Flashes and Floaters Hong Woon SJUH

Flashes and Floaters Flashes AND Floaters occurring together Virtually pathognomic for Posterior Vitreous Detachment

Flashes and Floaters ΔΔ Flashes or Floaters Posterior Vitreous detachment Migraine Aura Other causes of flashes and floaters Taking a history of flashes or floaters When to refer

Flashes or Floaters Vitreous syneresis PVD Vitreous haemorrhage Disciform Choroidal melanoma CMV retinitis CRVO Digoxin toxicity Optic nerve compression Optic neuritis AION Pituitary tumour Migraine Aura Charles Bonnet Syndrome Vitreous syneresis PVD Vitreous haemorrhage Asteroid hyalosis Posterior uveitis Entopic phenomenon CMV retinitis

Know how to diagnose confidently PVD Migraine aura without headache High index of suspicion not PVD or migraine aura if: Unusual features to flashes or floaters Other symptoms

Posterior Vitreous Detachment (PVD) Anatomy of vitreous Mechanism of PVD Epidemiology Symptoms Signs Complications

Anatomy of vitreous Mainly water (99%) Collagen filaments and hyaluronic acid Strongly attached at vitreous base Firm attachments at optic disc Attachments to retina decrease with age

Vitreous degeneration and syneresis Depolymerisation of hyaluronic acid Release water Pockets of liquefied vitreous Collagen filaments aggregate Fibrils Collapse of gel (syneresis) Visible as small floaters

Posterior Vitreous Detachment Posterior vitreous detached from retina Accumulation of lacunae Fluid escapes into retrohyaloid space Large floater Weiss’ ring Posterior hyaloid membrane

PVD: predisposing factors Age Myopia Cataract surgery Trauma Posterior uveitis

PVD: natural aging change Percent with PVD Age yrs If PVD present 73% chance of PVD in fellow eye if greater than 60 years of age

Symptoms of PVD None Flashes alone Floaters alone Flashes and Floaters Symptoms of complication Vitreous haemorrhage Retinal detachment

Photopsia from PVD Peripheral arcs of light (Moore’s lightening streak) Occurs on eye movement Dim – seen best in dim lighting Very brief, but recurrent Usually precedes onset of floaters May persist for months or years

Floaters from PVD Sudden onset floater Much more prominent than small floaters from vitreous syneresis Due to Weiss’s ring or prominent posterior hyaloid membrane May be described as curtain or shadow or blurring of vision Can see through curtain or around shadow

Acute complications of PVD Vitreous haemorrhage Retinal tear Retinal detachment

Symptoms of Vitreous haemorrhage Little spots/ Rain drops/ Sand storm Due to seeing individual red cells Black streaks Streaks of blood Extensive loss of vision Large vitreous haemorrhage Increased risk of retinal tear and retinal detachment

Symptom of Retinal tear No symptom from tear alone ~ 50% risk progression to Retinal detachment May be associated with small vitreous haemorrhage

Retinal detachment? Retinal tear allows retina to separate from retinal pigment epithelial layer Retina dependant on RPE and choroid for function Detachment gives rise to loss of function of detached area.

Symptom of Retinal Detachment Shadow Progressive Requires urgent surgery Visual prognosis best if macula not detached

Symptomatic Posterior Vitreous Detachment Risk of developing retinal tear ( ~ 8%) Risk of developing RD: 3 – 7% in symptomatic PVD If RD develops, it usually occurs within 6 weeks

Migraine aura without headache Any age but more common with increase age (~ 1% > 50 years of age) 77% first occurrence after 50 years of age 42% no history of migraine 44% migraine with aura sufferers report aura without headache at times

Migraine aura without headache Wave of depolarisation across cortex including occipital lobe Slowly evolving nature of visual symptoms

Forms of migraine aura Photopsia Fortification spectrum Scotoma Unformed flashes of light Fortification spectrum White or coloured Scotoma Often crescent shaped and shimmering Heat waves/ blurring/ hemianopsia

Migraine aura Dynamic: grows and moves across visual field over minutes Hononymous but may be difficult for patient to appreciate Spectrum of patterns but usually more formed than photopsia due to PVD and may be coloured

Other Conditions Atypical flashes or atypical floaters or other symptoms Optic neuritis Photopsia and blunt trauma Toxic, inflammatory or inherited retinal conditions CMV retinitis Vitreous syneresis Asteroid hyalosis Posterior uveitis

Optic neuritis Photopsia present in 70% Sparks Flickering peripheral vision May be precipitated by eye movement Main symptom will be blurring of vision

Photopsia following blunt trauma Indicates VR traction Can develop retinal tears without full PVD Must examine retinal periphery

Toxic, inflammatory, inherited retinal conditions Small, shimmering, blinking lights In affected field of vision Persistent

CMV retintis Flashes Floaters Vision not affected until macular involved Only in HIV or immunosuppressed patients

Vitreous syneresis Small multiple floaters Lines / tadpoles Seen best against bright background Move with eye Increased with myopia

Asteroid hyalosis Uncertain pathogenesis Degeneration Age > 60 yrs Calcium laden lipids Usually unilateral Remarkably few symptoms

Posterior uveitis Idiopathic / toxoplasmosis Very large numbers of small spots – individual cells + larger floaters Similar symptoms for small vitreous haemorrhage

Taking a history of flashes of light What are the flashes of light like? Arc of light / jagged / colours / brightness Where in the vision are they? How long does it last for? How does it develop? Is the vision affected? When do the flashes occur? Eye movement At night Timing? How often do they occur? When did they first start? Associated features? Taking a history of flashes of light

Taking a history of floaters What are the floaters like? Size? Number? See through? Movement? Are there any flashes of light? Is the vision affected? Timing When did they start? Associated features? Retinal detachment Myopia Eye surgery Taking a history of floaters

Why refer PVD? To exclude retinal tear / retinal detachment Retinal tear should be treated before retinal detachment develops Retinal detachment should be treated before macular involvement Surgery may be considered for floater in exceptional cases with persistent symptoms

When to refer PVD? Symptoms of vitreous haemorrhage Rain drops / dark streaks Symptoms of retinal detachment Shadow Recent history < 6 weeks High myopia / history of RD in fellow eye

What do we do with PVD? Dilated examination Discharge Confirm diagnosis Exclude retinal tear / retinal detachment Discharge Advised to return if new symptoms (increase in floaters/ shadows) Surgery for floater only in exceptional cases and only when symptoms persist

Summary Flashes and floaters often due to PVD Flashes alone may be due to migraine aura without headache Small risk if retinal tear and retinal detachment Ask for symptoms or history which may increase risk of retinal tear/ retinal detachment Risk of retinal detachment considerably reduced if symptoms greater than 6 weeks