“Eye care should be attentive to finding ways to try and reduce the burden for patients”
In a roundtable discussion, hosted in partnership with VivaQuity, OT investigates how floaters are managed in practice, and explains the research behind a daily supplement that could have significant benefit for patients’ quality of life
While floaters can be debilitating, many optometrists will be acutely aware that discussing treatment with patients is not always straightforward – whether because of cost, hesitation around seeking private treatment, or the potential side effects of surgery.
- Dr Frank Eperjesi, optometrist and EyeTools co-founder
- Dr Scott Mackie, optometrist and owner of Mackie Opticians, a Hakim Group practice
- Dr Thomas Kaercher, ophthalmologist in Heidelberg, Germany
- Professor John M Nolan, Nutrition Research Centre Ireland (NRCI) at South East Technological University (SETU).
During a roundtable hosted in partnership with VivaQuity, OT speaks to two UK optometrists about their current management of floaters in practice, discusses experiences of the VitroCap N with a German ophthalmologist, and hears from a vision scientist from the Republic of Ireland about the years of research that have gone into confirming the supplement’s viability.
Identifying vitreous floaters in the testing roomIn Scotland, Dr Scott Mackie finds that he rarely goes a day without encountering a patient who is being troubled by floaters – in fact, he identifies around 10 instances of posterior vitreous detachment (PVD) every week. He initially asks the question as part of his routine history and symptoms, and follows up by identifying how much the floaters impact on quality of life.
“I move on to ask if their floaters are getting worse, regarding duration or intensity,” Mackie, owner of Mackie Opticians, explained. “I ask when it troubles them the most. I would always cut it down to day driving or night driving. Night driving with floaters is a nightmare.”
Thankfully for Mackie, coming across a retinal detachment is much rarer than it is a PVD – allowing quality of life to be the main discussion point. As well as night driving, he sees reading as something that can be vastly impacted by floaters. He demonstrates the effect that floaters are having via a low contrast chart, which he finds “a bit of a game changer” for patients.
The Scottish requirement to dilate every patient means that Mackie sees more floaters than he might in another location – especially in myopes, as the vitreous starts to deteriorate after the age of 21.
It’s incumbent on the optometrist to further pursue and ask questions of the patient who says they have floaters
In the West Midlands, optometrist Dr Frank Eperjesi finds that floaters tend to present in one of two ways: the patient identifying the condition themselves and seeking out help, or, like Mackie, through history and symptoms.
In the first instance, Eperjesi moves on to identifying whether the patient has a retinal tear or detatchment, or whether there is one impending.
“When they present and volunteer that information, I get concerned, and obviously that opens up a whole raft of tests that I would do,” he explained.
When floaters are discovered via history and symptoms, Eperjesi said, “I further investigate that by asking, ‘How long have you noticed them for? Do you have many of them? Do they trouble you in your everyday life?’”
He believes that the VitroCap N can provide a treatment option for those patients who are troubled by floaters, but do not have a retinal tear or PVD, where there might not have been a solution previously.
“Because now we’ve got VitroCap N available, there’s a possibility of treating those people whose quality of life is affected by their floaters,” Eperjesi said. “That’s not something I used to ask much in the past, because, other than Vitreolysis or vitrectomy, there really wasn’t anything available for a person who had floaters that were troublesome to them.
“Now there is this alternative, I think it’s incumbent on the optometrist to further pursue and ask questions of the patient who says they have floaters,” he added.
The FLIES study in context: key numbers
- Over 20: how many years Professor John M Nolan and colleagues at the Nutrition Research Centre Ireland have been working on how targeted nutrition can be beneficial to the eye, particularly with regards to macular degeneration
- Four: the number of observational studies that had taken place across Europe before UK-based research began
- Six: years since optometrist Emmanuel Ankamah joined the Nutrition Research Centre Ireland research team to start his PhD investigating the nutrition of the vitreous
- 300: the number of patients screened ahead of the FLIES study
- 60: the number of participants who were recruited onto the trial, after the impact of floaters on daily life, functional data on the size of floaters, and measures of visual function were gathered
- 50%: the percentage of participants who were given the VitroCap N active intervention versus the number who were given a placebo
- Six: the number of months taken to see a benefit to those taking VitroCap N in terms of how they felt in their daily life, their contrast sensitivity, and the size of their floaters
- 20%: the average shrinkage of floaters in 70% of patients taking the VitroCap N
- 70%: the published success rate of the FLIES study.
Making the case for capsulesAlthough Eperjesi believes that the VitroCap N will allow him to treat his patients in a different way, he still raises a note of caution around persuading patients to invest in the treatment.
Making the tangible benefits to the individual’s day-to-day life clear is key, he said: “In my mind, either they have to volunteer that there is trouble in their everyday life, or have it pointed out to them through a thorough history and symptoms and low contrast sensitivity charts.
“In my experience, people don’t buy into something unless they’re going to get some benefit. And so, I need to point out to them the potential benefits of using something like VitroCap N. I think it’s important to find out why that person would invest that time and money,” he added.
Mackie would like to be able to give his patients more information on the side effects of the capsules, especially because he believes that patients are already wary of taking oral tablets when prescribed by an optometrist. This is something he has seen during his time as an independent prescriber.
“One of the blockers is that, the minute you prescribe oral drugs instead of those for eyes, there’s a bit of ‘hold on a minute here’,” he explained. “People want to know what the side effects are.”
With a preference for “conservative management” over “something as invasive as surgery,” Mackie finds it helpful to balance the pros and cons of oral treatments when discussing with patients.
“There are a couple of points that you have to discuss with people,” he said. “One thing we should let people know is the daily recommended limit. If you look at the daily recommended limit for zinc, or for vitamin C, the tablets are well within that, for men and women.”
He added: “You have to discuss that. You have to say to people, ‘if you do get any side effects, if you get a headache, if you get diarrhoea, then you stop, like [you would with] anything else.’”
In Germany, ophthalmologist Thomas Kaercher finds that his patients expect a full explanation of the treatments that they are being offered, whether therapeutic cleanses, surgery, laser, or micronutrients.
“We know that floaters are not limited to a certain period, let’s say one week or so like conjunctivitis,” he said. “It’s a longer-lasting, repetitive process. Some floaters disappear. Others reappear, often in an area of around four cubic centimetres. Four fifths of the eyeball is filled by the mitral, so this is a huge amount of tissue. In this tissue, a lot of metabolism occurs and causes those problems. We must not overwhelm the patient with this knowledge, but show them what this metabolism is like, and explain properly that it’s a long-lasting process, so they fully understand our therapeutic approaches.”
He shared a recent scientific paper, in which an elderly gentleman with Parkinson’s had tried to remove his floaters with water, causing erosion of the cornea.
“This indicates how severely affected the patient can be,” Kaercher said. “Not realising that the floater is inside the eye can cause injuries. This gives us good impression of how the patient feels. We should modify and correct this wrong impression.”
We must not overwhelm the patient with this knowledge, but show them what this metabolism is like, and explain properly that it’s a long-lasting process, so they fully understand our therapeutic approaches
Incorporating into optometry practice
Eperjesi said that the key message he will take away from the FLIES study is the improvement in quality of life that VitroCap N can give to patients – and he hopes that optometrists will engage with the science to such an extent that they do not feel like they are ‘selling’ when they recommend the micronutrient to patients.
“You can improve a person’s quality of life by advising them to use VitroCap N,” he said. “I think that’s a big message. When I go to a restaurant and have a great experience, I share that with my friends. I don’t look on that as I’m selling them anything. I look on it as sharing a positive thing that I experienced, and I think they’ll get some positivity if they experience it as well.”
He added: “Optometrists sometimes say, ‘I’m not a salesperson, I’m not selling tablets, I’m not selling glasses. I’m a clinician.’ But we need to try and get beyond that and focus on the quality of life. That’s a big message: that they will be doing the right thing for a large proportion of their patients who are struggling with floaters.”
You can improve a person’s quality of life by advising them to use VitroCap N
Mackie agrees that quality of life needs to be the point that is emphasised to patients. In paying for the capsules, he suggests setting up Direct Debits – something that he has found beneficial, in general terms, in his practices.
“We give them six months of tablets up front, and they’re always paying in arrears, because you don’t want a patient coming in, trying it for a month, and saying it didn’t do anything for them and that’s enough,” he explained. “You’ve got to set them up properly. I think the science speaks for itself. I think it’s how you then take that and go forward with it.”
Nolan wants to stress that the micronutrient is “not a silver bullet at this point in time,” but rather something that patients need to understand the value of complying with.
“It represents a lifestyle change,” he said, adding that “you have a very easy experiment every time a patient makes the decision following the information you give them to try this. If it doesn’t work, they’ll stop doing it.
“But what we’re seeing is, that’s not the case. The people in the trial have stayed on it, and the people that have tried it after a recommendation from their clinic have stayed on it too.”
He added: “Out of all my work, the communication that I’ve had personally from patients because of the benefit that they’ve seen [from the VitroCap N] has been phenomenal.
“The patients know a lot about this now. Eye care professionals have a duty of care to be alert, because people who are suffering do their own research. They want to know. So, I think it’s a new approach, even in eye care: a patient-led discussion. They want to know about it, and they want the information.”
You’ve got to set them up properly. I think the science speaks for itself. I think it’s how you then take that and go forward with it
Using research in practice
Nolan emphasised that peer reviewed sites that “represent science conducted by people who have an expertise in, in our case, the measurement of vision, and are performing human clinical studies” with “an original research question” are more trustworthy than white papers provided by companies.
“To answer a question, we conduct an experiment, obtain the data, analyse it independently, and report and discuss its findings,” he said. “That's the context of what a scientific paper should be.”
He added: “If that paper is valid, the independent experts that perform the peer review will critique it, and will make recommendations to improve it. Once you get through that process, you end up with a scientific publication.
“In general terms, I would really stress the importance of the eye care community to be alerted to peer reviewed science and to trust that type of science.”
Experiences of VitroCap N
With a decade of experience prescribing the VitroCap N to patients, Kaercher believes that starting the treatment early is key. “When I first see a patient presenting with floaters, I prescribe it for a period of three months,” he said.
He emphasised the importance of observing the retina for any change, degeneration or tear, throughout the course of treatment, to ensure patient safety.
Mackie believes that discussion is essential, including ensuring that the patient knows that floaters are a different condition to PVDs or retinal tears, and that this is on their record card. He also plans to discuss preventative measures, and to take measurement of low contrast sensitivity both when prescribing VitroCap N and after six months, in order to tangibly highlight the difference the supplement is making.
He said: “It’s all to do with the way that you discuss it. Discussion is so important to the patient. Make sure they get it. Give them the information leaflet, and let them reflect on what you’ve said. It doesn’t need to be the hard sell there and then.”
Mackie is confident that he has done his due diligence and is ready to start using VitroCap N in practice. “We’ve got 20 patients who are complaining about floaters,’ he said. “So, now that I know much more about it, let’s start.”
Patient usage is the only way to spread the message that the treatment works, Mackie believes: “Peer review is great, as of course is double blind placebo – it's fantastic; it’s gold standard. But let’s now find some real patients, who’ve had real advantages.”
One such patient is Nolan himself, who experienced floaters in his left eye after an incident in the sea in Hawaii. His floaters appeared one morning whilst playing tennis, which led his wife to suggest he start taking his own medicine.
He did, and has now been taking VitroCap N for a year. “I won’t come off them, because I disliked floaters so much. I would hate that to happen again. So, I take them every day,” he said.
He added: “This is a targeted, safe, tested micronutrient, that I will make part of my supplement usage as I move through my years.”
Future questions for the research team: “Any time you do a research study and answer a question, you create 20 more questions”
Nolan admits that, while the FLIES study’s results are strong enough to make recommending VitroCap N to the optometry profession safe, there are now other questions that his team hope to answer. Indeed, research on some of the following has already begun:
- What happens after six months?
- Why might some patients not respond to VitroCap N? Is it related to the severity, or whether or not they already have a PVD?
- How do the micronutrients of the vitreous change following intervention?
- What happens if dosages are increased?
Nolan said: “There’s a significant amount of work to be conducted, from this point forward,” emphasising that every time discussions or critiques are given to research “you have a new goalpost.”
He added: “We have a lot more to do, but we’ve enough now to start making safe recommendations to benefit patients – and we should do that.”