Long-Term Outcomes Following Complete Pars Plana Vitrectomy for Symptomatic Vitreous Floaters in Young Patients

1. Introduction

Vitreous floaters are a common ophthalmic complaint, appearing as mobile opacities in the vitreous cavity. While usually considered benign, floaters can impair vision and quality of life even when best-corrected visual acuity (BCVA) is preserved [1,2,3]. Floaters are prevalent in the general population, but only a minority seek care due to varying symptom severity [1]. Traditionally, patients with symptomatic floaters are reassured that symptoms will improve over time—often through neuroadaptation or gravitational settling. However, recent studies show floaters can persist for years and remain highly troublesome, especially for younger people and those with high visual demands [4,5,7]. The subjective burden can be significant, sometimes rivalling that of chronic retinal disease, even when BCVA changes are minimal or absent [2,6]. Pars plana vitrectomy (PPV) is widely considered the most effective treatment for symptomatic vitreous floaters. However, vitrectomy in otherwise healthy eyes remains controversial due to concerns about retinal detachment, cataract progression, endophthalmitis, glaucoma, and other complications. Accordingly, many reports focus on older or pseudophakic patients, while long-term follow-up data remain limited [9,10,11,12]. To reduce surgical risk, alternatives have been proposed, including limited or core vitrectomy (removal of only the central vitreous gel without PVD induction) and Nd: YAG laser vitreolysis (laser disruption of floaters). Despite their use, long-term efficacy and safety are debated, as reports describe persistent symptoms, recurrence, and delayed retinal complications [13,14,15,16,22].

Evidence on vitrectomy for floaters in young patients remains limited. This group presents unique challenges, including a more adherent vitreoretinal interface and predominantly phakic eyes, increasing long-term cataract and glaucoma risks. Younger patients may also bear a disproportionate functional and psychological burden from persistent floaters, with studies linking these to anxiety or depression [4,17,18,19]. This study aimed to evaluate the long-term outcomes and safety of complete PPV for symptomatic floaters in patients younger than 50 years old using a standardized technique and extended follow-up.

2. Materials and Methods

2.1. Study Design and Eligibility Criteria

This retrospective observational study included consecutive patients younger than 50 years who underwent 25-gauge pars plana vitrectomy (PPV) for primary symptomatic vitreous floaters at a single tertiary referral center over 10 years. Inclusion criteria were as follows: persistent symptoms for at least 24 months despite conservative management, and symptoms described by the patient as visually disturbing in everyday life. Surgery was considered only in carefully counselled patients with persistent and clearly disabling symptoms, when the subjective visual burden was judged to be consistent with the vitreous findings on clinical examination.

Eyes were excluded if vitreous opacities were secondary to other active ocular conditions, including vitreous hemorrhage, active intraocular inflammation, ocular trauma, or retinal detachment, or if vitrectomy was performed primarily for another vitreoretinal indication. Eyes with insufficient clinical documentation or inadequate postoperative follow-up were also excluded.

When both eyes of the same patient met eligibility criteria, both were included. Ocular variables and surgical outcomes were analyzed at the eye level, whereas demographic and non-ocular variables were recorded at the patient level when applicable.

2.2. Preoperative Assessment

All patients underwent a comprehensive preoperative ophthalmic evaluation, including best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, refraction, intraocular pressure measurement, and dilated fundus examination with peripheral retinal assessment. Symptom duration was recorded in months based on patient history. The presence or absence of posterior vitreous detachment (PVD) was assessed preoperatively during clinical examination.

Because of the retrospective design, the psychological burden associated with vitreous floaters was assessed using routine chart information rather than validated psychometric instruments. Specifically, self-reported anxiety or depressive symptoms attributed to vitreous floaters and the use of anxiolytic or antidepressant medication were recorded when documented in the medical record.

2.3. Surgical Procedure

All procedures were performed by the same experienced vitreoretinal surgeon (G.B.) using a standardized 25-gauge PPV technique. Triamcinolone acetonide was used intraoperatively to assist visualization of the posterior hyaloid. In eyes without a pre-existing PVD, active PVD induction was systematically attempted and achieved. Complete vitrectomy was then performed, including meticulous vitreous base shaving.

The peripheral retina was routinely inspected intraoperatively. Endolaser photocoagulation was applied in the presence of pre-existing retinal breaks, suspicious peripheral retinal lesions, or iatrogenic retinal tears. Air tamponade was used in all eyes with retinal breaks and, in selected additional cases, at the surgeon’s discretion. Combined phacoemulsification with intraocular lens implantation was performed only when clinically necessary.

2.4. Postoperative Follow-Up and Outcomes

Postoperative follow-up visits included BCVA assessment, slit-lamp examination, intraocular pressure measurement, and dilated fundus evaluation. Final follow-up was defined as the last documented postoperative visit.

The main outcome measures were change in BCVA from baseline to final follow-up, occurrence of rhegmatogenous retinal detachment, and need for reintervention for recurrent or persistent symptomatic floaters. Secondary outcomes included endophthalmitis, macular hole formation, visual field defects, new-onset glaucoma or changes in intraocular pressure-lowering therapy, cataract progression requiring surgery, and the presence of residual visually disturbing vitreous opacities.

2.5. Statistical Analysis

This was a descriptive, non-comparative study. Continuous variables are reported as mean ± standard deviation or median with range, as appropriate. Categorical variables are presented as frequencies and percentages. No formal inferential testing was performed.

3. Results

3.1. Baseline Characteristics

Eighty-nine eyes from 45 patients under 50 years who had pars plana vitrectomy for symptomatic vitreous floaters were included. The mean age at surgery was 37.0 ± 7.0 years; the median was 38 years (range, 24–48). Of these, 59.6% were younger than 40. Baseline demographic and preoperative characteristics are summarized in Table 1.

The median symptom duration before surgery was 32 months (27–48), indicating had not spontaneously resolved before surgery. Preoperative BCVA was generally preserved. In the majority of eyes, BCVA was unaffected by vitreous floaters; reduced acuity was observed only in eyes with pre-existing conditions such as high myopia or amblyopia. Only one eye exhibited a clinically meaningful BCVA reduction directly attributable to a dense central vitreous opacity.

Refractive status was mostly mild myopia. At surgery, most eyes were phakic (80/89; 89.9%), allowing long-term lens status assessment in this young group. Self-reported anxiety or depressive symptoms related to vitreous floaters were reported in 39.3% of cases. Use of anxiolytic or antidepressant medication was found in 24.7% of cases.

3.2. Intraoperative Findings

A minority of eyes had undergone previous treatment for vitreous floaters before referral. Seven eyes (7.9%) had a history of prior vitrectomy, all of which were partial procedures without complete vitreous removal. Ten eyes (11.2%) had previously undergone Nd:YAG laser vitreolysis without satisfactory symptom relief. All these eyes subsequently underwent complete PPV because of persistent or recurrent symptoms, in keeping with reports suggesting variable efficacy and a non-negligible complication profile for vitreolysis [14,15,16,22].

An air tamponade was used in 76 eyes (85.4%), including all eyes with identified retinal breaks. Intraoperative characteristics are summarised in Table 2.

3.3. Postoperative Outcomes

Median follow-up was 60 months (range, 58-72). BCVA remained substantially stable from baseline to final examination (mean change, +0.03 logMAR). No clinically significant visual acuity loss attributable to surgery was observed. The only eye with a preoperative reduction in BCVA caused by a dense central vitreous opacity showed marked postoperative improvement. Postoperative outcomes are summarised in Table 3.

No cases of rhegmatogenous retinal detachment were observed during the entire follow-up period. Major postoperative complications were infrequent and included one case of endophthalmitis (1.1%), one case of macular hole formation (1.1%), and two cases of permanent visual field defects (2.2%) related to intraoperative optic nerve touch during PVD induction. No eye required reintervention for recurrent symptomatic floaters or other postoperative complications.

No increase in glaucoma treatment requirement was observed during follow-up. No visually significant cataract requiring surgery was documented during the available follow-up. Although some patients occasionally reported perception of small residual dots, none described residual floaters as visually disturbing and no further intervention was required.

4. Discussion

This study provides long-term data on pars plana vitrectomy for symptomatic vitreous floaters in a distinctly young population, a group that remains underrepresented in the literature. The prolonged preoperative symptom duration in this cohort suggests that spontaneous resolution cannot be assumed in all young patients with visually significant floaters. In our cohort, the BCVA assessment could not detect any alterations before surgery. Our findings suggest that, in carefully selected eyes, complete vitrectomy with PVD induction may offer durable control, with a low incidence of major long-term complications. However, the occurrence of endophthalmitis, macular hole, and permanent visual field defects in a small number of cases demonstrates that this procedure is not trivial and should not be considered risk-free.

Interestingly, in the present series, patients showed a long duration of symptoms before surgery. Therefore, it supports the idea that resolution cannot be assumed in a substantial proportion of young patients. This is important because reassurance based solely on expected neuroadaptation may fail to reflect the lived experience of patients with persistent vision-degrading myodesopsia. Prior evidence has questioned the traditional assumption that floaters predictably become negligible over time, and more recent literature on young and myopic patients suggests that myopic vitreopathy and incomplete posterior vitreous separation may contribute to chronic, relatively stationary symptoms with limited spontaneous remission [4,20,21,28]. Our cohort is consistent with that interpretation and supports the view that persistent floaters in younger individuals may represent a genuine long-term functional disorder rather than a transient nuisance.

As in most prior series, preoperative BCVA was preserved in nearly all eyes and remained unchanged after surgery. This should not be interpreted as a lack of efficacy. In symptomatic floater patients, conventional high-contrast visual acuity has an intrinsic ceiling effect and does not sufficiently reflect the visual degradation caused by mobile vitreous opacities. The functional burden of floaters has been more closely linked to reduced vision quality, impaired contrast sensitivity, reading difficulty, and lower quality of life than to a measurable loss of Snellen or logMAR acuity [5,6,7]. The systematic review and meta-analysis by Dysager et al. further support this concept, showing very high postoperative satisfaction and measurable improvement in contrast sensitivity despite only modest average gains in BCVA [24]. Within that framework, the stability of BCVA in our series is entirely compatible with meaningful clinical benefit.

The age profile of the present cohort deserves particular attention. Most eyes were phakic, and many patients were younger than 40 years, allowing us to examine lens status in a setting where concern about cataract progression often discourages surgery. In the current series, no visually significant cataract requiring surgery developed during the available follow-up. This contrasts with pooled estimates from broader mixed-age cohorts, in which cataract is the most frequent postoperative event and occurs in approximately one-third of cases [24]. The difference is likely multifactorial and may reflect younger patient age, differences in baseline lens status, and the inherent limitations of comparing a single-surgeon retrospective series with meta-analytic data derived from heterogeneous studies. Nonetheless, our findings are in line with previous reports suggesting that lens progression after vitrectomy is strongly age-dependent and that cataract formation in young phakic patients may be considerably less frequent than is often presumed [10,11,12].

The absence of rhegmatogenous retinal detachment in this study is also noteworthy. In the 2022 meta-analysis, the pooled risk of retinal detachment after vitrectomy for floaters was approximately 1.5%, with retinal tears or breaks reported in nearly 3% of cases [24]. More recently, Karunatilake et al. reported an overall complication rate of 7.3% in a real-world series of 410 eyes, with retinal detachment representing the most common complication at 2.4% [25]. Against that background, the lack of postoperative retinal detachment in our cohort compares favorably with the published literature. However, this finding should be interpreted cautiously. Our sample size remains limited for rare events, and the absence of retinal detachment cannot be taken to mean that risk is negligible. Rather, it suggests that meticulous peripheral retinal inspection, prompt treatment of identified breaks, and a standardized surgical technique may help reduce this complication in selected patients.

The surgical strategy used in the present study differs from the more conservative approaches sometimes advocated for floaters. All eyes underwent complete vitrectomy, including PVD induction when necessary and careful vitreous base shaving. Limited or core vitrectomy without PVD induction has been proposed to reduce iatrogenic traction, but concerns remain about residual opacities, recurrent symptoms, and late vitreoretinal events if tractional interfaces are left in place [13,15,16]. In our cohort, no patient required reintervention for persistent or recurrent visually disturbing floaters, and treatment failure before referral was not uncommon, including cases after partial vitrectomy and Nd:YAG vitreolysis. The results support the idea that incomplete vitreous removal may be insufficient in a subset of highly symptomatic patients. At the same time, our data also make clear that complete surgery has its own hazards: two permanent visual field defects related to optic nerve contact during PVD induction and a single postoperative macular hole, indicating that surgical completeness should not be pursued without adequate expertise and careful intraoperative judgment.

The role of Nd: YAG vitreolysis remains especially relevant when discussing alternatives to surgery. Although laser treatment is commonly viewed as a less invasive option, the quality and consistency of the available evidence remain inferior to those for vitrectomy. Su et al. concluded that laser vitreolysis is not yet ready for broad adoption because long-term safety and efficacy data are insufficient, and published reports have documented complications that are probably underrecognized in routine practice [22,27]. In the present series, several eyes had previously undergone Nd: YAG vitreolysis without satisfactory relief and later required complete PPV. While our study was not designed to compare treatment modalities, this experience is consistent with the view that vitrectomy remains the most definitive option for severe and persistent symptomatic floaters when patient selection is rigorous.

Another important aspect emerging from this study is the psychological dimension of symptomatic floaters. Nearly 40% of cases were associated with self-reported anxiety or depressive symptoms, and approximately one quarter were associated with regular use of anxiolytic or antidepressant medication. Although these data were not collected with validated psychometric instruments, they are consistent with previous studies showing that symptomatic vitreous opacities may carry a substantial psychological burden [17,18,19]. This issue has real consequences for patient selection. The recent BEAVRS survey showed that the quality of life is the criterion most consistently used by vitreoretinal surgeons who offer floaterectomy, whereas other factors, such as symptom duration, visibility of opacities on examination, and documentation of PVD, vary across practices [26]. Our findings support a similarly individualized approach: surgery should be reserved for patients with persistent, clearly disabling symptoms, but the psychosocial consequences of floaters should not be underestimated simply because conventional acuity is preserved.

The favorable long-term profile observed in this series must nevertheless be interpreted in light of several limitations. The retrospective design introduces the possibility of selection and information bias; there was no control group, and postoperative benefit was not quantified with validated patient-reported outcome measures or contrast sensitivity testing. As a result, the present study is better suited to describing long-term clinical outcomes and complication patterns than to measuring the subjective magnitude of symptom relief. In addition, the single-surgeon design improves technical uniformity but may limit generalizability. These limitations are balanced by several strengths, including the relatively large number of young eyes, the predominance of phakic patients, the standardized surgical technique, and the extended follow-up, which is longer than in many previously published series.

Overall, these results support the perspective that symptomatic vitreous floaters in young patients warrant a more thorough clinical appraisal than has traditionally been provided. Persistent symptoms, preserved BCVA, and a relatively normal ocular examination should not automatically result in dismissal of the complaint. In carefully selected young patients with longstanding, visually disabling floaters, complete PPV with PVD induction may offer durable benefit with acceptable long-term safety. Nevertheless, the occurrence of serious, though infrequent, complications in this series highlights the necessity for precise counselling, realistic expectation-setting, and continued caution when considering surgery in otherwise healthy eyes.

5. Conclusions

In young patients, symptomatic vitreous floaters may persist for years and can be associated with substantial functional and psychological burden despite preserved BCVA. In carefully selected individuals, complete pars plana vitrectomy with PVD induction may be a viable option. Our findings emphasize that treatment decisions should remain individualized, as the procedure is elective and not without risk.