Modern Management Of Vitreous Opacities: Acquiring History And Performing A Thorough Clinical Examination
Part 1 of 2
Innovations in surgery have led to the increased capacity of eye care providers to effectively address concerns related to vitreous opacities (VOs). Those of us in the optometric community have, until recently, been hamstrung by the limitations of therapy that might mitigate or eliminate the floaters and flashes that patients often complain about. Our field is learning in real time how these medical advances can help patients, and it behooves us to pause and take stock of the state of surgery for VOs.
To further explore how these innovations could positively affect the lives of our patients, I joined a panel comprised of four eye care providers—an optometrist, a general ophthalmologist who concentrates on cataract surgery, and a pair of vitreoretinal surgeons—to discuss how optometrists and retina specialists can collaborate on caring for patients with VOs. Our discussions were recorded as a trio of podcasts, which you can find in the feed for The MOD Pod and at the QR code on the cover of this piece. A transcript of our discussion, which includes a discussion about examination tactics and the feasibility and utility of a standardized methodology for gathering history, is presented here, edited for brevity and clarity. Part 2 will be featured in the next issue of Modern Optometry.
—Walter O. Whitley, OD, MBA, Chief Medical Editor, Modern Optometry
GATHERING PATIENT HISTORY
Walter O. Whitley, OD, MBA: Optometry is often the first stop for patients with ocular conditions. For much of my career, I explained to patients that spontaneous resolution of their vitreous opacites (VOs) was likely, and the pathway to success involved the tincture of time. For some patients, however, this was not enough, as their VOs never settled.
Technologic innovations and re-framing the mindset regarding surgery for some VO cases have changed the solution tree. To that point, I’ve noticed that some patients with symptomatic VOs present with an awareness that surgical solutions are increasing in volume, and they ask me how I can help guide them toward surgical intervention.
When it comes to patients who present with symptomatic VOs, gathering patient history is a key component of any initial examination. I’d like to hear from the retina specialists on this panel—John W. Kitchens, MD, and Christina Y. Weng, MD, MBA—about the details that you look for in a patient’s disease course that influence your decision on whether or not surgery is a viable option for treatment.
LISTEN TO THE DISCUSSION ON THE MOD POD
Want to hear the long-form discussion of the topics reviewed in this piece? Visit eyetube.net/editorial-feature/vitreous-opacities-od to hear the relevant The MOD Pod episodes.
Christina Y. Weng, MD, MBA: Retina specialists often depend on imaging to confirm that anatomic findings match symptomatology for a number of diseases and disorders. But when it comes to VOs, imaging findings do not always align with a patient’s reported symptoms, and many retina specialists have to rely on patient history to track a patient’s progress. With that in mind, I primarily probe for three important details when gathering history from these patients:
- the duration of the condition,
- the severity of VOs,
- and the degree to which it has affected day-to-day visual function.
Without knowing the duration of a patient’s condition—that is, the time from which he or she first noticed a VO—it is difficult to say whether or not it will spontaneously resolve. Many patients who experience a posterior vitreous detachment (PVD) during the normal aging process will experience VOs. However, most VOs will not create long-term disruption because of neuroadaptation, and patients may never present to the clinic. In general, if a patient experiences disruptive VOs for at least 6 months, I find that it is less likely to spontaneously resolve, and I will begin considering whether surgical intervention is appropriate.
John W. Kitchens, MD: I agree with Dr. Weng that the visualization of VOs is difficult in the clinic given the limitations of our current technologies. Sometimes when a patient is in the OR and I’m in the middle of surgery, I see that the patient’s anatomy closely mirrors their reported symptoms—a confirmation that I would have preferred to see in the clinic than in the OR.
It’s also important to understand how symptomatic VOs affect our patients’ lives. Is someone’s driving or job performance impaired? Perhaps their ability to enjoy leisure activities has diminished? If VOs are putting the patient or others in danger or are otherwise adversely affecting their health, then I’m more likely to intervene promptly, regardless of the duration of the VOs.
Dr. Whitley: How does a patient’s ocular history affect the decision to intervene?
Dr. Kitchens: Knowing how many and which kinds of ocular surgery a patient has had can be used to estimate the degree of risk associated with surgery for VOs. Pseudophakic patients who have experienced a full PVD have lower risk than, say, younger patients who still have a natural crystalline lens.
Alison D. Early, MD: I would note that, as a cataract surgeon, I frequently hear from patients who notice VOs following IOL implantation. In many cases, this is because patients have improved contrast sensitivity, which allows them to perceive elements of their vision that were previously unnoticed due to a cataract.
Dr. Whitley: Optometrists have an opportunity to set up their patients for success. When a patient mentions decreased visual quality and VOs in the same visit, I see it as a signal to start asking questions. Is their life primarily disrupted by decreased vision linked with typical cataract progression? In that case, referring the patient to a cataract surgeon may be the most sensible route. Is the degree and duration of VOs enough to warrant referral to a retina surgeon? If so, then documenting history and communicating the patient’s condition could be instrumental in ensuring that this patient is promptly treated—if, that is, the retina surgeon decides that a vitrectomy is appropriate.
CASE SUBMITTED BY: Christina Y. Weng, MD, MBA
PATIENT PROFILE
Age/sex: 71-year-old man
Occupation: Hospital executive
Ocular history: Moderate myopia, multifocal IOL implantation OU
Lifestyle: Actively employed and working; hobbies include boxing, traveling, reading
PRESENTING DETAILS
- Presenting complaint: Severe symptomatic VOs OS immediately after cataract surgery 15 months prior; noticeable VOs OD, but not too bothersome; VA 20/20-OU
- Patient feels that quality of life has been disrupted by VOs
- Patient advised to schedule follow-up appointment for 3 months
- Discussed duration of VOs with referring cataract surgeon to confirm patient history
- See the figure for a similar case’s image
FOLLOW-UP DETAILS
- At 3 months after first examination, patient had not experienced resolution of symptomatic VOs. VA remains 20/20-OU.
- During discussion of risks related to surgery, patient was clearly able to calculate whether surgery would be a good fit for him.
- Patient and surgeon decided to proceed with surgery to address VOs.
INTERVENTION
- Procedure: 25-gauge pars plana vitrectomy at 10,000 cuts per minute with intravitreal triamcinolone injection OS
- Follow-up: On postoperative day 1, near-immediate relief was reported by the patient.
- Final outcome: 20/20 OS without symptomatic VOs. No complications. Patient was very happy.
- Notes: Patient felt that VOs OD were now more bothersome following successful surgery OS. He has requested evaluation for surgery OD.
PATIENT QUESTIONNAIRES: DO THEY HAVE A ROLE IN THE FUTURE OF VITREOUS OPACITY SURGERY?
Dr. Whitley: As an optometrist who practices in a surgical clinic, I frequently use lifestyle questionnaires to help patients articulate specifics about their conditions. I also use them in the context of dry eye disease, such as when I use the standardized patient evaluation of eye dryness, or SPEED, questionnaire.
This makes me wonder if creation of a questionnaire could be useful in the setting of VOs? Perhaps a standardized methodology to gather patient history and details about the degree of visual disruption due to VOs would be useful to the surgeon and could help sharpen the subjective elements of a chair evaluation for VO patients.
Dr. Early: Questionnaires may be particularly useful among patients who are weighing implantation of a premium IOL. One of the benefits of questionnaire use with such patients is that you get the chance to evaluate their personality, desired postoperative functionality, and lifestyle. In my experience, I’ve seen overlap among the patient types who want premium IOLs and those who are significantly bothered by VOs. Perhaps there is something to be said about patients who have high attention to detail or are very high functioning. Regardless, use of a questionnaire may very well have a role in VO management.
Dr. Weng: Anything that standardizes a presurgical process is, in general, a good idea. Because of the interdisciplinary and collaborative nature of VO management, a questionnaire may serve as an effective medium of communication between retina surgeons and referring providers.
Dr. Whitley: Which elements would be among the most necessary parts of a future survey used for these purposes?
Dr. Weng: Many of the elements we discussed elsewhere in this roundtable—duration of VOs, intensity of visual disruption, and the specific lifestyle elements that are negatively affected—would certainly be needed. A fourth component that would gauge the patient’s readiness for surgery would also be appropriate.
Dr. Kitchens: A questionnaire allows patients to be introspective about their condition, and raising the question of whether or not a patient is actually prepared for surgical intervention could ensure that the patients who visit a retina surgeon really are ready to act. A questionnaire would also provide a baseline level of detail upon referral. In some cases, referring providers—whether they’re optometrists, general ophthalmologists, or cataract surgeons—offer scant notes on a patient’s condition, which leads me to start from scratch with that patient. Knowing more about their history and experience with VOs may affect some surgeons’ decisions regarding the length of time needed between initial surgical consultation and scheduling surgery.
Dr. Whitley: Optometry’s familiarity with questionnaires makes me suspect that many optometrists could easily integrate a questionnaire into their workflow. Given that retina specialists don’t use questionnaires as often, do you think that there might be a ceiling to their usability?
Dr. Kitchens: I am attracted to anything that can possibly quantify preoperative and postoperative conditions. Many of the patients we see have 20/20 VA when they present, so the normal objective measurements that we use to assess the outcomes of other surgeries—say, removal of an epiretinal membrane—don’t apply to VO surgery. If we were able to score patients’ preoperative and postoperative visual function, we might be able to perform reliable research on the impact of VO surgery, thereby articulating the consequences of our intervention.
Dr. Early: Increasing patient satisfaction is a key tenet of cataract surgery. It sounds like that principle might apply to retina specialty, too—particularly in the context of surgery for VOs.
Dr. Whitley: Would a questionnaire have any uses beyond the clinic?
Dr. Kitchens: I wonder if they could be used as way to justify the need for surgery to insurance companies. If so, the retina community and the optometric community would need to come together to craft and validate a questionnaire that is scientifically sound and not just a series of subjective measurements that we assume are important.
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