Fighting Floaters

Gary Wörtz, MD, picks the brain of Inder Paul Singh, MD, on the topic of laser floater removal (LFR). Dr. Singh explains his transition from skeptic to advocate, comments on the advantages of laser vitreolysis, and details a retrospective study on patient satisfaction following LFR.

Gary Wörtz, MD: Open, outspoken. It’s Ophthalmology off the Grid—an honest look at controversial topics in the field. I’m Gary Wörtz.

From thumbs-up airplane-selfies to a Bhangra-reggae-bolly-funk band, Dr. Paul Singh is a man of many passions. In this episode, we are going strictly clinical. I wanted to speak to Paul about a procedure he has devoted significant efforts to: laser floater removal. In this episode, we will hear from Paul about the moment he stopped telling patients with floaters to “just deal with it,” his take on the risk of adverse events associated with vitreolysis, and much more.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.

Gary: Today I have Dr. Paul Singh who is joining us with Off the Grid. Paul, man, I just want to say thanks for coming on, and I cannot wait to talk to you about all things Paul Singh.

Paul Singh, MD: Oh man. Thanks for having me.

Gary: Oh man, this going to be fantastic. So, Paul, I think I first started hearing your name coming through the glaucoma circles, doing a lot of glaucoma stuff. But then there was this wave, this tidal wave, this tsunami of floater removal press, and it was like, all of a sudden, floater removal is like this crazy new topic that's everywhere. This seems like something that you have really been a champion for. I just want to back up. I want to back the bus up to the beginning. When was it that you had a patient or what was the tipping point where you're like, "Man, I'm gonna YAG that." Tell me the story because it had to be something.

Paul: I'll try to make it as quick as I can, the Cliff’s Notes version. Yeah, first of all, I was a skeptic like a lot of people out there. I had no idea about vitreolysis or floater removal. So, I had a patient of mine who is a physician, right? Every year, came in with the same complaint, "I got a Weiss Ring that's bothering me. I can't move, I can't see without moving my eye." So, he came in every year. I kept saying the same thing, "Just deal with it. Not my problem."

Gary: You'll live with it, it's not my problem.

Paul: Not my problem. Right.

Gary: It's all good, get used to it.

Paul: I do other stuff.

Gary: Exactly. “I'm a glaucoma guy.”

Paul: So, anyway, what happened is, all of a sudden, he gets so frustrated. He goes, "I'm going to go to a retina guy." I'm like, "Cool, go ahead."

Gary: Knock yourself out.

Paul: Yeah, I'm like, "All good, man." So, he goes to a retina guy, really good guy. The retina guy is like, "Wait, you're phakic, you're 45, and you're a doctor, and you have a Weiss Ring? Uh-uh, not doing a vitrectomy." So, this guy gets really frustrated, and he went to the east coast to a guy who has been doing this vitreolysis procedure for a long time. That's Dr. Karickhoff. He used this kind of specified laser. Well, this guy, this doctor, comes back after having the treatment done. He's like, "Oh my God, Paul, you've got to start looking into this. It worked!"

So, I looked at his vitreous, and it was gone. I'm like, "Holy cow." So literally, that week, my old monster water cooler laser finally died. So, I went to academy that year, and Ellex, a company that makes this laser, actually had this new procedure. A new laser came out, and I needed a YAG anyway. So, I bought the laser, just because I needed a YAG.

Gary: So, it was like…

Paul: Serendipity, man. So, then I came back, and I'm like, "I'll do a couple laser floaters here and there." After doing one or two of the kind of the prime, Weiss Ring kind of patients that were safe, I saw these patients come back, and I'm like, "Oh my God. A, it worked, and, B, it's safe. And then C, these are happy patients." You know, like patients coming back saying, "I can read again. I can drive again."

Gary: These are practice advocates.

Paul: Oh my God, they started basically exploding out and telling everybody, "This is the procedure you've got to do." And telling their friends, and next thing you know, we're getting people coming in without advertising. Just people needing this. It's such a need and a void of something to treat these patients with.

Gary: Well, it's really interesting how ... and this is the classic case of an unmet need, right? There's an unmet need of people who probably don't need a vitrectomy—that's maybe a little bit more aggressive than we would recommend—but are chronically bothered by obscurations in their visions, floaters. And, the technology and maybe it was ... you know, did you ever think like, "Man, if this guy wasn't a physician, maybe I wouldn't have taken his story so seriously." But the fact that you had a young physician patient, who you felt like he was a trustworthy source, and he sought this guy out and came back ... there's a real pearl here, and that's, we can learn a lot from our patients if we just listen to them, don't you think?

Paul: Absolutely. Look, we think about cataract surgery. You got a guy who is a 20/30 cataract, or 20/25, a glare at night to 20/60. His vision on its own is not bad, but you're like, "Well, if you're having complaints and you're having difficulty with daily functioning, we'll do something about it." It's the same principle. If you have someone coming in here with a floater and saying, "You know, I have to move my eye to kind of see," or "I can't read,” or “I can't drive at night because it gets in the way," that's as significant to me at least, and seeing the outcomes, as a cataract patient. So, I think you're right. Listening to them, not ignoring them, and not poo-pooing them. These people have been trained for so many years that nothing can be done.

Gary: Right, your floaters are your friends.

Paul: Your floaters are your friends, get used to them. Call them names, right? And then they come in, and you'd be amazed at how many people I do. I see a floater in the middle of a vitreous, and I'm like, "Hey, do you have a floater?" "Oh my God, yeah, Doc." Well, now we can do something. "Really, I thought nothing could be done." There's those people in your office. Not even advertising, just there. And they've been trained to ignore it, and it really bothers them.

Gary: Alright. So, give me the Cliff’s Notes version of how you categorize these floaters. Obviously, Weiss Ring, very clear. But I know there's a couple of categories you sort of defined and helped sort of categorize. I want you, in your own words, to sort of explain that. I'll butcher it.

Paul: Yeah, no worries man. Well, the first thing, you want to have symptomology. You want to have symptoms. If patients have symptoms, that's the only thing I treat. Just because I see a floater, I don't do anything about it. But we categorize it more in kind of depth and where they're located. The key factor is, you want to pick a patient who has a floater that's in the middle of the vitreous, or kind of mantle-interior. If it's too far posterior by the retina, you don't want to treat it, and if it's too close to your lens. So, I look at positioning, location.

I look at also, is it easy for me to document when I see the patient? Can I see it, and can I correlate it with the patient's symptoms? A lot of times you'll ask a patient, "Hey, where do you notice it? Does it come from the top, bottom, left, where does it come from?" And they'll describe it to you. So, being able to correlate it with the patient. Looking at the density. There's amorphous clouds, these string-like clouds. The amorphous clouds actually do very well, but they can take multiple sessions sometimes, so expectation building. The ones that I do not think are treatable, really, are the ones where they're like asteroid hyalosis: these thin lines and thin dots and fibers that some of the younger people come in with. We've tried them on those patients, they don't seem to be as happy.

But the larger amorphous clouds, the post-cataract surgery patients, those large Weiss Rings—those people are extremely happy. We've actually seen quality of vision improvement based upon objective testing, too, in those patients.

Gary: So, do you have an iTrace? Is that a technology you like?

Paul: I do. Yeah, I've used it a lot for this.

Gary: I think I've seen some data or something you were going to present on that. I don't want to burst the balloon, but can you talk to us a little bit about what you see with the iTrace?

Paul: Yeah, so first of all, we've noticed now, we actually presented at ASCRS this year and last year data on a retrospective study on patient satisfaction. So, we've known that patients are happy, and they would come in saying, "Doc, I can see better." Quality, contrast, is better. But you couldn't objectively show that. So, finally, we went ahead and did a study using the iTrace, which is basically ray-tracing. Basically, it can tell you contrast sensitivity and high-order aberrations and be compared for cornea versus internal optics. Long story short, pre and post vitreolysis, we've seen in these patients who have amorphous clouds in the middle of the vitreous, pre and post we saw significant difference in higher-order aberration and improvement in MTF curves as well.

So we are seeing now the quality of internal optics. It's not just subjective, patients saying, "Yeah, I think I'm happier now." It's these people now, you can correlate the objectifying with their subjective improvement. And that we actually presented already at ASCRS and submitting for publication now as well.

Gary: Oh, man. That's fantastic. So, the question that I think some people, whenever you're trying to learn a new technique, I think we all are fairly adept if you're a cataract surgeon, etc, you know how to use YAG lasers. So, I don't think there's a huge learning curve for that. I know it is a little bit more energy than we are used to delivering. Can you speak to what your settings are like and what a treatment session looks like?

Paul: Yeah, absolutely. So, first of all, if you don't mind me saying…

Gary: Yeah.

Paul: The idea of a YAG laser … it's not any YAG laser. There's specific types of YAG lasers. Really, two companies right now. Full disclosure, I do speak for Ellex, the company that I use the laser of. But there's also a company called LightMed, which makes a laser that also has similar type of illumination. Bottom line is, what was the reason why people did not have a good outcome historically with trying this procedure? We couldn't see the vitreous. We couldn't see the spatial context. Where is the floater? Where is the retina at the same time? For safety. And so, you have normal YAG lasers have an illumination tower coming from below or off axis.

What these guys did with these lasers is they made an illumination tower central or coaxial. That gives you that spatial context and the ability to see. So, number one, we have to make sure we use the right technology. Also, we look at the actual energy delivery. There's a physics lesson that I learn a lot, which is the idea of, "What happens when you increase the energy of a laser? And how much energy is dispersed in the eye?" It's a nonlinear relationship. Bottom line, when you increase the laser energy, the amount of energy increased in the eye itself is nonlinear. So, 1 mJ would be about 110 mm of dispersed energy. You go up to 10 mJ, it only goes up to about 220 mm. So very small increase in how much dispersion of energy in the eye, which is why, in terms of settings, we feel comfortable going to 5, 6, 7 mJ. It's a lot higher than a YAG capsulotomy, but because we know this basic data, we're not causing a huge amount of increased energy in the eye.

Number two is how quickly the energy is absorbed. It's about a 3-nanosecond pulse. So, when you fire the laser, the energy is dispersed or absorbed within a few milliseconds.

Gary: Right.

Paul: So, therefore, you cannot have heat building up in the eye. So, doing 300 to 400 shots, you're not causing heat to build up, which is why sometimes we use 200 to 300 shots for a Weiss Ring at 5, 6 mJ. And for amorphous clouds in our studies, sometimes three sessions, with like 600, 700 shots as well. So, using much more energy than you're used to with a YAG laser for a capsulotomy. And that's why, historically, a lot of the outcomes were not as good, because people were using energy levels of like 2, 3 mJ. It's going to push it away. Here, we're breaking and vaporizing. That's the other misconception. People think we're just breaking 1,000 pieces. We are breaking it apart, but we're also vaporizing. If you look at the energy, we're actually causing plasma breakdown.

Gary: Phase transformation.

Paul: Exactly. Fourth state of matter, right? Solid to gaseous state. But it's happening in such a small area, so you break apart a floater, but those pieces, then you go after those pieces to vaporize those smaller pieces, which is why it takes sometimes multiple sessions and multiple shots, unlike a YAG capsulotomy, just breaking up pieces of capsule.

Gary: Right, right. So, have you had any patients who've had, for example, macular edema or a retinal tear from these sessions? You know, I’m just kind of curious. That's one of those things theoretically I'm kind of thinking in my mind, would I worry about that?

Paul: That's a great question and a great worry. We should all be skeptical about that stuff. So, good news. We presented our paper at ASCRS looking at over 1,200 patients retrospectively. Over 400 of them were actually over 4 years’ follow-up. We had not seen in that study any detachments or retinal breaks. So, the reason why we're not seeing that is because you think about a YAG capsulotomy, people always bring up the YAG cap as kind of a historical dataset. But when you're hitting a YAG cap, the laser energy right, it's hitting the capsule, to the zonules, to the vitreous space. You have a direct connection. In the vitreous where we have…

Gary: It's like springs.

Paul: Exactly. Spring system. Here, we're just vaporizing these collagen strands in the middle of the vitreous. Number two, if you look at our datasets in terms of kind of severing, the definition is severing of vitreous strands and opacities. That's vitreolysis. So, we're not actually pulling traction. The physiology of a detachment is traction on the retina from the vitreous. So, we're not seeing that. More importantly, if you look at all of our adverse events, what we see is pressure spikes that can happen. That's the one thing I see more than anything else, especially if the patient is phakic right behind the lens, we've found in the subset of patients, about 15 in 3,000 cases, where pressure is up to like 40+. So, we limit the number of shots in the certain patients that have glaucoma or if the floater is too close to the lens.

Gary: That's great data, Paul. One other thing I'm kind of curious about it coding. You know, when you do a new procedure, that's always the question. How do we code for this? Is this a patient-pay procedure, sort of a premium procedure? I think there are codes for this. What's the recommended route for that? I guess the disclaimer there is, everyone has to make their own coding decisions.

Paul: Thank you.

Gary: I'm not going to put you on the spot. Any tips you can share with us?

Paul: Yeah, I mean, I'm not a consultant. I'm not like Corcoran Consulting or anything like that, but I will tell you this. It is a little bit of an ambiguous area right now. I personally do bill insurance, because if you look at the code for Medicare for vitreolysis, it basically says severing of vitreous strands and opacities with a laser. Now, in our opinion, for a lot of these floaters, what we're doing is a combination of vaporizing, but we're also severing the strands. It's a collagen matrix. So, you're severing these strands, and some of them, you're actually causing the floater to fall away, too.

So, I do believe that's what we're doing in combination with vaporization. So that's why I do bill the code. What I do make sure, though, is that if you do that, you make sure in the chart to document symptoms. In my consent form, it says, “These affect my daily functioning.” Yes or no, they circle yes. They also circle yes or no that they understand that this may require more than one session. And thirdly, they realize it may not be able to get rid of all the floaters. But documentation is huge. I also like to document the floater. Some imaging, whether it's slit-lamp photography, B-scan, OCT, we've done some great OCT work now, showing them pre and post. Something to document the floater. And then if you can afterwards show that you had some resolution, that is huge. That way if you ever do get audited, hypothetically, you're using the code the way it states, and you have symptomology to back up why you did it.

The other way of doing it, rather, is coding it based upon ... just say it's an uncovered procedure, and doing it out of pocket. But if you do that, you have to do it for everybody. You can't pick and choose. So really right now, Corcoran is kind of having a hard time figuring out what to say to everybody. So really, my advice is, you do coding. If you do bill to insurance, make sure you document very aggressively and are very good about everything you're doing, especially symptomology.

Gary: We're just sort of dabbling ... we have the same laser that you have, so we have the Ellex laser, and it's a fantastic laser for just YAG capsulotomy. I mean, it's fantastic. Best I've ever used. I don't speak for them, not a consultant. And we are dabbling, and we're trying to sort of get started in this program. Any resources on the web you could point us to? Does Ellex have resources online?

Paul: They do. They have a really good resource if you want to go to Ellex.com. They actually have a floater site that talks about, has videos from me, and some other providers around the world, have some advice on it. And some cool videos that show you. On eyetube.net and also YouTube, there's some videos on, and I have some as well, on how to do it and some instructional videos. But there is a learning curve, and my point to anybody starting out, is pick a pseudophakic patient. You don't want to worry about hitting the lens. You want to have a good view, and Weiss Rings are the best ones to start with because you can correlate those very clearly with the patient’s symptoms.

So Weiss Rings or middle of vitreous, you know you're far away. And in clinical pearls, if the floater is in focus, with this Ellex laser, with illumination system, if the floater is in focus and the retina is out of focus, then you have enough space to fire. Those are the kind of ones I would start with. As you get better and you feel comfortable utilizing the laser and being able to titrate the illumination, etc, then you can move to more anterior and posterior floaters as well.

I do think there is a learning curve, just understanding how to visualize and maximize visualization, and then feeling comfortable going to higher levels of energy. A 5, 6, or 7 mJ, we freak out. It took me about 100 cases to feel comfortable going to a 7 or 8 and just staying there and just zapping for like 500 shots. That does take some time.

Gary: And there's a special lens that's required. This is not just your YAG capsulotomy lens that you're using, correct?

Paul: Yeah, it's a special lens. Actually, two companies make lenses specifically designed for vitreolysis. Volk makes—and I have no financial interest in this—a lens called the Singh Vitreous Lens, which is maximizing visualization all the way from a lens all the way to the retina. They also have another one called the Idrees lens. They're both very good lenses. Ocular Instruments also makes a set of three lenses as well, which are all designed specifically for maximizing visualization.

Gary: Oh, man. Paul, I think we're going to wrap it there. I wanted this to be a quick, hard hitting, just the facts, okay?

Paul: No worries, man.

Gary: But I want to make sure that you know that we're going to do another podcast at some point in the future where we sort of unpack ... I want to know more about your story. You're a musician, you've got a lot of really cool things going on professionally, and so we've just hit the very tip of the iceberg.

Paul All good.

Gary: But man, thank you so much for coming on the show today.

Paul: Thanks, man, appreciate it.

Gary: Paul is truly a champion for patients with floaters. His dedication to fulfilling an unmet need is how ophthalmology and all of medicine advances. If any listeners have further questions on vitreolysis, don’t hesitate to reach out—Paul is passionate about this education.

So, with that, thanks for listening to Ophthalmology off the Grid. For more episodes like this, visit eyetube.net/podcasts, and if you like what you hear, please be sure to rate, review, and subscribe. Until next time…

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.