Eye Floaters: When should we refer urgently?

What is it?

  • sensation of moving spots, usually gray or dark in color, across the visual field of one eye.
  • painless

 

Causes

Image result for posterior vitreous detachment

  • Posterior vitreous detachment (PVD)- extremely common
  • As we age, the vitreous humor, which is essentially a bag of jelly that occupies the posterior chamber of the eye, shrinks. As the vitreous shrinks, it separates from the retina. The bending of light that occurs in these pockets of separation and the associated traction on the peripheral retina results in the perception of floaters and flashes, respectively.

 

Image result for posterior vitreous detachment

 

 

Why & When should we worry?

Flashes-and-Floaters

  • With time, PVD becomes more stable, so that patients with longstanding symptoms of floaters and flashes (months to years) are of much less concern.
  • In the acute phase (days to weeks), however, the tractional forces on the areas of retina that are newly unsupported by underlying vitreous may be sufficient to lead to a retinal tear.
  • Retinal tears may in turn lead to retinal detachment and permanent visual loss if not promptly identified and treated by an ophthalmologist.

 

How to detect?

Image result for vitreous hemorrhage

  • most strongly predictive of retinal tear – vitreous hemorrhage or pigment (so-called “tobacco dust”) on direct ophthalmoscopy
  • description of decreased visual acuity
  • LIMITATION – lack of skill, opthamoscopy

 

When to refer?

  • high-risk findings (e.g. decreased visual acuity, either subjective or objective, or any finding on slit-lamp examination or direct ophthalmoscopy) consultation should occur on the same day.
  • Those with frank signs of detachment, such as a curtain of darkness encroaching on the visual field or the appearance of a billowing retina on ophthalmoscopy, require emergent consultation, as minutes may matter in these cases.
  • Without any other findings, they suggest that follow-up should occur within 1-2 weeks, with the caveat that if there is any progression or change in symptoms that they should return immediately.

 

Differential

  • Flashes – brief, repeated sensations of bright light, usually at the periphery of the visual field. Painless.
  • Retinal detachment – Curtains or cobwebs encroaching on any part of the visual field of one eye represent true ocular emergency.
  • Transient ischemic attack (TIA) involving the ophthalmic artery – amaurosis fugax, unilateral symptoms, typically a curtain-like visual field cut lasting seconds to minutes in the upper or lower half of the visual field of one eye.
  • Non ocular – usually bilateral –  postural hypotension and migraine [flashing lights (scintillations) of migraine are most often colorful]

 

What patient should expect when follow up with ophthalmology

  • No treatment – most floater will adjust by time
  • Laser
  • Surgery to remove the vitreous and replace with another solution
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