Clinically significant vitreous opacities (CSVO), more commonly referred to by patients as “floaters,” are a frequent yet often under-treated cause of visual disturbance. While most vitreous opacities are benign and self-limited, a subset of patients experience persistent, disabling symptoms that meaningfully impair visual function and quality of life—sometimes to a degree comparable to age-related macular degeneration or diabetic retinopathy.1,2
Epidemiologic data highlight their prevalence: in one international survey of 603 smartphone users, 76% reported floaters, with 33% describing associated visual impairment.3 The most common etiology is posterior vitreous detachment (PVD), although myopia, prior intraocular surgery, retinal pathology, trauma, and inflammation are well-recognized risk factors.
Even when Snellen acuity is preserved, these patients frequently report reduced contrast sensitivity, glare, and difficulty reading, underscoring the disconnect between standard visual acuity measures and functional disability.1,2
Surgical management of CSVO
Given the limitations of observation alone in certain cases, a structured approach to patient selection and surgical management has emerged to address CSVO safely and effectively. Initial evaluation focuses on distinguishing acute from chronic symptoms and confirming PVD on examination or OCT.1,2
For patients who have been symptomatic for 6 months or longer, are pseudophakic (or have undergone cataract surgery in preparation), and meet other anatomic criteria, vitrectomy can be considered. Using a 25- or 27-gauge system, surgeons perform a core vitrectomy with careful—but non-aggressive—peripheral shaving, posterior capsule opening if indicated, thorough scleral depression, and targeted endolaser for suspicious lesions, followed by air-fluid exchange.1,2
When performed under these strict criteria, reported complication rates are very low, with retinal detachment risk under 0.5% and minimal incidence of post-operative epiretinal membrane formation, making CSVO surgery an increasingly viable option for appropriately selected patients.1,2
Inder Paul Singh, MD, offered his insights into successfully removing clinically significant opacities utilizing the Vista 1-Step vitrectomy probe (MicroSurgical Technology [MST]).
Management of patients with severe symptoms from CSVO is challenging. While some surgeons are dismissive of this phenomenon, patients are truly bothered by CSVO and, in many cases, have significant amounts of vitreous debris degrading their contrast sensitivity, visual quality, and near vision.
The Vista 1-Step vitrectomy probe is an FDA-cleared, 27-gauge, needle-point, single-use vitrector, designed for seamless introduction through the sclera, without the need for microvitreoretinal (MVR) blades or trocars. The dual-blade probe can be paired with the surgeon’s customary phaco/vitrectomy device and is capable of up to 11,000 cuts per minute (cpm).
The Vista 1-Step vitrectomy probe can be used for:
- Pars plana-assisted anterior vitrectomy (PPAAV) to address vitreous prolapse during IOL repositioning or secondary IOL cases
- PPAAV during cataract surgery in the event of a broken capsule
- For the removal of CSVO in pseudophakic patients
Criteria for patient selection
In a complex case or lens exchange when a vitrectomy is planned, try using the 1-Step for a PPAAV to increase your comfort level with the device and the pars plana approach. Once comfortable, you can start using it for CSVO removal.
For initial cases, choose pseudophakic patients who are highly symptomatic, with opacities throughout at least half of their central visual axis. Patients with both monofocal and multifocal IOLs will be appreciative of the improvement in their quality of vision.
Pearls for surgical success with the Vista 1-Step vitrectomy probe
- I perform this procedure in the office, under topical anesthesia, with 5mg of diazepam for mild sedation. Afterwards, I put patients on a BID steroid and an NSAID for 1 week.
- Measure 3.5mm behind the limbus in any location that is convenient for your hand position, mark the eye, then enter with conviction. I initially engage at an angle and, once I feel resistance, then I keep the vitrectomy probe perpendicular to the sclera and directed towards the posterior pole.
- Remain in the anterior vitreous, behind the lens, and keep the probe relatively still, using very slow movements to capture all the liquified vitreous. Keep the vacuum on a very low setting (< 100mmHg) so as not to pull on the vitreous face.
- At the end of the case, and again at post-op day 1, week 1, and month 1, closely examine the retina with an indirect ophthalmoscope to ensure there are no tears.
The Vista 1-Step is an excellent tool for the anterior segment surgeon seeking to gain experience with pars plana-assisted anterior vitrectomy. It provides an opportunity to help patients who are suffering from clinically significant vitreous opacities, improving contrast sensitivity, overall quality of vision, and near visual acuity.
In conclusion
CSVO represents a meaningful and often underestimated cause of visual disability, with a disproportionate impact on quality of life despite relatively preserved visual acuity on standard testing.
Advances in surgical instrumentation, such as the Vista 1-Step vitrectomy probe, offer ophthalmologists a safe, efficient, and minimally invasive option to address CSVO in carefully selected patients.
As more ophthalmologists embrace these refined approaches, the field moves closer to bridging the gap between traditional conservative management and proactive intervention, ultimately enhancing both patient satisfaction and visual function.
