Why do I have new floaters after cataract surgery?
New floaters after cataract surgery have different causes depending on when they appear. In the first days and weeks, they are usually floaters that were already there but are now easier to see because your vision is clearer, together with a few specks from the normal mild inflammation of healing. These settle. Months or years later, more floaters can appear as the gel inside the eye changes, and sometimes separates from the retina. For most people the floaters become much less noticeable with time. Because a separating gel can occasionally tear the retina, new floaters need a dilated eye examination promptly, ideally within a day or two. A sudden shower of floaters, new flashes, a shadow or curtain, or floaters with pain, redness or worsening vision need assessment the same day.
Why do floaters appear in the first days after surgery?
Floaters that appear straight after surgery are rarely new. A cataract makes vision cloudy and dim, and this hides faint floaters in the gel behind it. Once the cataract has been removed and vision is clear again, those floaters become visible, sometimes for the first time in years. Because the change is sudden, they can seem quite pronounced.
Any operation also causes some mild inflammation, and cataract surgery is no exception. A few inflammatory cells drift in the fluid and gel inside the eye and can be seen as small dots. They last for a few days or weeks and clear up by themselves as the eye heals, helped by the anti-inflammatory drops used after surgery.
Why can more floaters appear months or years later?
The vitreous is a clear gel that fills the back of the eye and is attached to the retina, the light-sensitive layer lining the inside of the eye. With age, the gel slowly liquefies and clumps. Its collagen fibres gather into strands that float in front of the retina and cast shadows. These shadows are what you see as floaters.
The natural lens is quite thick. The artificial lens implant that replaces it is much thinner, so after surgery the gel can move forward into the extra space. This change speeds up the gel's breakdown, and more floaters can appear as it liquefies further.
Eventually the gel peels away from the retina altogether. This is called a posterior vitreous detachment. It happens to most people eventually, and cataract surgery tends to bring it forward. When it happens, it often brings a new set of floaters. In a study that followed eyes with an imaging scan for a year after cataract surgery, the gel separated much faster than in similar eyes that had not had surgery; complete separation within the year was about seven times more likely. In another study of people in their fifties who had had surgery on one eye only, the gel had separated in about half of the operated eyes, compared with about a fifth of their other, unoperated eyes.
A separation can happen in the months after surgery or years later. It is not a sign that the operation went wrong. It is the same change that would usually have happened in time, arriving earlier.
What do these floaters look like?
People describe dots, threads, cobwebs, a hazy smudge or a ring that drifts across their vision and lags behind when they move their eye. They are most noticeable against a bright, plain background such as the sky, a white wall or a computer screen. When the gel separates, some people also see brief flashes of light at the side of their vision, more obvious in dim light, as it tugs on the retina.
The eye cannot tell you which kind of floater you have. Floaters you have always had and new floaters from a separating gel can look much the same, which is why new floaters still need to be examined.
What else can cause floaters after surgery?
Floaters that are newly visible, a few inflammatory cells and changes in the gel account for most new floaters after cataract surgery. Less common causes need to be recognised, and timing and the other symptoms help to distinguish them.
| Cause | When it usually appears | What else you may notice | How urgent |
|---|---|---|---|
| Floaters you already had, now easier to see | From the first days | The same floaters as before, suddenly more obvious | Mention them at your review |
| Inflammatory cells | First days, lasting days to weeks | Small dots or specks; clear up by themselves | Mention them at your review; sooner if increasing or with worsening vision |
| Breakdown or separation of the vitreous gel | Months to years after surgery | Dots, threads, a ring or cobweb; sometimes flashes at the side | Examination within a day or two; same day with a shower of floaters, a shadow or reduced vision |
| Retinal tear or detachment | Months to years after surgery | A shower of new floaters, flashes, a shadow or curtain | Same day |
| Bleeding into the gel | Any time | A cloud of dark dots or a reddish haze | Same day |
| Infection inside the eye | Usually within the first one to two weeks | Worsening vision, increasing redness or pain, haze | Same day, without delay |
| After laser for a cloudy capsule | Days after the laser | A few new specks | Mention it at your review; same day with warning signs |
Infection. Infection inside the eye (endophthalmitis) is rare, affecting about 1 in 2,500 operations in a large United States registry, but it can permanently damage sight if treatment is delayed. It usually appears within the first one to two weeks. The main warning signs are vision that is getting worse, increasing redness, pain or light sensitivity, often with a haze or floaters. More than a quarter of people with this infection have no pain, so the absence of pain is not reassurance if vision is deteriorating.
Bleeding. A small bleed into the gel can cause a sudden cloud of dark dots or a reddish tinge. It can come from a torn blood vessel as the gel separates, from a retinal tear, or from other retinal conditions such as diabetic eye disease. Blood thinners do not usually cause a bleed on their own but can make one larger.
A fragment of the old lens. Occasionally, when surgery is complicated by a break in the thin capsule that holds the lens, a piece of the cataract can fall back into the gel. This is usually recognised during or soon after the operation and causes blurred vision and inflammation as well as floaters. A second operation to remove it is often needed.
Laser for a cloudy capsule. Months or years after cataract surgery, the capsule behind the implant can become cloudy. A YAG laser is used to open it. A few specks from the capsule can float in the eye for a while afterwards. This is a different treatment from YAG laser used to treat floaters, which is discussed below.
Blurred vision that develops a few weeks after surgery without new floaters has different causes, such as swelling at the centre of the retina. These are explained in the article on blurred vision after cataract surgery.
Is a retinal tear more likely after cataract surgery?
Yes, a little, because surgery brings the gel's separation forward. Most separations are harmless. But where the gel is firmly stuck to the retina, its pull can tear a small hole. Fluid can then pass through the hole and lift the retina away, which is a retinal detachment.
A shadow or curtain
A dark shadow that starts at one edge and spreads across the vision, like a curtain being drawn, can mean the retina is detaching.
When people of any age see eye specialists with new floaters or flashes from a separating gel, a retinal tear is found in roughly 1 in 20 to 1 in 6, depending on the setting. In a large study of 8,305 people seen in a general eye-care network, previous cataract surgery was one of several features linked with a higher chance of a tear or detachment. The others were blurred vision, male sex, age under 60 and previous laser vision correction.
Overall, retinal detachment after modern cataract surgery is uncommon. A Western Australian study of more than 65,000 operations found a risk of about 7 in 1,000 over ten years. An Austrian study of a similar size found that about 6 in 1,000 eyes developed a detachment or a retinal break over a typical follow-up of about seven years. A review of the research estimated the risk after cataract surgery at roughly ten times that of the general population, although it remains low in absolute terms. The risk is higher with:
- a longer, short-sighted (myopic) eye
- younger age at the time of surgery
- male sex
- a break in the lens capsule or loss of vitreous gel during the operation.
These figures are averages across large groups. Your own risk depends on your eye, which is one reason an examination matters more than a statistic.
What happens at the examination?
The important question is not whether you have floaters, but whether the retina is intact. Answering it needs a dilated examination of the retina, including its far edges, where most tears occur.
Drops are put in to widen the pupil. The eye specialist then looks at the retina with a microscope and a hand-held lens, or with a head-mounted light. Gentle pressure on the eyelid can be used to bring the far edge of the retina into view. They also look in the gel behind the lens implant for tiny pigment granules or blood, which make a tear more likely.
A scan of the retina (optical coherence tomography) shows the gel separating at the back of the eye and the centre of the retina in detail. If blood or haze stops a clear view, an ultrasound scan can show whether the retina is attached. Your optometrist may do the first check and arrange referral if a tear or other problem is suspected.
The dilating drops blur vision and make bright light uncomfortable for several hours. Do not drive until your vision has returned to normal, so arrange someone to take you home.
Why might I need a second check?
A retinal tear can develop after a reassuring first examination, because the gel may still be separating. In a review of studies of people with a newly separated gel and no tear at the first visit, about 3 in 100 developed a tear within six weeks. In a study of almost 8,000 eyes seen in a retina practice, a tear was found later in about 1 in 40 and a detachment in 1 in 100; some appeared more than six weeks after the first visit. In a separate study of more than 8,000 people, later problems were much less likely when the first examination showed no blood in the gel, no weak areas of retina and no previous tear or detachment in the other eye.
For this reason a second dilated check is often arranged a few weeks after the first. Whatever the plan, return the same day if you notice a new shower of floaters, more flashes, a shadow, or any drop in vision, even if you have recently been told the eye is healthy.
What if a tear or detachment is found?
A retinal tear without a detachment is usually treated in the clinic with laser, or occasionally a freezing treatment, applied around the tear. This creates a scar that seals the retina down, much like a spot weld. It takes a few minutes, and the floaters remain afterwards.
A retinal detachment needs an operation, usually soon after it is found. Several techniques are used, including vitrectomy, which removes the gel that is pulling on the retina. Early treatment gives the best chance of good vision, particularly before the centre of the retina has lifted. The retinal detachment page explains the operations and recovery.
Will the floaters go away?
Usually they become much less noticeable. The inflammatory cells clear, and some of the other floaters fade or sink below the line of sight. The brain also adapts and learns to ignore what remains. Over time, most people no longer really notice their floaters, although a small proportion continue to be troubled by them. In Dr Chen's experience, most people with new floaters from a separated gel are much less troubled by them within about six weeks. He generally suggests allowing three to six months before considering any procedure for floaters, because many settle in that time.
What can be done if floaters do not settle?
For most people, time and reassurance are the treatment. A minority are still genuinely troubled months later, particularly when reading, using screens or driving, and for them the effect on daily life can be real.
YAG laser vitreolysis. A laser can break up some floaters, particularly a single, well-defined Weiss ring that sits safely away from the lens implant and the retina. In the only sham-controlled trial, about half of the treated people reported a significant improvement at six months, compared with none of those given a sham treatment. It does not suit most types of floaters, and the evidence remains limited. The article on YAG laser for floaters explains who may be suitable.
Vitrectomy. A vitrectomy removes the gel, and the floaters with it, through three tiny openings in the white of the eye using a fine vitrectomy probe. It is usually performed as day surgery under local anaesthetic with intravenous sedation. It is the most effective treatment for persistent floaters: across published series, around nine in ten people are satisfied or report that their symptoms are relieved. It is also a real operation with real risks, the most important being a retinal tear or detachment, which occurred in about 1 to 3 in 100 eyes in recent series. Serious infection is rare, roughly 1 to 2 in 1,000.
Having already had cataract surgery removes one of the main drawbacks of vitrectomy. In an eye that still has its natural lens, vitrectomy commonly causes a cataract within a few years. With a lens implant already in place, that is no longer a concern. It does not change the other risks, and the decision still depends on how much the floaters affect your life. The floaters page and the article on recovery after vitrectomy for floaters explain the operation and what to expect.
Vitrectomy for floaters performed by Dr Simon Chen
This short video shows real eye surgery.
Watch on YouTube →
mivision · October 2018
Degenerative Floaters: A Practical Review
Dr Simon Chen and Dr Chris Hodge. A review for optometrists covering assessment, observation, laser and vitrectomy.
Read the article →Other questions about floaters after cataract surgery
Is my lens implant causing the floaters?
Not directly. The implant sits in front of the vitreous gel and does not itself produce floaters, although its thinner shape gives the gel more room to move, which can speed up the gel changes that do. Some people see a dark crescent or shadow at the edge of their vision after cataract surgery. This is a different effect of light passing the edge of the implant, called negative dysphotopsia, and it stays in the same place rather than drifting. It is explained in the article on negative dysphotopsia.
Did something go wrong during my operation?
Usually not. A separation of the vitreous gel after cataract surgery is common and expected, and it happens after perfectly routine operations. It is the same change that would normally have happened later. Floaters that come with blurred vision, pain or redness soon after surgery are different and need prompt review.
Will I get floaters in my other eye after its operation?
You may. The gel in each eye separates on its own timetable, and cataract surgery can bring the separation forward in either eye. The same advice applies to both: new floaters need a dilated examination, and warning signs need same-day assessment.
Can the gel separate more than once?
The main separation happens once, although it can take weeks or months to complete. After it is complete, new floaters from other causes, such as bleeding, can still occur, so any sudden change still needs to be checked.
I already had floaters before surgery. Do I need to be checked again?
If the floaters are the same as before, they usually do not need urgent review; mention them at your next appointment. A sudden increase, a new type of floater, flashes or a shadow is a new event and needs examination, even if you have had floaters for years.
Where can I read more?
Which changes need urgent assessment?
Contact your ophthalmologist urgently, or attend an emergency department, if you notice:
- a sudden shower of many new floaters, or a cloud of dark dots
- new flashes of light
- a dark shadow or curtain spreading in from any side of your vision
- vision that is getting worse
- increasing pain, redness or light sensitivity after surgery.
A shower of floaters
A sudden burst of many new floaters, sometimes like a cloud of dark dots or smoke, can mean a retinal tear has bled into the gel.
New flashes of light
Brief flashes or flickers, often at the side of the vision and more obvious in dim light, come from the gel tugging on the retina. New or increasing flashes need prompt assessment.
Retinal detachment is usually painless, so the absence of pain is not reassurance. In the first weeks after surgery, use the contact details on your discharge instructions.
References
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