Download FAQ on floaters - docteur Edouard BENOIS

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FAQ on floaters
Q: How are floaters removed?
A: By vitrectomy. Three small incisions are made in the eyeball through which the
vitreous gel is removed, while simultaneously the eye is filled with a clear salt solution.
Q: What’s the difference between 25G and 23G surgery?
A: In “classic” 20G vitrectomy, the conjunctiva is detached from the sclera (eyeball) at
the beginning of the surgery. Three 20G (0.9 mm diameter) incisions are made in the
sclera through which the surgery is performed. At the end of the surgery, the scleral
incisions are sutured, after which the conjunctiva is reattached in its original position.
In 23G (0.6 mm diameter) surgery, the instruments are thinner than 20G instruments,
allowing a transconjunctival approach: three little tubes (trocars) are inserted in the
sclera through the conjunctiva. Hence, the conjunctiva is not detached. At the end of
the surgery, the trocars are removed, and the small incisions close spontaneously. This
surgical approach results in much faster healing and less discomfort.
25G surgery (0.4 mm diameter) uses the same approach as 23G (trans-conjunctival),
but the used instruments are of less quality. Therefore, only 23G is used at present.
Q: What type of anesthesia is used?
A: A vitrectomy can be performed under local anesthesia, general anesthesia or localunder-gas anesthesia.
In local anesthesia, a drug is injected below the eye using a needle. This approach is
preferred in older patients. In general anesthesia, the patient is completely put asleep
(as in other surgeries). This is preferred in younger patients and in children. Sometimes
the patient is put asleep using gas for a short time (minutes) during which the local
anesthesia is given. This reduces stress and pain for the patient, without a “full” general
anesthesia.
The anesthesia option is discussed with the surgeon before the surgery. In patients
aged over 50, an extra preoperative examination is needed when the patient will have a
general anesthesia.
Q: Does vitreous (and floaters) come back after surgery?
A: No. It does not grow back.
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Q: Is all the vitreous removed from the eye?
A: Removing all the vitreous is only possible in patients with an artificial lens (after
cataract surgery). In phakic patients, approximately 90% of the vitreous gel is removed.
Only the very peripheral vitreous is left in place, which is not observed in the visual
field. The vitreous is always removed up to the area where it merges with the peripheral
retina, which is called the “vitreous base”. Trying to remove 100% of the vitreous in a
phakic patient damages the lens (creating cataract). Therefore, in some patients, the
surgery is combined with a simultaneous cataract extraction and lens implantation (see
below).
In younger patients, the vitreous gel is adherent to the retina. In older patients, this gel
has detached (posterior vitreous detachment or PVD is present). If no PVD is present, it
is created during surgery, although this requires more surgical effort (and skill).
Otherwise, a lot of vitreous is left in the eye, leading to persistence of vitreous floaters.
Moreover, a PVD is likely to happen in the near future, again increasing the number of
floaters and increasing the risk of retinal breaks in the periphery, which may lead to a
retinal detachment (see below).
Q: Is it possible to stain the vitreous for better visualisation?
A: Since a few years, several products are used to stain the vitreous. A present, most
popular is triamcinolone (Kenalog®, Kenacort®). With the advent of new illumination
sources during vitrectomy (Xenon light), the need for these dyes becomes rare.
However, if visualisation of the vitreous is difficult, I have the triamcinolone ready to
use.
However, please note that this drug is not intended for intra-ocular use, and can
sometimes create side-effects. Therefore, I choose not to use it as a standard feature,
rather when the circumstances demand for its use.
Q: What are the risks of a vitrectomy?
A: The three major risks in decreasing incidence are:
1) Development of lens opacities (cataract). The incidence depends on the age of
the patient: from <10% younger than 30 years, over 50% at age of 50, up to
100% at age 65. If cataract develops (usually within months after the surgery,
rarely during surgery), a cataract extraction and artificial lens implantation is
necessary. This is an ambulatory procedure with fast postoperative recovery of
vision.
In some patients, the vitrectomy is combined with a simultaneous phacoemulsification (small-incision removal of the lens by ultrasound), with artificial
lens implantation.
2) Development of retinal breaks when a posterior vitreous detachment (PVD) is
created. To avoid secondary retinal detachment, in most vitrectomies, the
vitreous base is photocoagulated with laser. If a retinal detachment would
develop (incidence <0.5%), additional surgery is necessary to repair the retina.
In advanced cases of retinal detachment, a decreased postoperative vision may
result.
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3) Postoperative infection. This is a rare complication (<0.05%), but the most
severe. Emergency treatment with injection of antibiotics and/or another
vitrectomy is mandatory. In case of severe infection, decreased postoperative
vision may result.
Since this complication usually occurs within days after the surgery,
postoperative check-ups during the first days are mandatory.
Furthermore, in 20% of patients, an increased ocular pressure may result after 2-3
weeks from the postoperative corticoid drops. These patients are called “steroid
responders”. In such case, the corticoid drops must be stopped, and non-steroidal antiinflammatory drugs and possible pressure-lowering drugs prescribed. Therefore, a
postoperative eye pressure measurement after a few weeks is recommended.
Q: Will my eyesight be fine from the first day?
A: Usually not. The pupil will remain dilated for a few days after the surgery, and
postoperative inflammation may also blur the visual perception. Moreover, clumps and
threads of inflammatory cells may simulate floaters during the first weeks after surgery!
These cell-packets dissolve by themselves, but it may take up to several weeks.
Postoperative corticoid drops are prescribed to reduce postoperative inflammation,
resulting in faster disappearing of inflammatory cells from the eye.
Q: How long will my operated eye be reddish?
A: That differs: in some patients, it’s even hard to see the on first postoperative day
which eye was operated. In other patients, the eyes can be completely bloodshed. In
the latter case, regression of the subjconjunctival blood may take up to 3 and
sometimes even more weeks. Regardless of the early postoperative appearance, the
final result is similar in all cases: after a few weeks, the operated eye looks exactly as
before the surgery.
Q: May I fly after the surgery?
A: Yes. Only when the eye is completely filled with air or gas during a vitrectomy, flying
is not allowed during 2 weeks. However, during a vitrectomy for floaters, only a small
amount (if any) of air is used to stabilize the eye pressure, which induces no restrictions
for flying.
Q: Will I have pain in my operated eye?
A: Usually not, since no sutures are placed on the eye. A discomfort is normal,
postoperative pain may be indicative of a postoperative complication: infection, tension
rise…
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Q: What’s the cost of the surgery?
A: Total cost of the surgery, medication, anesthesia, drugs and one night hospital stay
typically amounts up to Eur 5000. In some cases, this may be reimbursed by your
health care insurance. Please ask your local health care company about this issue.
Upon request, the necessary paperwork can be prepared for reimbursement, and an
official invoice is always received from the hospital within 6 weeks after the surgery.
Q: Do I have to pay in advance?
A: For foreign patients, a deposit of this amount is requested before the surgery. This
deposit can be made using bank transfer, or can be done with a credit card. This
deposit can be made the day before the surgery.
Please note that in case of cancellation, administrative costs may be charged, since too
many patients made reservations without showing up at the date of the surgery.
Q: How can I make an appointment for an ambulatory visit?
A: Please call my secretary on +32-16-332660 (fax is +32-16-332367, email
[email protected]). Ask for an appointment with Prof. P. Stalmans on a
Wednesday morning.
Q: Is any obligation (surgery) associated with an ambulatory visit?
A: No.
Q: What’s the waiting list?
A: For an ambulatory visit: approximately 4-6 weeks. For surgery: from 2 to 6 weeks,
depending on the season (usually shorter in summer season).
Q: Is it possible to schedule surgery shortly after an ambulatory visit to avoid
double travelling?
A: For patients living far abroad, a surgery slot can be reserved 2 days (Friday) after
your visit on Wednesday. Please note that in case of cancellation, administrative costs
will be charged, since too many patients made reservations without showing up at the
date of the surgery.
Q: Is it possible to have both eyes operated simultaneously?
A: No. This is too dangerous in case complications would occur. I prefer to leave two
months between both surgeries in case both eyes need to be operated.
In patients coming from far abroad, the second eye is sometimes scheduled on the
Tuesday following the Friday of the first eye, but only at the request of the patient for
practical reasons.
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Q: Where can I find practical information for coming to and staying in Leuven?
A: On the websites below:
www.uzleuven.be: website of the hospital. The ambulatory visit is in the St-Rafaël
hospital, surgery is performed in the St-Pieter hospital. Please note that these are
adjacent buildings. You should NOT proceed to the main building “Gasthuisberg”,
except for possible preoperative anesthesia examination or for proceeding to the
financial department.
Address of St-Rafaël: Kapucijnenvoer 33, 3000 Leuven.
Address of St-Pieter: Brusselsestraat 69, 3000 Leuven.
www.leuven.be: website of the city of Leuven. Leuven is a rather small (2 Km diameter)
student city (30 000 students). Therefore, all local travelling can be done by foot or by
bus. Many shops, stores, pubs, and other student-leisure related facilities are present
all-over the city.
On this website, you can also find information on the hotels in Leuven. Closest to the
hospital are the following hotels:
50m-Jackson’s **. Brusselsestraat 110, phone +32-16 20 24 92. www.hoteljacksons.be
100m-Ibis hotel **. Brusselsestraat 52, phone +32-16-29 31 11.
150m-Kloosterhotel ****. Predikherenstraat 22, phone +32-16-21 31 41.
www.kloosterhotel.be
500m-Holiday Inn ***. Alfons Smetsplein 7, phone +32-16-31 76 00.
www.fly-sn.be: flying to Belgium (Airport: Brussels)
www.b-rail.be: trains (from Brussels to Leuven)
www.delijn.be: busses (for travelling in and around Leuven)
www.viamichelin.be: online maps and route planner
Peter Stalmans, M.D., Ph.D.
Assistant Professor
Vitreoretinal surgeon
Dept. of Ophthalmology UZLeuven
Capucijnenvoer 33
B3000 Leuven
Belgium
+32-16-332660
+32-16-332367
[email protected]
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