I don’t think my doctor saw the floater. How is that possible?

I am often contacted by potential patients prior to them coming out for an evaluation or examination. There are a few screening questions that I will ask to at least place them in some category as far as the potential treatability of that patient. The age grouping is probably the most important. Another question is whether they have had a local eye examination and if so, did the Doctor describe anything that sounded like a posterior vitreous detachment. Another line of questioning with highly variable answers is the question as to whether the local examining doctor actually saw the floaters. This sounds like a very straightforward and simple question but I assure you that it is not.

I have yet to see or hear of an ophthalmology training program or medical textbook that emphasizes the diagnosis of simple eye floaters. There is plenty of time devoted to pathological conditions that can cause floaters such as proliferative diabetic retinopathy, vitreous hemorrhages , inflammation, etc. but generally, it appears that the common practice is to simply rule out the pathology and then comfortably declare the diagnosis of floaters. This means that when your doctor told you that you have eye the floaters, they may or may not have actually seen the culprit floaters responsible for your symptoms – even though they competently made the diagnosis. How can that be? Is that even ethical?

fig. 1 The ability to see the fence in the foreground depends on the depth of focus, the aperture of the lens and the focal point.

Optics are a funny thing sometimes. The eye floater sufferer may or may not see their floater, or they may see it to varying degrees of distress depending on the ambient lighting, the size of the pupil, whether they are looking at a bright plain background or a busy distracting one, etc. similarly, the examining eye doctor may or may not see a prominent floater based on the instrumentation and lenses they are using as well as where their plane of focus lies. The ophthalmoscopes and examining lenses used in ophthalmology are designed to focus in the focal plane of the retina. Much like the example in figure 1 where the photographer is shooting through a chain-link fence.

So a patient presents to their local eye doctor’s office with the concern over their new “moving shadows” in their vision. The doctor, upon reading the complaint on the chart, is thinking “probably floaters” but is obligated to find or rule out any significant pathology of the retina or other structures of the eye. Using retina-examining lenses and scopes, they look right through the “chain link fence”, that is, right through and past the eye floaters. They simply may not see, or may not be particularly impressed by the floaters that they do see. It happens all the time. Thinking back to when I was a general ophthalmologist, I can not really remember any particularly impressive eye floaters and yet I’m sure I had many patients suffering them. I do not criticize the other doctors, but I do believe the profession itself and its dogma have generally missed the boat when it comes to recognizing the significance of eye floaters.

So when you think back to your frustration when you left the eye doctor’s office and were wondering why the doctor did not seem interested, it was more likely optical reasons rather than not caring about your conditions. – Dr. Johnson

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