When is vitrectomy worth considering for persistent floaters?

Will my floaters settle without treatment?

Often, yes. Most troublesome floaters appear when the vitreous, the clear gel that fills the eye, separates from the retina at the back of the eye. This is called a posterior vitreous detachment. For most people the floaters it brings become much less noticeable over the following months. They rarely disappear completely, but they tend to drift away from the centre of vision and the brain gradually learns to ignore them.

No study gives a reliable percentage or timetable for this settling, so there is no fixed date on which floaters should be "better". Guidance from the American Academy of Ophthalmology describes vitrectomy as an option when floaters are still bothersome after several months. Dr Chen generally suggests allowing three to six months after floaters begin before considering surgery, the approach he also described in his 2018 review for optometrists written with Dr Chris Hodge.

In one large clinic series of 651 eyes with bothersome floaters, just over half chose to watch and wait, and their measured vision stayed stable over the following year. Some people who first chose to wait later decided on surgery. The people who went on to have surgery had lived with their floaters for about five years on average.

How do I know if my floaters are troublesome enough for surgery?

There is no score or size of floater that decides it. The question is how much they interfere with your life after a fair period of adapting. People considering surgery often describe losing their place when reading, being distracted during computer work, or a moving shadow while driving or playing sport. Keeping a short note of which activities are affected, how often, and whether things are improving makes the discussion with your surgeon more useful.

The letter chart is a poor guide. Most people with floaters read the chart normally, yet dense floaters can reduce contrast sensitivity, which is the ability to see faint detail against a similar background. Some clinics measure contrast sensitivity or use ultrasound to gauge how dense the floaters are, and in research settings these measures track how bothered people feel. They support the decision rather than make it.

It helps to be honest about the effect on wellbeing too. Studies report that people with persistent floaters have more anxiety and low mood than people without them, and that wellbeing often improves after successful treatment. In a questionnaire study of 266 people with floaters, the average person said they would give up about one year in every ten of remaining life to be free of them. That does not mean anyone should rush into surgery, but it does explain why the operation is sometimes reasonable for a problem that doesn't threaten sight.

Surgery is most likely to help when floaters are large or dense and clearly get in the way of daily tasks. It is less predictable when they are faint, and it cannot guarantee that you will never see a floater again. The eye floaters guide explains how floaters are assessed at a consultation.

What needs to be checked before surgery is discussed?

Floaters that began in the last few weeks need a dilated examination of the whole retina first, not a surgical plan. About one in seven people with sudden new floaters and flashes has a retinal tear, and new tears can still appear in the weeks afterwards. A tear found early can usually be sealed with laser.

Vitreous detachmentRetinal tear and detachment

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The examination also looks for causes other than an ageing vitreous. Floaters caused by bleeding inside the eye, inflammation (uveitis) or infection need treatment directed at that cause, and the options below do not apply in the same way. The article on what floaters are made of explains these different materials.

Your description of the floaters and the examination findings should make sense together. If they do not, further assessment is more useful than moving straight to surgery. And if new flashes, a sudden increase in floaters or a change in vision appear while you are waiting, that needs a fresh examination rather than simply more waiting.

If the retina is healthy and the floaters are the ordinary kind, the discussion can turn to whether they are bothersome enough to treat.

Could laser or other treatment work instead?

For many people, watching and adapting is the right choice, and it is by far the most common one.

YAG laser vitreolysis uses short laser pulses to break up a floater. It can help some people with a single, well-defined ring-shaped floater, called a Weiss ring, that sits safely away from the lens and the retina. In the only trial that compared laser with a sham treatment, about half of the treated people reported a significant improvement at six months, compared with none in the sham group. That trial included only Weiss rings, and most floaters are not suitable. UK guidance from the National Institute for Health and Care Excellence recommends the laser only within research, and later follow-up described some delayed retinal tears. The article on YAG laser for floaters covers who may be suitable.

Weiss ringDiffuse strands

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No eye drops or medicines are an established treatment for floaters. Some supplements are sold specifically for floaters, and one of them, VitroCap N, has been tested in a randomised trial against a placebo. In that study of 61 people, those taking the supplement for six months reported less discomfort from their floaters and had smaller floater areas on imaging, while the placebo group did not change significantly. How much weight to give this is debated: it was a small, single-centre study, it used a questionnaire designed for the trial, only people who completed it were analysed, the supplement's maker helped fund it and has a royalty agreement with the university involved, and the result has not yet been repeated by independent researchers. Some people choose to try a supplement while they wait; it is not a substitute for an eye examination. The article on treating floaters without surgery covers supplements and eye drops in more detail.

You do not have to try laser before discussing surgery; the choice depends on the type and position of your floaters.

What does vitrectomy for floaters involve?

A vitrectomy removes the vitreous gel, and the floaters within it, from inside the eye. It is usually performed as day surgery, with intravenous sedation and a local anaesthetic to numb the eye. Three tiny openings are made in the white of the eye. Modern instruments are very fine (25 or 27 gauge), and the openings normally seal without stitches.

Vitrectomy probe →1Infusion line →2Floaters →3Light pipe →4Retina →5+

1. Vitrectomy probe2. Infusion line3. Floaters4. Light pipe5. Retina

An infusion line keeps the eye inflated, a light pipe illuminates the inside of the eye, and the vitrectomy probe cuts and removes the gel. The eye makes its own fluid to fill the space afterwards; the gel does not grow back. For routine floater surgery an air or gas bubble is not usually needed. The vitrectomy surgery page describes the operation in more detail.

Surgeons differ in how much gel they remove. Retinal tears during surgery have been more common in several studies when the surgeon has to separate the gel from the retina, so many surgeons remove mainly the central gel and examine the edge of the retina carefully during the operation, treating any tear they find. Leaving the gel attached, however, makes new floaters more likely later. Neither approach suits every eye. The article on how and why surgeons' approaches differ explains these choices in more detail.

Vitrectomy for floaters performed by Dr Simon Chen

Vitrectomy for floaters performed by Dr Simon Chen

This short video shows real eye surgery.

Watch on YouTube →

How likely is vitrectomy to help?

Across published series, around nine in ten people say they are satisfied, or that their symptoms have been relieved, after vitrectomy for floaters. A systematic review of 18 studies, covering 2,077 eyes, found that satisfaction or relief was reported by at least 90% in the studies that measured it. Individual series range from about 85% to 96%. Being satisfied is not the same as never seeing a floater again: in an international study of 581 eyes, 92% were satisfied and 86% reported that their symptoms had resolved completely in daily life. In a prospective study of 64 patients, people rated how much floaters impaired their vision on a scale of 0 to 100; the typical (median) score fell from 44 before surgery to 11 a year later.

Contrast sensitivity and vision-related quality-of-life scores improve on average. The letter chart reading usually changes only a little, because it was often normal beforehand.

These results come from studies without an untreated comparison group, and not everyone answered the follow-up surveys. The numbers are encouraging, but they are not a guarantee.

Some floaters can come back. In one series, no new floaters developed in 179 eyes whose vitreous had already separated from the retina, but about one in seven of 99 eyes whose vitreous was still attached developed them. This was most common in younger, short-sighted people who still had their natural lens. In a survey four to seven years after surgery, about three in ten eyes, among those whose owners replied, had some floaters again, but only about 2% were described as significant.

What are the risks of vitrectomy for floaters?

The two risks that matter most are an earlier cataract, if you have your natural lens, and retinal detachment. The figures below come from published series and describe groups of eyes, not your individual risk, which depends on your age, eye and the surgical technique. Some complications overlap, so the percentages should not be added together.

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Cataract deserves particular thought if you are in your fifties or older and still have your natural lens. For many people the realistic plan is vitrectomy now and cataract surgery within a few years. It is a bigger trade-off for younger people whose natural lens is still clear and can still focus up close, because replacing the lens ends that natural focusing. For people who are short-sighted, that later cataract operation can also reduce their dependence on glasses. The article on cataract surgery after vitrectomy explains what to expect.

Does it matter whether I have had cataract surgery?

Yes. If you have already had cataract surgery, the main downside of vitrectomy, an earlier cataract, no longer applies. The risk of retinal detachment remains, so having had cataract surgery does not by itself make floater surgery the right choice.

Before vitrectomyLater: fluid-filled eye with cataract

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If you are older and a cataract is already starting, removing it at the same operation, or before the vitrectomy, is one option. It avoids a second operation later, but removing the lens carries its own small risks, including macular swelling. The evidence comparing these approaches for floaters comes from small, short-term studies, so the decision is individual.

What should I ask before agreeing to surgery?

It helps to leave the discussion with clear answers to these questions:

• Do the examination findings explain the floaters that bother me?
• What improvement is realistic, and what may stay the same?
• How do my lens and the state of my vitreous affect the risks and the plan?
• Would waiting longer, or laser, be a better option for me?
• What recovery, follow-up and possible further treatment should I plan for?

For some people, floaters that keep interfering with daily life make surgery worthwhile. For others, living with the floaters remains preferable to accepting the risks of an operation. Both can be reasonable choices after a careful assessment.

What is recovery like?

Recovery after routine floater surgery is usually quicker than after many other retinal operations, because a gas bubble and head positioning are not normally needed. Vision is often blurred for the first days, eye drops are used for a course your surgeon sets, and most people return to light activities within about a week. Your surgeon will give instructions for your own eye.

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The week-by-week guide to recovery after vitrectomy for floaters covers driving, exercise, travel and screens.

Other questions about floater surgery

Where can I read more?

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 →

When do floaters need urgent attention?

Contact your ophthalmologist urgently, or attend an emergency department, if you notice a sudden shower of new floaters, new flashes of light, a shadow or curtain across part of your vision, or a sudden drop in vision. These can be signs of a retinal tear or detachment, which can be painless. The guide to flashes, floaters or a curtain explains why these symptoms need prompt assessment.

After vitrectomy, also seek urgent help for sudden loss of vision, severe or increasing pain, or a new curtain or shadow. Do not wait for your next appointment.