Can't Look Through Microscopes

[The Beav]

Hi everyone. I've found my question addressed a couple of times by searching the forum, but I haven't been able to find many straight answers, hopefully some of you can help?

I'm an MS2 who is interested in ophtho. My concern is that I've got really bad floaters that make it difficult for me to focus on things through a microscope.

So what do you think, are the procedures done under magnification in ophtho similar to using a microscope? I've used an ophthalmoscope and slit lamp before without too much trouble, is that a good indicator? Obviously I'll eventually just have to look for myself, but I thought I'd see what the experts think. Thanks.

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[fourchambered]

It's tough to say if slit lamps work for you but regular microscopes don't. I think the best solution is to go to the OR and watch cases through the microscope. Try to find an attending case where there won't be a resident, and just sit next to them and watch through the microscope, see how it goes. I wish I had known as soon as second year. It will also be a good opportunity for you to meet some faculty and get your name out. Best of luck.

 

[KHE]

Hi everyone. I've found my question addressed a couple of times by searching the forum, but I haven't been able to find many straight answers, hopefully some of you can help?

I'm an MS2 who is interested in ophtho. My concern is that I've got really bad floaters that make it difficult for me to focus on things through a microscope.

So what do you think, are the procedures done under magnification in ophtho similar to using a microscope? I've used an ophthalmoscope and slit lamp before without too much trouble, is that a good indicator? Obviously I'll eventually just have to look for myself, but I thought I'd see what the experts think. Thanks.

Is the problem that the floater seems to get in the way with the microscopes but not the slit lamp?

 

[orbitsurgMD]

Hi everyone. I've found my question addressed a couple of times by searching the forum, but I haven't been able to find many straight answers, hopefully some of you can help?

I'm an MS2 who is interested in ophtho. My concern is that I've got really bad floaters that make it difficult for me to focus on things through a microscope.

So what do you think, are the procedures done under magnification in ophtho similar to using a microscope? I've used an ophthalmoscope and slit lamp before without too much trouble, is that a good indicator? Obviously I'll eventually just have to look for myself, but I thought I'd see what the experts think. Thanks.

Some floaters seem more noticeable against brightly illuminated fields, and an OR microscope has brighter field illumination than a typical slit lamp, and the illumination is usually always co-axial in the operating microscope. Slit lamps are multi-axial, by design.

If your floaters are bothersome to you, and you have not been examined subsequent to their becoming apparent to you, I suggest you have an eye examination including a dilated posterior segment examination. Most floaters are nothing to worry about, but not all.

Sometimes you just need to get used to them. Sometimes they will become less apparent if the inciting cause, usually a small fold of vitreous body that has become detached loosens further and falls farther away from your central visual axis.

 

[jsh1986]

Apropos the June AJO article on vitrectomy for floaters, how often in your clinical practice have you done/referred to retina pts with "high-performance professions" for PPV with the indication being only floaters? I imagine the possibility that pilots, microsurgeons etc could potentially be limited by them??

Some floaters seem more noticeable against brightly illuminated fields, and an OR microscope has brighter field illumination than a typical slit lamp, and the illumination is usually always co-axial in the operating microscope. Slit lamps are multi-axial, by design.

If your floaters are bothersome to you, and you have not been examined subsequent to their becoming apparent to you, I suggest you have an eye examination including a dilated posterior segment examination. Most floaters are nothing to worry about, but not all.

Sometimes you just need to get used to them. Sometimes they will become less apparent if the inciting cause, usually a small fold of vitreous body that has become detached loosens further and falls farther away from your central visual axis.

 

[The Beav]

Thanks for the replies everybody, I think you're right that I will just have to go look for myself.

Some floaters seem more noticeable against brightly illuminated fields, and an OR microscope has brighter field illumination than a typical slit lamp, and the illumination is usually always co-axial in the operating microscope. Slit lamps are multi-axial, by design.

If your floaters are bothersome to you, and you have not been examined subsequent to their becoming apparent to you, I suggest you have an eye examination including a dilated posterior segment examination. Most floaters are nothing to worry about, but not all.

Sometimes you just need to get used to them. Sometimes they will become less apparent if the inciting cause, usually a small fold of vitreous body that has become detached loosens further and falls farther away from your central visual axis.

I had thought about the illumination differences between a slit lamp and a microscope, so it sounds like an OR microscope is more like a regular microscope than a slit-lamp?
On a regular microscope my floaters are usually just slightly annoying/distracting at the lower and medium magnifications, but once I go oil immersion it's like I'm looking through soup.
I'm always told that my brain should slowly start ignoring the floaters, but they just seem to be getting constantly worse, maybe my brain isn't as smart as I would like to think. I've had floaters forever and have a family history of detached retina, so I get checked every year.

Is the problem that the floater seems to get in the way with the microscopes but not the slit lamp?

I'm just wondering if, since I have difficulties looking through microscopes, I might have similar troubles in ophthalmology since there are so many procedures done under magnification.

 

[orbitsurgMD]

Apropos the June AJO article on vitrectomy for floaters, how often in your clinical practice have you done/referred to retina pts with "high-performance professions" for PPV with the indication being only floaters? I imagine the possibility that pilots, microsurgeons etc could potentially be limited by them??

You could also be limited by CME, cataract, endophthalmitis or other complications of an intraocular surgery, especially a very invasive posterior core vitrectomy. The surgery itself could cause a retinal detachment.

 

[MR1]

Apropos the June AJO article on vitrectomy for floaters, how often in your clinical practice have you done/referred to retina pts with "high-performance professions" for PPV with the indication being only floaters? I imagine the possibility that pilots, microsurgeons etc could potentially be limited by them??

We do it half a dozen times a year at my fellowship. Not to say PPV is a benign surgery but with 23/25G, it isn't what it used to be. Floaterectomies have to be picked with care is all I'll say, same as your 20/20 PSC cataracts.

 

[MstaKing10]

Most floaterectomies we did during fellowship were on highly functioning and anxious patients who had a prior history of cataract surgery usually with a toric or multifocal IOL. I think in these patients the floaters may indeed be magnified, particularly with multifocals. Occasionally we did one on a patient with a history of posterior uveitis with lots of debris in the vitreous. A young, phakic pt with 20/20 vision I would stay away from like the plague. Not only due to the risk of an intraoperative complication but what about the likelihood of needing cataract surgery in your 30's? No thanks!

 

[collosalmockery]

Most floaterectomies we did during fellowship were on highly functioning and anxious patients who had a prior history of cataract surgery usually with a toric or multifocal IOL. I think in these patients the floaters may indeed be magnified, particularly with multifocals. Occasionally we did one on a patient with a history of posterior uveitis with lots of debris in the vitreous. A young, phakic pt with 20/20 vision I would stay away from like the plague. Not only due to the risk of an intraoperative complication but what about the likelihood of needing cataract surgery in your 30's? No thanks!

So you are suggesting these young individuals with bright future to suffer from floaters just because of some risks?

In a young healthy retina, chances of retinal detachment from PVD induced vitrectomy are less than 1% (extensive literature, and Dr. Steve Charles' estimate from his practice to me as his patient). Chances of retinal tears are higher but if it is correctly treated right away during the surgery, your retina is like a brand new retina (of course depends on extent of the tear and its position).

Cataracts in young healthy eyes after floaterectomies is a very patient dependent phenomenon. It can appear in 2 days (which suggests intraoperative damage) or in next 30 years. In 30 years after getting floater-only-vitrectomy, I reckon cataract surgeries will be MUCH more safer and less invasive than they currently are. So to tell a young bright intelligent patient whose academic life is suffering from severe floaters to continue to suffer is quite misplaced and selfish.

Post-operative Exogenous endophthalmitis is a very scary risk but its risks range from 1/1000 to 1/3500 depending on whatever study you follow. You can take steps before getting the surgery to minimize this risk, get your MRSA colonization tested etc etc

Moreover, all literature studies on floater vitrectomies have suggested that patients viscual acuity remained the same or IMPROVED (except in cases with complications). This is because a synretic vitreous with varying refractive indexes through out the visual axis will mess up one's vision. No one should have to suffer when there are treatments available.

OP, if your floaters effect your life much, and you'd want to have a pristine clear vision, do look into floater only vitrectomies and properly research it. I hope you will make a right decision for yourself. Dont let your floaters decide your specialty!

Its ironic how LASIK, which also has complications associated with it, is offered so "easily," sometimes the patient is lured into it, just to get one rid of his/her glasses while floaters are passed off as "in one's head." Pathetic behavior from most ophthalmologists. But I thank doctors like Dr. Hanscom and Dr. Charles who take floaters seriously.
It is precisely this behavior of the ophthalmic community because of which significant vitreous opacities have not been taken seriously at large. Or by now, we possibly could have had a pharmacologic solution. Ocriplasmin has recently shown to be very effective in inducing PVD, and I hope in future it can be used along with vitrectomy to make floater only vitrectomy more safer than it already is. Better yet if a pharmacologic agent to dissolve condensed collagen in vitreous fibrils can be somehow developed, it will revolutionize how floaters are perceived and treated.

Visit floatertalk.yuku.com for more discussion on how you can rid yourself of your malady: floaters.

 

[collosalmockery]

Here is an editorial by Dr. J Sebag published very recently, young ophthalmologists take heed, floater patients are sick and tired of many from the old conservative ophthalmic club. There are many young floater patients who have loaded their guns to take their lives if their floater symptoms dont get better or if their floater vitrectomies go bad and they end up blind from endophthalmitis (floatertalk.yuku.com), it is a very serious situation and these people SHOULD be helped. Anyways, the editorial:

http://www.vmrinstitute.com/images/PDF-Articles/Floaters%20and%20the%20Quality%20of%20Life.pdf

When we rule out pathology by these
modalities, we advise patients that they are free of disease.
Such advice is apparently a frustrating and unfulfilling experience
for patients with "floaters." From their point of view,
the consulting ophthalmologist who sought evidence of
disease and found none has nonetheless failed to address their
health and quality-of-life issues.
.....

The subjective experience of sudden floaters is very
common after PVD. While many patients complain that
this is bothersome, ophthalmologists tend to pay little
heed to these symptoms other than to rule out anomalous
PVD3,8 manifesting as either peripheral or posterior retinal
pathology. Once the absence of disease has been assured,
the typical eye care professional ceases to be concerned
about the issue of floaters. While the Hippocratic principle
of "primum non nocere" has guided our approach to date, it
may well be time to reexamine our perception that floaters
are simply an innocuous, indeed curiously desirable, manifestation
of the "normal" aging process.

...

Most remarkably, the investigators of this study found
that these patients were willing to take an 11% risk of
death and a 7% risk of blindness to get rid of symptoms
related to floaters. As the authors state, patients with
floaters are willing to trade off 1.1 years out of every 10
years of their remaining lives to get rid of the symptoms of
floaters.

 

[MstaKing10]

So to tell a young bright intelligent patient whose academic life is suffering from severe floaters to continue to suffer is quite misplaced and selfish.

Believe me, if I was selfish I would be doing floaterectomies all the time. It's a 15 minute procedure that bills just as much as a complex vitrectomy that takes 2.5 hours. It's not self serving at all, but rather, looking out for the best interests of my patients. This is why there is so much controversy surrounding this issue. You may be right, and the visual impact of floaters may very well be underestimated by retina surgeons. But the complications associated with vitrectomy on young eyes, albeit rare, is still something to be considered. If the patient has a full understanding of the risks involved and has reasonable expectations, certainly surgery may be a reasonable alternative. I am very happy that things turned out well for you, and I'm sure the majority of patients in your circumstance would be just as content. It's the rare one with the complication leading to a horrible outcome that I fear.

At the end of the day, the OP needs to have a full ocular exam and consultation with an ophthalmologist to figure out what is the best way to proceed.

 

[collosalmockery]

Believe me, if I was selfish I would be doing floaterectomies all the time. It's a 15 minute procedure that bills just as much as a complex vitrectomy that takes 2.5 hours. It's not self serving at all, but rather, looking out for the best interests of my patients. This is why there is so much controversy surrounding this issue. You may be right, and the visual impact of floaters may very well be underestimated by retina surgeons. But the complications associated with vitrectomy on young eyes, albeit rare, is still something to be considered. If the patient has a full understanding of the risks involved and has reasonable expectations, certainly surgery may be a reasonable alternative. I am very happy that things turned out well for you, and I'm sure the majority of patients in your circumstance would be just as content. It's the rare one with the complication leading to a horrible outcome that I fear.

At the end of the day, the OP needs to have a full ocular exam and consultation with an ophthalmologist to figure out what is the best way to proceed.

I fully understand your hesitation in offering floater vitrectomy to every patient who complains of floaters. And I do agree that the risks, albeit rare, are quite life altering if the patient happens to be unlucky. So that is why I hope, by at least raising awareness that floaters are after all not benign, safer procedures/treatments can be developed to help patients. In my whole medical school experience, floaters were never mentioned as a disease but only an indication/symptom of a more complex disease such as retinal tear. It is about time that in young patients we start recognizing floaters if not as a disease then at least as an abnormal pathology of the vitreous with devastating psychosocial effects (much more than what acne patients suffer). I counseled couple of young patients who dropped out of school, spent years in a closed dark room to avoid their phobia of floaters that they had, they had stopped reading books, stopped going outside and enjoying the sunshine etc etc. In this young patient group, floaters are not due to PVD but due to extremely pathological vitreous liquefaction and synresis close to rhe retina, and hence that is why these patients see non-tolerable persistent, dark black, clearly defined, light distorting and blurring shadows as opposed to the ones created in PVD patients who mostly have tolerable blurred, vague, non-persistent shadows.

 

[NeuroOph]

You'll just have to try it. The slit lamp microscope should be a pretty good gauge. Likely you will be fine. I've heard of one ophthalmologist who was on disability for a PVD. But you are likely a high myope or Ex NFL football player. By the way, what is oil immersion microscopy? 200 magnification? You won't be getting any where near that in Ophtho unless you are a pathologist.

 

[PBEA]

vitrectomy for typical PVD. Are you joking? Hey guy, put the weapon down and slowly back away, slowly, slowly.....

 

[collosalmockery]

I have many floaters like this in both my eyes, yet I still can see through a microscope. So even though I can see perfectly despite the junk in the eye, I guess we should count ourselves to be blessed to at least see. That is what an ophthalmologist with crystal clear vision tells you. I wonder if he is willing to exchange his vision for this one though?