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Ultra Q Reflex Offers a New Floater Strategy

BY STUART MICHAELSON

Just as music fans otherwise uninterested in jazz may own the classic Kind of Blue album by Miles Davis, many people who don’t know Latin are familiar with primum non nocere … or at least with its English translation: “First, do no harm.”

Andrew Merkur, MD, a retina specialist at the University of British Columbia in Vancouver, applies that philosophy to floater treatment. A new component, Ultra Q Reflex, marketed by Ellex, Inc., of Minneapolis, MN, previewed at the 2012 American Academy of Ophthalmology. Ellex markets it as the only YAG laser designed specifically for treating floaters. Approved indications are posterior capsulotomy, iridotomy, and posterior membranectomy (including Nd:YAG laser vitreolysis). It is approved in the United States, Europe, and Canada, where its use for vitreolysis started this year.

“Given an existing problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good,” says Dr. Merkur, who is currently evaluating the Ultra Q Reflex in a trial of YAG laser vitreolysis for patients with highly symptomatic floaters who would otherwise undergo incisional vitrectomy.

TOLD TO LIVE WITH THE PROBLEM

Vitreolysis, a painless outpatient procedure involving a nano-pulsed ophthalmic YAG laser to vaporize strands and opacities, is one of four treatments for floaters: the others are vitrectomy, enzymatic or chemical vitreolysis (experimental), or no treatment at all. Patients with floaters, Dr. Merkur says, are often thought to be exaggerating or manifesting anxiety or depression as physical symptoms, and ophthalmologists often tell patients to accept them. Definitive treatment, for severe cases, is incisional vitrectomy.

Dr. Merkur says that, during his training, YAG laser vitreolysis was considered a “fringe” treatment. He offers small-gauge vitrectomy surgery only for incapacitating symptoms and reduced vision, which amount to fewer than two among 300 surgeries annually.

Dr. Merkur’s interest grew from “a concept of releasing internal vitreoretinal traction on retinal tears via YAG laser vitreolysis.” A patient, despite having argon barrier laser photocoagulation treatment for a horseshoe tear retinal detachment, showed signs it was progressing. YAG laser vitreolysis released the internal vitreoretinal traction with subsequent spontaneous retinal reattachment.

STUDY, EVALUATIONS SCHEDULED

This success spurred his upcoming study by the University of British Columbia research ethics board. Pre- and post-treatment evaluation by OCT, ultrasound, and biomicroscopy will be performed, and a placebo arm will have the laser beam focused on a contact lens with a central 100% opacity. Participating patients will not pay for the procedure, which costs about $2,000 per eye.

Dr. Merkur finds the proprietary slit-lamp illumination tower design of the Ultra Q Reflex user-friendly, allowing for convergence of the user’s vision, slit lamp beam, and the He:Ne laser focus beam onto the same optical pathway; its off-axis viewing, useful for YAG capsulotomies and iridotomies; and the Reflex Illumination mirror, which allows the operator to deliver YAG laser treatment coaxially and in off-axis positions and which quickly moves out of the way during laser beam firing.

Dr. Merkur says that, for patients with highly symptomatic floaters, “YAG laser vitreolysis will likely be the safest treatment modality,” adding, “there will be a small subset of patients in whom only surgical intervention will be efficacious. “ RP