Acute onset flashers and floaters

DDX

1. PVD (most common)
   1. Concern for Retinal Detachment
2. Classic Migraine
3. Acephalgic migraine (no HA)
4. Occipital lobe disorders
   1. Ischemia or infarction
   2. hemorrhage
   3. arteriovenous malformation
   4. seizure disorder
   5. neoplasm may present
   6. Postural hypotension

Diagnosis

• Eye exam
  • Stress on:
    • Visual acuity
    • Visual field confrontation test
    • Direct ophthalmoscopy
    • Slit lamp

Management

Suggested Approach for Referral of Patients With Presumed PVD

Floaters and/or flashes with “red flag” sign of acute Retinal Detachment Monocular visual field loss (“curtain of darkness”)	Same-day referral to retinal surgeon (minutes may matter) High risk of Retinal Detachment
New-onset floaters and/or flashes with high-risk features including Subjective or objective visual reduction examination Vitreous hemorrhage or vitreous pigment on slitlamp examination	Same-day referral to ophthalmologist or retinal surgeon for dilated eye
New-onset floaters and/or flashes without high-risk features	Referral to ophthalmologist for dilated eye examination within 1 to 2 weeks Counsel patient regarding high-risk features that should prompt urgent reassessment
Recently diagnosed uncomplicated posterior vitreous detachment with New shower of floaters New subjective visual reduction	Rereferral to ophthalmologist to rule out new retinal tear or detachment The ophthalmologist should be contacted to help determine urgency
Stable symptoms of floaters and/or flashes for several weeks to months, not particularly bothersome to the patient and without high-risk features	Elective referral to ophthalmologist Counsel patient regarding high-risk features that should prompt urgent reassessment