Acute onset flashers and floaters

Background

• • 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

DDX

1. Ocular causes
   1. Floaters and/or flashes
      1. Posterior Vitreous Detachment
      2. Retinal tear or Retinal Detachment
      3. Posterior Uveitis
   2. Predominantly floaters
      1. Vitreous Hemorrhage secondary to proliferative retinopathy
   3. Predominantly flashes
      1. Oculodigital stimulation
      2. Rapid eye movements
      3. Neovascular age-related macular degeneration
2. Nonocular causes
   1. Migraine aura (classic)
   2. Migraine aura (acephalgicmigraine)
   3. Occipital lobe disorders
   4. 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 (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

Source

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.