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Flashes and floaters. Eye series--9

Article in Australian Family Physician · November 2003

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 EDUCATION: Eye series

Flashes and floaters

Eye series – 9
Chris Hodge, BAppSc, DOBA, is Research Director, The Eye Institute, Chatswood,
New South Wales.
Tim Roberts, MBBS, FRANZCO, FRACS, is Consultant Ophthalmic Surgeon, Royal
North Shore Hospital and The Eye Institute, Chatswood, New South Wales.

Figure 1. Breakdown of retinal layers

A 55 year old woman presents to your practice noting ‘flashes and floaters’
in her peripheral vision. They had begun the previous night and have increased in
size. She tells you it seems as if there is a ‘cobweb’ moving in front of her eye. Apart
from glasses for shortsightedness there is no other previous ocular history.

Question 1 Answers
Name the differential diagnoses.
Answer 1 Figure 2. Partial detachment in the peripheral
retina
Question 2 Differential diagnoses can include:
Describe the possible mechanisms of • posterior vitreous detachment (PVD) ilarly a PVD may not always develop into
retinal detachment. • PVD with a retinal tear or detachment a more serious condition. The vast major-
• (in a diabetic) - vitreous haemorrhage ity of PVDs occur spontaneously (often
Question 3 • ocular inflammation while asleep) and are not related to
Name the possible risk factors. • migraine. stress, heavy exercise or a bump on the
The vitreous gel fills the central cavity of head.
Question 4 the eye providing structural support. If the vitreous is more firmly attached to
When is referral necessary? Over time the vitreous undergoes several the retina than the retina is to the under-
changes most notably liquefaction, even- lying pigment epithelial layer (RPE), the
Question 5 tually leading to separation from the PVD may lead to a tear or detachment of
What are the treatment options? retina. This is a relatively normal event the retina from the RPE layer (Figure 1).
occurring in people aged 40–70 years and Until otherwise proven, retinal detach-
Question 6 is called posterior vitreous detachment ment (RD) should be suspected in all
What is the visual prognosis? (PVD). The pulling action of the vitreous cases of flashes and floaters and treated
upon the retina results in flashes noticed as an ocular emergency. There is no way
by the patient. Likewise, as the gel falls to distinguish a PVD from a retinal tear
away the patient may also notice floaters without a dilated retinal examination.
passing across the line of sight (best
explained as being similar to the ‘squig- Answer 2
gles’ in egg white moving around and Retinal detachment may be due to:
casting a shadow on the retina). Almost • a break or tear in the retina (rheg-
90% of patients that notice flashes in matogenous detachment) (Figure 2)
their peripheral vision will have a PVD. • increased traction of the membranes
Not all patients are symptomatic and sim- on the retinal surface, or

Reprinted from Australian Family Physician Vol. 32, No. 10, October 2003 • 851
n Flashes and floaters

• accumulation of fluid or mass under- be adequately focussed around the tear

neath the retinal layer without any (eg. a small pupil or dense cataract). If
corresponding tear in the retina (usually the tear has progressed to a full detach-
due to inflammation or tumours). ment laser will have no effect and surgical
Rhegmatogenous is the most common repair is required (Figure 3). Several
type of detachment. Common causes options exist:
include PVD, blunt trauma, intraocular • intraocular gas may be used to
surgery and myopia. Rhegmatogenous massage the detached layer back to its
tears occur most commonly in the periph- Figure 3. Full RD requiring immediate original position (pneumatic
surgical intervention
ery. Once the retina is torn, fluid from the retinopexy)
vitreous can enter the subretinal space between 0 and 2–3%. Complicated • suturing a small silicon band or buckle
and peel the retina off. Presenting initially surgery that may cause vitreous loss onto the sclera (scleral buckle)
as a ‘curtain’ or shadow across the periph- increases the chance of detachment pushing the detached area back onto
ery, if left untreated the detachment will • trauma – both direct and indirect the retina. Laser or cryotherapy is
rapidly progress to involve the macula trauma to the eye may lead to detach- then used to create inflammation and
and lead to severe loss of vision. ment. Patients involved in contact or subsequent scarring to close the
Tractional detachments occur as a result extreme sports (eg. boxing, bungee retinal tear.
of adhesions between the vitreous and the jumping) have an increased risk of In complicated cases a vitrectomy may be
retina. The most common causes of trac- RD. Intraocular trauma can lead to required. In the majority of cases of
tional detachment are proliferative scarring and further damage exudative detachment the retina will
diabetic retinopathy and penetrating • systemic disease – patients with condi- return to its natural position only when
ocular trauma. Fibrous retinal tissue will tions such as Marfan and Stickler the underlying cause is removed.
attach itself to the vitreous gel leading to syndromes are at a higher risk of Inflammatory detachments may only
contraction of the retinal layers and developing RD. Due to the scar tissue require drainage of the subretinal fluid.
finally detachment. Various retinopathies formation of resolved haemorrhages,
and macular degenerative conditions can diabetic retinopathy can lead to trac- Answer 6
lead to the formation of potentially tional changes to the retina The final visual outcome is dependant on
harmful fibrous areas of retina. The for- • race – some cultures have shown an the duration, underlying cause and loca-
mation of fluid in the subretinal layers increased incidence of RD. tion of the detachment. Although the
due to inflammation (eg. retinitis) can majority of surgical procedures success-
cause the outer retina to expand and Answer 4 fully re-attach the retinal layer, if the
detach itself. Localised tumour growth Retinal detachment represents a serious macula itself is detached, vision does not
can lead to a similar effect and is called ocular emergency and should be referred usually return to its pre-detachment level.
exudative or serous detachment. immediately to an ophthalmologist for If treated promptly the patient can retain
further assessment. very good acuity, the longer a retina has
Answer 3 detached though the less likely the vision
Several factors can predispose to the Answer 5 will return due to irreversible damage of
onset of RD. These include: In the majority of cases surgery is indi- the photoreceptor cells.
• myopia – over 40% of all patients with cated to restore structure and re-attach A peripheral tear or detachment will not
RD will be myopic. Several interre- the retinal layers. Surgery is dependant affect the central vision. The patient will
lated factors such as myopic retinal on the type, underlying cause, location continue to have good visual acuity but
degeneration, increased rates of vitre- and size of the detachment. In cases of may notice a permanent shadow and
ous degeneration and PVD increase retinal tears without subretinal fluid, laser subtle loss of peripheral vision. If the
the possibility of RD in these patients surgery is used. A series of small burns macula or central vision is involved, it is
• age – the incidence of RD increases around the break will eventually scar and unlikely the patient will regain good
with age due to changes described seal the retina to the underlying tissue. reading vision. The prognosis of an
above Treatment is carried out with anaesthetic exudative detachment depends on the
• surgery – can lead to increased vitreo- drops on the slit lamp and is painless. underlying cause and the level of subse-
retinal traction both during and after Patients can go home immediately after quent damage.
the operation, particularly in the treatment. Cryotherapy acts to cause a AFP
elderly. Postsurgery RD rates vary similar effect and is used if the laser can’t Conflict of interest: none declared.
852 • Reprinted from Australian Family Physician Vol. 32, No. 10, October 2003

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