Vitreous floaters: Etiology, diagnostics, and management

Vitreous is a hydrated extracellular matrix comprised primarily of water, collagens, and hyaluronan organized into a homogeneously transparent gel. Gel liquefaction results from molecular alterations with dissociation of collagen from hyaluronan and aggregation of collagen fibrils forming fibers that cause light scattering and hence symptomatic floaters, especially in myopia. With aging, gel liquefaction and weakened vitreoretinal adhesion result in posterior vitreous detachment, the most common cause of primary symptomatic floaters arising from the dense collagen matrix of the posterior vitreous cortex. Recent studies indicate that symptomatic floaters are not only more prevalent, but also have a negative impact on the quality of life that is greater than previously appreciated. We review the literature concerning management of symptomatic vitreous floaters, currently either with observation, vitrectomy, or Nd:YAG laser. Published evidence is consistent with a low-risk profile and excellent success rate for floater vitrectomy, particularly with sutureless small gauge instruments and a limited core vitrectomy without PVD induction. Nd:YAG laser treatment of floaters, reported less commonly, claims resolution of floaters ranging between 0% and 100%; however, both peer-reviewed literature and assertions on web-based nonpeer-reviewed laser vitreolysis sites remain to be substantiated, and at present only vitrectomy has proven value. Prospective studies using objective, quantitative outcome measures are required to assess the relative efficacy and safety of these two procedures as well as new therapies such as pharmacologic vitreolysis.