An Interview with Dr. Johnson

Dr. James Johnson works from his office in Irvine, California. Compiled by Kelly Garrison

What exactly happens floaters to that are lasered?

The YAG laser emits the beam in a cone-shaped pattern. At the apex (or tip) of the cone, there is a concentration of energy. Using focusing lights, this apex is directed onto the front surface of the floater material.

The laser "shot" lasts 20 to 30 nanoseconds (0.000000030 seconds), and at that moment the concentrated laser light creates a small plasma bubble.

Plasma is the fourth state of matter, the first three being solids, liquids and gas. Matter that has been converted to plasma has the electrons pulled away from their usual location and creates a high-energy state of the matter. This process actually converts the floater material to a micro-gas bubble that floats away.

It is important to understand that the laser does not break the floater into small pieces, but actually changes it to a gas. The gas is reabsorbed into the bloodstream over the coarse of several hours.

What determines how many floaters can be removed during the procedure?

Time, location, and total energy. For longer treatments, I am working against the clock. After 30 to 45 minutes, I'll notice that the laser shots are becoming less effective, probably in part due to a little swelling (or edema) of the cornea. In addition, floaters that are too close to the retina or lens may not safely be treated.

During the treatment, I monitor the energy of each shot, as well as the total energy used during the treatment and keep it within a certain range.

How do you prevent the patient from moving his/her head during surgery?

There is a head strap on the laser that snugly holds the head in place. In addition, a hand-held contact lens stabilizes the eye quite well. The combination allows me to focus on objects that are very small with great accuracy. Sedatives are available to patients who think they may not feel comfortable sitting still for a prolonged period of time.

What short and long term complications or side effects is the patient at risk for? What are the odds of these complications?

Short Term: dilation of pupil, corneal swelling, occasional discomfort (mild to moderate) from the corneas being a little scuffed up from the contact lens. I have not witnessed any rise in eye pressure but that is a potential problem.

I continually monitor and remain aware of the location of my treatment, and avoid aiming near the lens or retina. A misfired shot could conceivably cause a cataract formation or injury such as bleeding from the retina or damage to the receptors. There have not been any documented cases of loss of vision, but we must state that possibility.

How should a patient prepare for laser surgery of floaters? What type of exam(s) are needed in advance?

A complete eye examination should be completed prior to any laser treatment. Most people come to us already with the diagnosis of floaters after an exam that includes a dilating the retina to ensure that there is no retinal detachment or area at risk for same. I also perform or repeat this exam prior to any laser treatment.

Are there cures for all of these potential complications? Which, if any, would have no remedy?

If a cataract were to develop, the patient might need cataract surgery. If the retina were hit in the periphery, it would not likely be noticed, but if it were hit in the center of the vision (in the macula) there could conceivably be a decrease in visual acuity. None of these have been reported yet.

Can an ophthalmologist train to become a specialist in vitreous issues? Are there resources available to obtain credentials for this type of expertise?

Currently, there is no official or unofficial training or courses for Laser Vitreolysis techniques and applications. There is, though, a Vitreo/Retinal subspecialty of ophthalmology. These specialists perform vitrectomy procedures.

In our residency training, there is a supervised training and certification on the YAG laser. General ophthalmologists may use this laser hundreds of times in the course of a year.

Usually the laser is used for anterior segment procedures, namely, Capsulotomies and Iridectomies. The use of the laser in the vitreous is an adaptation of a laser we are already familiar with.

What are a patient's odds of seeing significant improvement? No improvement?

So far, every patient that I have treated has described about an 75-90 percent improvement on the first treatment. Most patients will need a second (and sometimes third) treatment to clear up most of the rest. There have been a few patients that have such thin, transparent floaters that I wasn't even able to see them, and so I could treat them.

What kind of health insurance coverage can I expect for the surgery?

There is a recognized insurance procedure code (CPT 67031) for Laser Vitreolysis. Most major insurance providers should reimburse for most of the procedure. Currently, I am not participating with any insurance providers, but I do provide support documentation so patients can submit the invoice to their insurance carriers. It is advised to contact the carrier first to see if they will pay for the procedure.

How does your procedure compare to that of floater treatment specialists, Dr. Geller (Florida) and Dr. Karickhoff (Virginia)?

The procedure and experience should be very similar with all three. We do have different lasers, but that is just a technical difference and personal preference.

What is your hope for the future of floater treatment? How can the doctors, the public and floaters sufferers best help the cause?

Eye care professionals can be collectively blamed for not listening to patients and taking the floaters seriously. If we did, there would be. We have always considered it adequate to pronounce the eye as healthy, and send the patients on their way. I am more attuned to how people suffer these floaters - usually suffering in silence because no one wants to take them seriously.

I am looking into better ways of locating and documenting the floaters, possibly with B-scan ultrasound or better yet, Ocular Coherent Tomography. The optics of lasers were designed for working on the anterior portion of the eye, and it is difficult to deliver the laser to the periphery of the eye. Maybe someday there will be a nontoxic way of enzymatically removing the floaters. Until then, Laser Vitreolysis is an attractive, noninvasive alternative to a much more aggressive Vitrectomy procedure.

It is really exciting to be on the cutting edge of a newer treatment. I do want to thank doctors Geller and Karickhoff for being the true pioneers and establishing the credibility and success for this procedure. It is incredibly rewarding to help these patients, in some ways even more so than our LASIK patients since some of our floater patients are on the border of functional disability. I am promoting this part of my practice slowly and cautiously so as to maintain it's credibility. The biggest obstacle will be convincing other eye care specialist that it is a legitimate treatment so they can help refer their long suffering floater patients.

James H. Johnson, MD
American Board of Ophthalmology Diplomat
Orange Coast Laser Vision Center
2646 Dupont Drive, Ste. 270
Irvine, CA 92612
(949) 251-1497
Fax: (877) 83-LASIK
Info [at] OCLaserVision.com
www.GotFloaters.com