatments

Eye's 'Microbiome' Could Give Clues to Better Dry Eye Treatments

By Dennis Thompson HealthDay Reporter

FRIDAY, March 29, 2024 (HealthDay News) -- Folks suffering from dry eyes might have a problem with the naturally occurring bacteria found on the surface of their eyes, a new study suggests.

There are key differences in the microbes found on dye eye patients compared to folks with normal eyes, researchers found.

“Once we understand the eye microbiota properly, it will improve disease diagnosis at an early stage,” said lead researcher Alexandra Van Kley , a professor at Stephen F. Austin State University in Nacogdoches, Texas.

Researchers found the specific bacteria species most prevalent in people with normal eyes were Streptococcus and Pedobacter .

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On the other hand, more Acinetobacter species were present in people with dry eye.

“We think the metabolites produced by these bacteria are responsible for dry eye conditions,” researcher Pallavi Sharma , a graduate student in Van Kley’s lab, said in a university news release. “We are performing further research to understand the metabolic pathways associated with the Acinetobacter to better understand the disease.”

For the study, researchers collected swab samples from the eyes of 30 volunteers, and then performed genetic analysis to determine the eye microbiome of each person.

The researchers also believe that there’s a strong connection between the gut microbiome and the bacteria found in the eyes, Sharma said.

“Any alteration in the gut microbiome affects other organs and can lead to disease,” Sharma said. “Therefore, we are trying to identify patterns of an imbalance between the types of microbes present in a person's ocular microbiome for people with different health problems.”

Researchers next plan to explore the gut microbiome of patients with dry eye, to better understand how the bacteria there relates to the microbiome of the eye.

The research team presented its findings Tuesday at the American Society for Biochemistry and Molecular Biology’s annual meeting in San Antonio, Texas. Research presented at scientific meetings should be considered preliminary until published in a peer-reviewed journal.

More information

The American Academy of Ophthalmology has more about dry eye .

SOURCE: American Society for Biochemistry and Molecular Biology, news release, March 26, 2024

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Watching a solar eclipse without the right filters can cause eye damage. Here's why

Nell Greenfieldboyce

A woman watches an annular solar eclipse on October 14, 2023 using special solar filter glasses at the National Autonomous University of Mexico. Carlos Tischler/ Eyepix Group/Future Publishing via Getty Images hide caption

A woman watches an annular solar eclipse on October 14, 2023 using special solar filter glasses at the National Autonomous University of Mexico.

On April 8, as millions of people try to watch a solar eclipse sweep over North America, eye doctors across the United States will be on high alert.

That's because, while a solar eclipse is a stunning celestial event, it can also be dangerous. Looking at any part of the exposed sun without the right kind of protection can permanently injure the eye's light-sensitive retina.

And if past eclipses are prologue, it's likely that some eclipse-gazers will show up at doctors' offices with significant eye damage.

For April's eclipse, going from 'meh' to 'OMG' might mean just driving across town

In 2017, during the solar eclipse seen across the United States, that happened to multiple people despite abundant media coverage about the danger of looking at the sun when it is anything less than fully and completely covered by the moon.

In New York City, for example, one young woman came to the New York Eye and Ear Infirmary of Mount Sinai, complaining of blurred and distorted vision.

She had peeked up at the crescent sun without eyewear at first, then looked at it longer while wearing what she thought were appropriate eclipse glasses.

Everything you need to know about solar eclipse glasses before April 8

"But the problem was she was handed glasses from someone else," says ophthalmologist Avnish Deobhakta , so she didn't know if the eyewear really met safety standards .

Doctors found a permanent, crescent-shaped wound on her retina; there's no treatment for that kind of injury, which is similar to the kind of light-induced damage caused by pointing a laser into the eye.

Other eclipse-related eye injuries were reported in California and Utah .

Given that more than 150 million people directly viewed either a partial eclipse or a total solar eclipse, however, the number who suffered eye problems may seem relatively small.

Plan to watch the eclipse from a wild mountain summit? Be ready for harsh conditions

"We've got less than 100 cases across Canada and the U.S.," says Ralph Chou , an eclipse eye safety expert with the University of Waterloo in Canada.

But no one knows for sure how many people damaged their eyes in 2017, he says, because not every case gets written up for a medical journal, and people may not seek help for less severe vision troubles.

"A lot of them, if they actually happened, were probably relatively minor and, you know, they resolved on their own within weeks or months," says Chou, who says that about half of those who experience significant blurring on the day after an eclipse will recover almost completely.

Some of that recovery may just be the brain learning to compensate and "fill in" the blanks, says Deobhakta, who notes that "there's two eyes, and often there's asymmetric injury. Your brain kind of gets used to it."

The eclipse gives astronomy clubs an opportunity to shine

He notes that there are ways to enjoy the eclipse without looking up at all; everyday household objects like colanders allow you to create pinhole projectors that let you watch an image of the sun becoming more and more crescent-shaped.

"My advice is to not look at the sun, because you may not realize that it is affecting your retina. It does not hurt. It doesn't burn at the time. It's not as if you feel it," says Deobhakta.

If you do choose to look up at the sun when it is partially eclipsed, says Deobhakta, "make sure you really are sure that you have the standard glasses that have the right filters."

The American Astronomical Society has a list of vetted suppliers .

Will you be celebrating the solar eclipse? NPR wants to hear from you

If you still have reliable eclipse viewers from 2017 that are in good condition, those should still work fine, says Chou.

He notes that eclipse viewers usually have a "best by" date on them, but that is to satisfy European regulations related to personal protective equipment.

"It's essentially meaningless because the filters do not age," says Chou. "If you've taken good care of the viewers from 2017, they haven't been crushed or folded or whatever to damage the mountings, then they're perfectly safe to use for this eclipse."

Despite the warnings, some people try to glimpse the partially-eclipsed sun without eye protection, thinking that a quick look won't cause any harm. While an initial glance at the sun may not cause lasting damage, says Chou, repeated peeks do add up.

"At some point, you may tip yourself over the critical threshold," says Chou. "Unfortunately, you don't realize that until far too late."

The eye damage only becomes apparent hours after it occurs. Typically, people wake up the morning after observing an eclipse and see a spot of extreme fuzziness in the center of their field of vision.

There is one time when it's safe to look up at the sun with the naked eye, experts say, and that's when the sun is totally covered by the moon.

This eclipse phase is only visible from the so-called " path of totality ," a stretch of land from Texas to Maine. And the experience of totality doesn't last long — up to four and a half minutes or so, depending on your location.

When the sun is 100% obscured, the sky abruptly darkens and the once-bright sun becomes a dark circle surrounded by a ghostly white ring called the corona.

If people wear super-dark eclipse eyewear during these dramatic moments, they'll miss the whole show.

"People get so concerned to not hurt their eyes, which of course is super important, that they don't take their glasses off when the moon completely covers the sun," says Laura Peticolas , a space physicist at Sonoma State University. "And then they're like, 'I never saw the corona.'"

So knowing when to take the glasses off, and when to put them on, is key.

Chou says that in the last moments before the sun gets totally covered, the thin crescent of the bright sun breaks into discrete points of bright light. These are called " Baily's beads ," and they are the last bits of light from the disk of the sun shining through the valleys on the edge of the moon.

"And as they go out, their disappearance is a signal that it is now safe to remove the filters and look at the sun without a protective filter," he explains.

As soon as the sun starts to re-emerge, the glasses need to immediately go back on.

"It is possible to observe the eclipse in perfect safety," says Chou, who has seen 19 total solar eclipses.

He encourages people to go out and enjoy an event that won't happen again in the United States until 2044, even as he realizes that some people will be too fearful of eye damage.

"I recognize that there are going to be people who just don't trust the science and just don't trust the public service announcements and are just going to ignore the eclipse as much as they can," says Chou. "It's an unfortunate thing."

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A decade of aphantasia research: what we've learned about people who can't visualize

People who can't visualise an image in their mind's eye are less likely to remember the details of important past personal events or to recognise faces, according to a review of nearly ten years of research.

People who cannot bring to mind visual imagery are also less likely to experience imagery of other kinds, like imagining music, according to new research by the academic who first discovered the phenomenon.

Professor Adam Zeman, of the University of Exeter, first coined the term aphantasia in 2015, to describe those who can't visualise. Since then, tens of thousands of people worldwide have identified with the description. Many say they knew they processed information differently to others but were unable to describe how. Some of them expressed shock on discovering that other people can conjure up an image in their mind's eye.

Now, Professor Zeman has conducted a review of around 50 recent studies, published in Trends in Cognitive Sciences , to summarise findings in a field that has emerged since his first publication. Research indicates that aphantasia is not a single entity but has subtypes. For example, not everyone with aphantasia has a poor autobiographical memory or difficulty in recognising faces, and in a minority of people, aphantasia appeared to be linked to autism. People who cannot visualise are more likely to have scientific occupations. Unexpectedly, although people with aphantasia can't visualise at will, they often dream visually.

Professor Zeman's review provides evidence that whether people have aphantasia or hyperphantasia -- a particularly vivid visual imagination -- is linked to variations in their physiology and neural connectivity in the brain, as well as in behaviour. For example, listening to scary stories alters skin conductance in those with imagery, meaning people sweat -- but this does not occur in people with aphantasia.

Aphantasia is thought to affect around one per cent of the population, while three per cent are hyperphantasic. These figures rise to around five and 10 per cent with more generous criteria for inclusion. Both aphantasia and hyperphantasia often run in families, hinting at the possibility of a genetic basis.

Professor Zeman, who now holds honorary contracts at the universities of Exeter and Edinburgh, said: "Coining the term 'aphantasia' has unexpectedly opened a window on a neglected aspect of human experience. It is very gratifying that people who lack imagery have found the term helpful, while a substantial surge of research is shedding light on the implications of aphantasia.

"Despite the profound contrast in subjective experience between aphantasia and hyperphantasia, effects on everyday functioning are subtle -- lack of imagery does not imply lack of imagination. Indeed, the consensus among researchers is that neither aphantasia nor hyperphantasia is a disorder. These are variations in human experience with roughly balanced advantages and disadvantages. Further work should help to spell these out in greater detail."

The paper is entitled 'Aphantasia and hyperphantasia -- exploring imagery vividness extremes', and is published in Trends in Cognitive Sciences.

"I struggle to fully immerse myself in role-play with my children"

Solicitor Mary Wathen's frustration that she struggled to engage in role playing games with her two young children, when she found all other engagement with her children so fulfilling, was her sign that she had aphantasia, meaning she cannot visualise imagery.

The 43-year-old, from Newent near Cheltenham, said: "One of my friends said that he uses the images in his head to enhance role play. When I asked him to explain this in more detail it became clear that he -- and everyone else in the room -- could easily create an image in their head and use that as the backdrop for the role play. This was totally mind-blowing to me. I just cannot understand what they really mean -- where is this image and what does it look like? To me, unless you can see something with your eyes, it's not there."

Mary's shock intensified when she realised her husband, has such vivid visual imagery that he is probably hyperphantasic. "He thinks in moving pictures, like movies -- sometimes to the point that he can mistake those thoughts for memories. To me, that's unfathomable."

Mary has come to realise that her lack of visual imagery may well account for her difficulties with memory. She said: "I can comprehend and retain concepts and principles really well but I'm unable to recall facts and figures. I can't recreate something in my head or 're see' something that is not actually there in that moment.

"I've found it quite saddening to learn that other people can call to mind an image of their children when they're not there. I'd love to be able to do that, but I just can't -- but I've learned to compensate by taking plenty of photos, so that I can relive those memories through those images.

"Whilst I'm sure there are wonderful advantages to being able to think in pictures, I think it's important to remind myself that there are advantages to having aphantasia too. I'm a really good written and verbal communicator -- I think that's because I'm not caught up with any pictures, so I just focus on the power of the word. I'm also a deeply emotional person and perhaps that's my brain's way of overcompensating; I feel things as a way of experiencing them, rather than seeing them.

"I think it's really important to raise awareness that some people just don't have this ability -- particularly as using visual imagination is a key way that young children are taught to learn and engage. Primary teachers need to know that some children just won't be able to visualise and that could be why they're not engaging in those kinds of activities. We need to ensure we cater for everyone and encourage other ways of learning and engaging."

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Materials provided by University of Exeter . Original written by Louise Vennells. Note: Content may be edited for style and length.

Journal Reference :

• Adam Zeman. Aphantasia and hyperphantasia: exploring imagery vividness extremes . Trends in Cognitive Sciences , 2024; DOI: 10.1016/j.tics.2024.02.007

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