Acute onset flashers and floaters

Background

Eye anatomy.

• Photopsia is defined as a visual phenomenon characterized by the perception of flashes of light or flickering in the visual field.

Clinical Features

• Floaters
  • A sensation of gray or dark spots moving in the visual field
  • Caused either by light bending at the interface of fluid pockets in the vitreous jelly or cells located within the vitreous
  • May persist for months to years
• Flashes
  • Monocular, repeated, brief flashes of white light in the peripheral visual field
  • related to traction on the peripheral retina from areas of tightly adherent vitreous jelly

Differential Diagnosis

Acute onset flashers and floaters

• Ocular causes
  • Floaters and/or flashes
    • Posterior vitreous detachment
    • Retinal tear or retinal detachment
    • Posterior uveitis
  • Predominantly floaters
    • Vitreous hemorrhage secondary to proliferative retinopathy
    • Sympathetic ophthalmia
  • Predominantly flashes
    • Oculodigital stimulation
    • Rapid eye movements
    • Neovascular age-related macular degeneration
• Non-ocular causes
  • Intraocular foreign body
  • Migraine aura (classic)
  • Migraine aura (acephalgicmigraine)
  • Occipital lobe disorders
  • Postural hypotension

Evaluation

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

Retinal Images

• 

  Central Retinal Vein Occlusion (CRVO)

• 

  Retinal detachment

• 

  CMV retinitis

• 

  Open-angle glaucoma (cupping)

• 

  Roth spots due to retinal vein occlusion (retinal hemorrhage)

• 

  Central retinal artery occlusion: cherry-red spot, retinal edema and narrowing of the vessels.

Disposition

Referral of patients with presumed posterior vitreous detachment

Clinical Assessment	Disposition
Floaters and/or flashes with “red flag” sign of acute Retinal Detachment Monocular visual field loss (“curtain of darkness”)	Same-day (immediate) referral to retinal surgeon (minutes may matter) High risk of Retinal Detachment
New-onset floaters and/or flashes with high-risk features: Subjective or objective visual reduction examination Vitreous hemorrhage or vitreous pigment on slitlamp examination	Same-day referral to ophthalmologist or retinal surgeon
New-onset floaters and/or flashes without high-risk features	Referral to ophthalmologist within 1 to 2 weeks Counsel patient regarding high-risk features
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 Contact ophtho 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

See Also

Eye Algorithms

• Red eye
  • Bilateral red eyes
  • Unilateral red eye
  • Red eye (by symptoms)
  • Red eye (peds)
    • Neonatal conjunctivitis
• Periorbital swelling
• Acute vision loss (noninflamed)
• Acute onset flashers and floaters
• Painful eyes with normal exam
• Neonatal eye problems

References

1. Hollands H, Johnson D, Brox AC, Almeida D, Simel DL, Sharma S. Acute-Onset Floaters and Flashes: is this patient at risk for retinal detachment? JAMA. 2009;302(20):2243-2249.