Spots and Strings and Shadows, Oh My!

Solving the mystery of eye floaters.

Photo by Nerissa Johnson.

Jaya B. Kumar, MD

Driving in busy city traffic is a task George* does not relish. Traveling the jammed freeways isn’t much fun for him, either. Both settings pose a challenge for George, who, even with his glasses on, has difficulty distinguishing the lines on the road.

One sunny morning, as George, 59, was driving his customary route to work, he encountered a new challenge. Small, strange black spots appeared and hovered in his line of sight, distracting him as he drove. Concerned, George called his eye doctor, who told him the spots were eye floaters and probably nothing to worry about.

“Most people describe eye floaters as little spots or cobwebs that appear in their field of vision,” notes Jaya B. Kumar, MD, a board-certified, fellowship-trained retina specialist at Florida Retina Institute. “Eye floaters are essentially small clumps of collagen material drifting in the vitreous. Vitreous is the gel that fills eighty percent of the volume of the eye and helps the eye maintain its shape.

“The clumps of material floating in the vitreous cast shadows on the retina. The retina is the light-sensitive layer of nerve cells lining the back of the eye. It sends visual signals to the brain, which turns them into images.”

“Vitreous floaters can take many shapes,” elaborates S.K. Steven Houston III, MD, another board-certified, fellowship-trained retina specialist at Florida Retina Institute. “Patients often tell their doctors they see round spots that look like amoebas floating in their vision. Floaters can also look like clouds, strings or hairs. Sometimes, patients report seeing small rings.

“People who experience flashing lights should see their eye care provider right away.” – Dr. Kumar

“There is actually a well-described floater shape called a Weiss ring. Weiss rings form when the vitreous gel separates from the eye’s optic nerve. The circular Weiss rings maintain the round shape of the optic nerve.

“Eye floaters are more pronounced when looking at a white background, a lit-up computer screen or a blue sky with clouds,” he continues. “In dim light, a dark room or at night, floaters are not as easily discernible.”

Flashing a Warning

There are several reasons eye floaters form. Most commonly, they’re a result of the natural aging process.

“Over time, as the eyes age, the vitreous gel within the central cavity of the eye that is adherent to the retina starts to condense,” Dr. Houston describes. “Little globs of condensed gel begin separating, or detaching, from the retina. This is called a vitreous separation or post-vitreous detachment. Eye floaters are shadows of these detached globs of gel.”

“Eye floaters can also form from bleeding in the eye, which can occur in people with diabetes who have an advanced complication of diabetic retinopathy or high blood pressure,” Dr. Kumar notes. “In addition, eye floaters can develop from inflammation in the eye related to eye surgery or from certain medical conditions.

“The only way to determine the cause of eye floaters is through a dilated eye exam, during which the ophthalmologist can get a good look at the retina and back of the eye. Conditions such as inflammation and bleeding are visible when the pupils are dilated.”

While eye floaters are more common in older individuals, they can develop in younger people as well, Dr. Houston acknowledges.

“When eye floaters develop in younger people, they most often occur in those who also have myopia, or nearsightedness,” he relates. “They can also develop in younger people who have suffered a trauma to their eye or have an inflammatory condition called uveitis. But in most cases, eye floaters develop in people fifty years old and older.”

In the majority of occurrences, eye floaters are harmless. Often, they fade away over time, or the brain becomes accustomed to them, so people no longer notice the spots or strings in their vision.

“In ninety-plus percent of patients, eye floaters improve within one to six months without treatment.” – Dr.Houston

“But floaters that appear suddenly; increase in size, number or frequency; are associated with severe pain or look like a curtain over the vision should be evaluated right away to make sure there are no major eye complications involved,” Dr. Houston adds.

“What is concerning is when patients start seeing flashes of light, lightening streaks or arcs of light accompanying the floaters,” Dr. Kumar warns. “That could indicate the vitreous is tugging on the retina, which can lead to a retinal tear. People who experience flashing lights should see their ophthalmologists right away.”

“A retinal tear may not cause a significant visual disturbance because tears are generally in the periphery of the retina,” Dr. Houston observes. “If caught early, a tear can be lasered in the clinic before it causes any problems.

“But a retinal tear can progress into a retinal detachment, which is when the retina actually peels off the back of the eye wall. A detachment is a much more serious complication.

“When the retina is detached, it can no longer function to send visual signals to the brain. Patients can go from seeing clearly to being nearly blind fairly quickly. That’s why patients seeing arc-like flashes should be evaluated by a retinal specialist to rule out a tear or detachment.

“Thankfully, through surgery, we can usually get the retina back into position so it can function again. We can often restore significant vision with surgery if it’s performed right away.”

During retinal detachment surgery, the vitreous is removed and a laser is used to “essentially weld around the tear to reattach the retina to the back wall of the eye,” according to Dr. Kumar.

“Afterward, we put a gas bubble in the eye to tamponade the detachment. The gas bubble typically dissolves over time, but it can cause the patient’s vision to be blurry for two to six weeks after surgery.”

Mini-Laparoscopic Surgery

At Florida Retina Institute, the evaluation of patients experiencing eye floaters begins with the dilated eye exam. Dr. Kumar and Dr. Houston use the exam to determine the cause of the floaters and to search for serious eye issues, including tears in the retina. Treatment depends on the cause of the floaters and whether or not they are visually significant and impacting the patient’s quality of life.   

If the floaters are the result of bleeding or inflammation in the eye, the ophthalmologists recommend management of the underlying health problems, such as diabetes or high blood pressure, and treat the retinopathy.

These conditions are generally treated in the clinic with medication. Floaters caused by post-vitreous detachment due to aging are generally not treated unless they are disabling for the patient.

“For patients with common eye floaters, we typically watch them for a period of time, and the floaters usually go away on their own,” Dr. Houston reports. “In ninety-plus percent of patients, eye floaters improve within one to six months without treatment.

“But some people will continue to be bothered, and floaters can be very symptomatic. Patients with eye floaters often say they feel like they are under water, and the floaters disrupt their vision when reading and driving. When patients have symptoms for more than six months, we may consider surgical treatment to remove the vitreous gel and the floaters in it.”

“Surgery for eye floaters is called a pars plana vitrectomy,” Dr. Kumar explains. “It is essentially a laparoscopic surgery performed through three small ports in the eye. We use one port to infuse the eye with fluid. The other two ports are for a light and an instrument that operates like a sophisticated vacuum. It is used to clear out all of the vitreous gel in the back of the eye.

Photo by Nerissa Johnson.

S.K. Steven Houston III, MD

“The infusion we use is a balanced salt solution that helps replace the vitreous gel during surgery. Over time, the eye naturally starts to create aqueous, which is the fluid that fills the front cavity of the eye. Aqueous begins to fill the back cavity of the eye after the vitreous is removed.”

“The vitreous gel really only serves one purpose early in life, before patients have their natural lenses removed due to cataracts,” Dr. Houston reveals. “Vitreous acts like an oxygen free radical. It prevents the natural lens from getting too much oxidation, which causes cataracts. It does no harm to the eye to have the vitreous removed after the patient has had cataract surgery.”

Vitrectomy is an outpatient procedure. Patients have the surgery and go home the same day. It is performed while the patient is lightly sedated, but awake and breathing on their own. Once the patient is sleepy from the anesthesia, the ophthalmologists numb the eye and perform the mini-laparoscopic surgery. It takes 15 to 30 minutes to complete.

“Following vitrectomy for eye floaters, the patient’s vision typically goes back to normal or better within three days of the procedure,” Dr. Kumar assures.

Fortunately, most eye floaters are of the harmless variety that go away on their own over time. That was true in George’s case. While he found his eye floaters distracting at first, they didn’t impact his vision or quality of life enough to warrant vitrectomy. With time, George’s eye floaters simply floated away.

*Patient’s name withheld at their request.
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    • Florida Retina Institute

      Founded by James A. Staman, MD in 1979, Florida Retina Institute has 19 locations throughout Central Florida, North Florida, and Southeast Georgia. They have proudly delivered Excellence in Vitreo-Retinal Diseases and Surgery for 40 years. T... Read More

    • Jaya B. Kumar, MD

      Jaya B. Kumar, MD, is board certified by the American Board of Ophthalmology and the National Board of Medical Examiners. She earned a bachelor of science degree in the Honors Program and a Doctor of Medicine degree at St. Louis University in S... Read More

    • S.K. Steven Houston III, MD

      S.K. Steven Houston III, MD, is board certified by the American Board of Ophthalmology. He earned a Bachelor of Science degree in Materials Science and Engineering from the University of Florida and a Doctor of Medicine degree from University o... Read More