A Psychological Perspective of Eye Floaters

Participants

The participants were recruited from among patients referred by ophthalmologists in different areas of northern Italy to the ophthalmology department of a public hospital in the area. The inclusion criteria were developed to attain the best possible heterogeneity of the sample in line with theoretical sampling (Flick, 1998). This method makes it possible to explore the phenomenon in different situations and to choose and enlarge them on the basis of the hypotheses; new situations or cases might be involved according to the new hypotheses to be tested. We chose participants who had different experiences of eye floaters: those who experienced them with or without a corresponding opacity of the vitreous body and those who neither experienced eye floaters nor presented a high opacity of the vitreous body. Finding these patients was easy, and quite soon certain themes became repetitive among them because their stories were similar. Instead, it was difficult to find someone who did not experience eye floaters, even if he or she presented a high opacity of the vitreous body, mainly because these people usually do not resort to consulting an ophthalmologist. Consequently, sampling ended once we found a single such case. At this point, we considered thematic saturation to have been reached (Morse, 1995). In the end, the total number of participants was 11, including 5 men and 6 women aged between 44 and 78 years who had suffered from eye floaters for periods ranging from one month to 50 years prior to the study.

Data Collection

According to the usual procedure of the ophthalmology department, all patients who asked for a consultation underwent an eye examination and echography to assess the opacity of the vitreous body. The aims and methods of the research were presented to them, and they were asked if they wished to participate. Those who accepted completed a questionnaire by providing demographic and clinical data; only some of them, according to the inclusion criteria presented above, were asked whether they wanted to participate in an interview with a psychologist to recount their experiences. If they accepted, they were given an appointment with the interviewer (a researcher specializing in performing clinical interviews) in a clinic within the hospital at a set date and time. Once they had discussed once more the reason they were there and signed the informed consent form, they participated in a semistructured interview (Kvale, 1996) lasting 1 hour.

Although flexible, the interviews followed a common line that focused on the themes we wanted to explore. After a brief general introduction, the interview began with a broad question about the person’s experience with the disorder and went on to explore various topics: When did the eye floaters begin? What happened in that period? When did the person see floaters, and when did he or she not see them? How did he or she explain what had happened? What did other people think? Which solution did the person try? What were the results? What did he or she think of doing? What kind of person was he or she?

The last question opened a way to access the broader area of self-description and allowed the interviewer to deepen the knowledge of the person. The conversation could then continue exploring different areas of the person’s life, sometimes apparently irrelevant to the research aims. The interviewer allowed the people to tell their stories freely, which made them feel more comfortable. Sometimes they needed encouragement, whereas in other cases it was difficult to stop them from talking. In both cases, it was useful to introduce the dependency grid. This is an instrument created within personal-construct psychology to explore how people use their resources to satisfy their needs. It helped the participants in our study to explore an area they might not have explored spontaneously, or to channel an unbroken narration into more defined and relevant fields. In fact, it allowed them to go further into specific anecdotes (in which they would sometimes got lost) and enabled them to reach the point they wanted to reach, as they at times acknowledged themselves.

The participants were asked to list the people who were important to them, which constituted the resources included in the grid columns, and the interviewer added self as the last resource in the grid. In accordance with the traditional version of the grid (Fransella, Bell, & Bannister, 2003; Kelly, 1955), revised to eliminate dated and American expressions (Walker, Ramsey, & Bell, 1988), a list of 23 problem situations (e.g., a time when the participant felt frightened, was lonely, or in poor health) forming the rows of the grid was presented. The person was asked to think of a time when each situation had occurred and to indicate the person or the people (among those indicated by him or her and including him- or herself) that he or she would have gone to for help. The administration of the grid usually opened new fields of conversation, and each interview ended when these had been sufficiently elaborated upon and the person had nothing more to add. The participants usually thanked the interviewer for the opportunity to talk about their experiences, and the interview ended with a short summary of what the interviewer understood of the participant’s experience. This also allowed both sides to verify the general meaning of the conversation and to negotiate it. Interviews were audiotaped and fully transcribed. Ethical principles were adhered to throughout the study. We shared each step of the interview with the participants and informed them of their right to withdraw whenever they wanted. We presented the material anonymously and obtained ethics committee approval.

Data Analysis

We conducted a qualitative analysis of the interviews, guided by the principles of grounded theory (Glaser & Strauss, 1967; Strauss & Corbin, 1998). We did not use the traditional method of theoretical coding derived from grounded theory because we integrated the system of categories developed for each case with a short description of the case and compared groups of cases. Flick (1998) termed this method thematic coding, but he underlined its links with grounded theory. Smith (1997) also suggested that theoretical claims can be derived through case study within a grounded theory approach if, “rather than using the cases to test a pre-existing fully formed theory, with this approach one is attempting to develop a theory on the basis of the material in the case studies” (p. 193).

We conducted a preliminary analysis following each interview and used its results as a guide for the subsequent interviews and to verify the saturation criteria. Therefore, data generation and data analysis proceeded simultaneously. We started the analysis by reading through the interviews to form a general impression. In the second reading, we identified and categorized the central themes. We revised some of these categories in light of the other interviews and included notes and comments. On comparing the similarities and differences between themes, we refined the categories we identified and arrived at the final categories, which we integrated with the results of the other instruments.

We analyzed dependency grids using the GRIDSTAT program by Richard Bell (2002) and considered the following indices derived from literature (Bell, 2001; Walker, 1997): the amount of resources (indicating how many people were significant to the patient); the amount of resources effectively used; the uncertainty index by row and column, which points out the dispersion of dependency, respectively, in different situations and among different resources; and the percentage of choices by column, indicating the dependence on each resource. Integrating these data with those obtained from the eye examination and the echography, we identified the following categories:

The demographic and clinical data derived from the questionnaire were included in these categories, whereas the quantitative analysis of them was being carried out for a larger sample that participated in the survey mentioned above.

Personal Experience

Eye floaters were principally described not as an illness or a disorder but as a nuisance. This turned out to be their distinctive characteristic, as these descriptions by different participants showed: “A nuisance and then it passes”; “It is not like a punch in an eye, which you feel and which hurts you”; “It is a nuisance; it is a nuisance for me when I think of it. If it does not come into my mind, I see it and I don’t worry.” The first participant quoted above underlined the transient nature of his experience; the second one focused on its feature of painlessness; and the third suggested that paying attention to the floaters made him worry. Paying attention to the floaters made them visible, whereas they were not visible in other conditions. This was a recurrent feature underlined by the participants in our research, who noted that eye floaters occurred or were more evident when they were relaxed, as opposed to when they were busy, as the following quotation illustrates:

During your free time, it is obvious that you start thinking about what happens to you because you have more time to think. Instead, I don’t think about these things when I am busy. I think when I am not busy doing something, or when I have nothing to do. This is the difference: When I am busy, I am not so worried.

It was as though the eye floaters required attention to be seen, which is similar to the descriptions of how they first began. When the participants were asked when they first started to see eye floaters, they often answered that it was following a stressful event or when nothing in particular had happened. However, upon going into greater depth, we discovered that it was during a quiet period, perhaps following a difficult or busy one. For instance, one woman said that World War II was over and her life was starting to begin again (her love affair began, she began to go out with friends, and so on)—that was when she first saw eye floaters.

The unclear explanation of their occurrence, corresponding to an often unclear explanation by physicians to their patients, sometimes led to inflated fantasies about the nature and the cause of the problem. Let us take, for example, the case of a woman who confused eye floaters with the shadows she saw because of a maculopathy from which she was suffering. This woman thought that they were caused by the brain, because she also suffered from epilepsy and was used to explaining her unexpected and unexplained experiences in these terms. However, personal experiences changed according to the participants’ perceptions of the disease. In fact, although some minimized the entity and the duration of the experience, others emphasized its entity and continuity: some sometimes saw “spots” and “wires,” whereas others always saw “big crowds.” The reaction was, consequently, different, ranging from ignoring or simply accepting them to searching for a solution or fighting them. These different experiences did not necessarily correspond to the different levels of opacity of the vitreous body, as the following descriptions show.

When Eye Floaters Are Not a Problem

Two people, one man and one woman, both middle aged (54 and 43 years old, respectively), with a recent onset of the disorder (from 1 year to 3 years previously), did not present posterior vitreous detachment or high vitreous opacity at the medical checkup. Neither did they consider eye floaters to be a problem, because the man had “accepted them,” and the woman said, “It doesn’t bother me because it does not provoke pain or discomfort, but seeing the world with spots is not very pleasant.” The man explained the floaters in terms of age. He said, “Maybe it has to do with the wisdom of the elderly,” and smiled. The woman attributed them to a trauma she had experienced 3 years before, when her second child was an infant and woke up during the night. When she went to tend to him, he accidently gave her a big knock on the head.

Both participants had resorted to only one specialist for a consultation and accepted the explanation and suggestion they received. They trusted in medicine even if they did not often seek medical advice. In fact, they both had a general attitude toward illness such that they did not worry about it. The man said that he had a “quite skeptical relationship with other illnesses,” and that he used “drugs and pills as little as possible.” The woman said, “I am one who naturally neglects herself, and if I have something, I move on. I will get over it; it will pass. I simply remove it.” They both confided mainly in themselves and felt that most things depended on them, as the man’s words expressed: “Everything is given by the personal contribution of everybody: Yes, you have to manage yourself . . . if you take things in such a responsible way, you work hard.” They were both hard workers (an employee of the Inland Revenue Service and a lawyer), and were involved in family management, but myodesopsia represented a dilation of this role for both of them. They could start to be involved in themselves, as the following reports of their experiences illustrate:

I live much more calmly now than ten or fifteen years ago, when I had to take my young daughters to school, but then I had less time for myself. Now, I have more time to do sports, gardening, to remain quiet, calm.

This story [the child’s hard knock] made me realize that it is true that they are children, but this is not a reason for . . . it is not right that I destroy myself for them.

An 88-year-old woman did not consider floaters to be a problem; neither did she have many corpuscles in the vitreous body. What she had in common with the previous two participants was that she had begun to see floaters only recently (during the previous 3 months), and that she was coping with them without worrying too much about them. She was a retired teacher, a widow with two adult children, and she generally confided mostly in herself. All three of these participants showed a higher percentage of dependence on themselves (from 26% to 55%) rather than on others (from 20% to 25.6%), according to the dependency grid.

When Eye Floaters Are Ignored

A 69-year-old woman was referred to the department for myodesopsia following a normal checkup for glaucoma. Ten months before our meeting, she had started to see a gray curtain, “like mist,” in front of her right eye, the eye with glaucoma. She saw some floaters, but they were not a problem and had recently almost disappeared. However, posterior vitreous detachment and a lot of floaters were observed through echography. She had no explanation for her disease, but she did not seem to care; she did not think about it because, she added, “I don’t usually think.” Furthermore, she had other problems at the time, although she had none when the floaters began. She did not look for more explanations and solutions than those proposed to her. She trusted the physicians she met and followed their advice. She described herself as a person who was not particularly problematic, had a normal life, and had always been healthy. She was sure of herself and had “clear ideas.” She had worked since she was 17 years old, had a daughter when she was 29, and was used to solving her problems on her own and confiding in herself more than in others—as the dependency grid confirmed (69.2% dependence on herself). Her story tells us that others tended to depend on her more than she depended on them.

When Eye Floaters Are a “Puzzling” Problem

Two people, a 65-year-old man and a 76-year-old woman, perceived floaters as a problem even if there was no correspondent opacity of the vitreous body or posterior vitreous detachment. The first onset occurred in the distant past (30 years before for the man and 50 years for the woman), but the problem had recurred recently (a couple of months earlier). Neither of these people gave particular explanation. One of them said, “Nothing in particular happened, and it wasn’t as if I had any particular problems. It started out of the blue.” Both patients were worried and afraid that the floaters might indicate a tumor or might lead to blindness. Consequently, they had begun to pay more attention to the floaters, which had caused them to limit their own lives. The man described floaters as “this filth in the eye; it does not look like a sign but like a beast.” He was not satisfied with the explanation he had received. He expected to be helped, but he had not readily asked for help or recognized it when he received it. He distrusted those who tried to take care of him, especially doctors, and blamed them for not having found the solution to his problem:

I was worried the first day when I was checked. She [the doctor] was a bit shocked when she saw this thing. . . . I was soon upset because she told me, “Blooming hell,” or something or other, and I asked her, “Do I have a monster inside my eye?” . . . The doctor told me nothing more; she did not clearly tell me what it could be. I want to know what this thing is!

He described himself as a hard worker from a poor family who was always busy in one job or another. He said he had started to see flashes following an accident at work, after which he changed jobs.

The woman seemed meek and amiable in the interview. She did not talk spontaneously, but rather waited for questions. She showed the same attitude toward medicine, i.e., waiting for a solution that did not depend on her doing anything: “If they tell me something, I do it, but if they do not tell me what to do, what can I do? I cannot do anything on my own!” She was used to placing herself in the hands of others, so she trusted doctors and readily accepted and followed their instructions. She described herself as sociable and satisfied, “normal,” a person who liked to be in company but did not let herself go (“It is not that I attack other people”). From her anecdotes, we detected a whirl of emotions bottled up beneath her meek attitude. Recently, when the floaters had become a problem, what the woman had tried to exclude from her personal perceptive field instead emerged and disturbed her. She was starting to think that her choice to follow others’ directions was a mistake and felt angry about it. Both the patients showed very rarefied dependency, with few recourses indicated (from 5 to 7), and low total dependency (from 16 to 19 ticks in the grid). Nonetheless, they confided more in others (from 33.3% to 68% dependence on a partner) than in themselves (0% dependence on themselves).

When Eye Floaters Are a “Manageable” Problem

Five people, 3 men and 2 women between 50 and 73 years of age, considered eye floaters to be a problem and presented high opacity of the vitreous body. Two of them also presented posterior vitreous detachment, and one of them had a retinal detachment. The onset of eye floaters had occurred in the distant past (as much as 20 years before) or recently (up to 1 month before); however, in the latter case, the person had already seen some floaters before. They were all active people who were used to working, and the eye floaters limited their lives. This was particularly evident in one case: a 67-year-old doctor who attributed eye floaters to an accident that had happened 2 years before and provoked posterior vitreous detachment. He gave up working and enjoying the many hobbies he once had. He stayed at home and developed a “reactive depression,” which was how he self-diagnosed his condition. He was not usually worried about his illness; rather, he said that he “ignored pain”:

I have never had phobias about physical pain; quite the opposite: I have always ignored pain. I know something about physical pain and moral pain because I experienced losses in my family and I reacted without weighing on myself or on others. I have never surrendered: I am a person who . . . I visited patients using my wheelchair five days after the serious accident. I was at my workplace after twenty days, and I broke my ankle again after twenty-five days because I had returned to work too early.

Eye floaters represented an invalidation of his personal role, which was founded on a strong sense of personal responsibility and commitment, as his words expressed well:

When you work, people confiding in you and trusting you . . . I could not go on working anymore! It is the same for the playful activities, for the hobbies, for the motorbike and all other activities where physical efficiency is relevant. Even if I am aware that the policeman pulling me over doesn’t see spots before my eyes, which isn’t the case for an alcohol test, out of honesty, I preferred to end [them].

He could no longer do what he did before, and he felt that he was a burden to his wife and children. This was particularly difficult for him to accept because he was used to confiding primarily in himself, as the results of dependency grid showed (36.4% dependence on himself). He experienced the loss of his personal role as a loss of meaning in his life, and he called it “depression.” He considered surgery to be the only solution for his problem, and he tried to do everything he could to reach this solution.

The active search for a solution forced many of these patients to contact more than three optometrists. A 62-year-old woman who had suffered from eye floaters for more than 18 years had devoted most of this period to understanding her illness, and she founded a group for people suffering from the same problem. She understood her problem in medical terms, and even though she had posterior vitreous detachment, she did not want to have surgery. Her commitment to the struggle against eye floaters probably helped her to cope with them. This allowed her to continue to feel as active and useful as she always had been, as her self-description and personal story showed and the results of the dependency grid confirmed (39.1% dependence on herself).

The Common Meaning of Eye Floaters

According to the different narrations reported above, eye floaters have largely assumed the general status of a nuisance, an ambiguous experience that is difficult to explain or even understand. This makes this experience particularly interesting. In fact, it represents an example of ambiguous illnesses that force the medical field to face up to the uncertainty inherent in its own nature (Greenhalgh, 1999; Griffiths et al., 2010; Griffiths, Green, & Tsouroufli, 2005) and poses important questions for physicians and researchers. Physicians are accustomed to attributing uncertainty to mental illness, especially when the diagnosis is controversial, such as posttraumatic stress disorder or “nerves” (Foss, 2002; Shaw, 2004; Spoont et al., 2009). However, they find themselves in greater difficulty when they cannot explain or treat illnesses affecting the human body, such as some chronic illnesses with uncertain trajectories (Åsbring & Närvänen, 2004; Corbin, 2003; Corbin & Strauss, 1987; Parry, 2003).

Assuming a dualistic perspective, they might “solve” the problem by attributing the physical illness to a mental cause, but in so doing, they cannot answer the questions posed by the patients or propose a treatment for their suffering, other than referring them to a mental health practitioner (Cipolletta, 2006b). Often patients believe that medicine can explain and cure every illness, and they will continue searching for a medical solution at all costs. Sometimes they are treated and end up feeling as though they have an “imaginary” illness. In the current research study we attempted to overcome these common pitfalls by embracing the patient’s point of view and trying to understand it from a psychological perspective—by referring to a personal-construct psychology perspective, in particular. Using a qualitative approach has enabled us to embrace and subsume the results derived from different instruments, including quantitative ones. The grounded-theory-based analysis of the interviews is coherent and in keeping with the constructivist framework because both depart from the reconstruing of personal experiences.

Contrary to the common opinion that eye floaters represent a restriction of a person’s perceptive field, the experiences reported by the participants in our study might be better described in terms of dilation. They represented the possibility of seeing something the participants had not seen before, i.e., the spots and threads in their perceptive field, as well as the opportunity to take care of themselves and dedicate more time to their hobbies and other leisure activities, or to consider their own fallibility and need of help from others. People usually say that eye floaters begin when they are stressed, underscoring once more the link with the need for closure and retirement as a common response to reducing fatigue. This was also a frequent answer given by the participants in our study, but going into more depth during the conversations, eye floaters turned out to be more visible when the participants were relaxed. This is compatible with the shared affirmation that floaters are especially visible when one looks up to gaze at the sky. Again, they represent dilations, rather than constrictions, of the perceptive field.

Given this shared meaning, the reaction and way of experiencing eye floaters varied among the participants. Eye floaters were not a problem for those who did not suffer much from them or who had high opacity of the vitreous body. They were ignored by those who presented high opacity of the vitreous body but did not complain about the eye floaters. They became a “puzzling” problem for the physicians who dealt with those who suffered a lot from them but presented low opacity of the vitreous body, and they were a “manageable” problem for the physicians who dealt with those who suffered a lot from eye floaters but also presented high opacity of the vitreous body or even vitreous detachment. We cite the last two experiences, referring to what they represented for the physicians, because they are created in the encounters that patients have with their doctors. As is the case for most “ambiguous illnesses,” this is the discriminating feature in understanding and coping with the phenomenon.

The differentiation among all the experiences, then, depended on the psychological aspects considered more than on the demographic or clinical variables, such as the age of the person or the duration of the illness and its clinical signs. Differentiating the patients’ experiences might help us find the most suitable approach to dealing with each situation. It is possible to trace some directions for intervention on the basis of the different experiences we found, as summarized below.

Different Experiences and Subsequent Clinical Suggestions

In the first kind of experience, people perceived extraneous bodies and admitted that these sometimes interfered with their usual activities, but they did not consider them to be a problem and explained them as a result of a trauma, a change in habits, advancing age, and so on. They were people who did not worry about their health and, in particular, confided in themselves and trusted in their own responsibility. Consequently, they consulted one or two experts and were satisfied with the explanation received or accepted that a clear explanation could not be given. In these cases, it is probably sufficient to reinforce the solution that people have already found. They might only be helped in recognizing the meaning that eye floaters have in their lives and in following their alternatives to their usual roles. For instance, they can start to take care of themselves without feeling guilty because taking care of themselves no longer implies disregarding others or pampering themselves.

It was difficult to find people who ignored eye floaters because they usually do not resort to seeing an ophthalmologist. One person we met did not complain about the sight limitation even though she presented important clinical signs. She preferred to ignore the disorder rather than consider what it might imply, and she probably did the same with other illnesses. Recognizing the existence of a problem would probably have implied considering herself to be ill or frail, which would have involved needing and asking for help—something that was unbearable for her. Constriction governed her life and prevented her from seeing floaters. That is why she did not consult a specialist for this problem; we met her purely by chance. With people who have similar experiences, it is preferable to avoid contradicting or doubting their perceptions by trying to convince them that they should be seeing floaters or conveying to them the message that they are lying or omitting something. It is more useful to adopt an exploratory attitude that allows the person to recognize the signs of a worsening condition.

The third path of experience is the most difficult to approach because, in this case, the patients see eye floaters as a problem without corresponding clinical signs. This raises the question of why they need to mention them at all. In fact, if we consider illness to be a solution that the person finds, then, even if it is painful, it must be considered preferable to something else. Thus, we might also ask ourselves what would happen if these people did not see eye floaters.

Floaters allowed one of the participants in our study to change jobs and feel more realized, but he probably could not admit it, so he preferred to ascribe his choice to the work accident and his subsequent disorders. In the case of one woman, the eye floaters corresponded to the possibility of considering something she had previously excluded, i.e., trusting herself more than she trusted others. Again, this was probably difficult to accept because it would have implied losing her relationships, which were based on her depending on others. In both cases, eye floaters allowed the patients to face the threat represented by an imminent comprehensive change in their core structures (Kelly, 1955). They reacted to the threat with hostility, defined by Kelly (1955) as the effort to extort validating evidence in favor of a type of social prediction that has already been recognized as a failure.

In fact, both of these individuals maintained their previous constructions of themselves and of their relationships, thereby assigning to floaters the exaggerated role of representing a dramatic change that went much further than the real change produced in their perceptive fields. The same hostility characterized the relationships with their physicians: one man diminished them but pretended to receive a solution that they could not have had; a woman completely delegated the search for a solution to the physicians. Even if the outlook was different in each case (in one evidently hostile and in the other submissive), the connotation of the relationship was similar, i.e., mutual frustration because the patients were not satisfied and the physicians felt that they could do nothing to satisfy their requests.

In these cases, perpetuating this ruinous search for a solution would be useless or even harmful. Confirming the gravity of the problem or supporting the person’s choice by looking for a surgical solution would reinforce the hostility and make the patients feel more worried than they already are. Conversely, contradicting the person or minimizing the problem would probably generate conflict. If a solution is strongly required, it might be more useful to propose a placebo or some alternative therapies such as biofeedback, relaxation, or music therapy (Kaluza & Strempel, 2007), whose effects on this illness have yet to be studied. It is also possible to suggest asking for psychological support to help the person shift his or her attention from the symptom to life. This would allow the patient to consider the situation, i.e., try to solve the problem of eye floaters and attempt to find an alternative solution. If the patient passively waits for a solution, it might be sufficient to reassure him or her by expressing understanding of his or her experience and, in so doing, giving it meaning. If anxiety is considered to be the reaction of a person to something that he or she does not know, as Kelly (1955) defined it, giving meaning to the unknown might already be a cure.

In the fourth path of experience, eye floaters were perceived as disabling, but we defined them as “manageable” because both patients and physicians had an explanation for them and, together, could look for a solution. For these people, eye floaters represented an invalidation of their role because they implied recognizing their need for help and their dependence on others for it. They confronted the guilt derived from this invalidation by actively searching for a solution that was coherent with their usual choice to confide in themselves more than in others. The participants in our study found a solution (surgery for the man and a commitment to the struggle against the illness for the woman); thus, they could retrieve their old roles and continue to live satisfying lives. Otherwise, psychotherapy might help patients to reconstrue their personal roles in a way that will allow them to integrate the floaters in their lives.