1. Flashers, Floaters and Double Vision

2. Objectives
Develop a safe approach to the disposition of patients complaining of both...
sudden onset of unilateral flashers and floaters
double vision

3. Case 1 62 y.o. female with hypertension and no ocular history
1 week of a large floater in her left eye
Believes her vision on the left has deteriorated
In this same week she had an episode of “light flashes” in the left periphery
Assessed by optometry 6/12 ago and says “everything was normal”

4. Case 1 corrected right 20/20, left 20/50
pupil exam, field testing normal
no RAPD
dilated direct ophthalmoscopy normal
U/S not done

5. Ocular
Floaters and/or flashers
PVD - 24% (50-59) 87% (80-89)
RD - 0.3% (lifetime), 14% (if complaining of flashes/floaters)
Predominate Floaters
vitreous hemorrhage - usually proliferative diabetic retinopathy
Predominate Flashers
oculodigital stimulation
rapid eye movements
age related macular degeneration
Non-ocular
migraine with aura - binocular visual problem
occipital lobe disorder - binocular visual problem
postural hypotension- binocular visual problem

7. Disposition ? What would you do in this case at 1pm on Monday?
What would you do in the case at 1am on Saturday?
Is this case an “emergency” or “urgency”

8. Does this patient have retinal detachment?
Flashes/Floaters (one/both) LR of
Subjective OR objective visual loss with flashes / floaters LR of 5.0
Vitreous Hemorrhage or Pigment on slit lamp exam LR
No data for “sudden grey curtain obstructing vision”

9. Can bedside U/S safely rule out retinal detachment?
prospective study of U/S scan by ED physicians in patients with sx/sx of RD yielded a 97% sensitivity, 92% specificity (Shinar Z. Chan L. Orlinsky M. Use of Ocular Ultrasound for the Evaluation of Retinal Detachment. J Emerg Med. Jul )
another study with similar methodology demonstrated a 100% sensitivity and 83% specificity (Yoonessi R. Hussain A. Jang TB. Bedside Ocular Ultrasound for the Detection of Retinal Detachment in the emergency Department. Acad Emerg Med. Sep 2010.)

10. Is RD a true emergency?
MORD pilot study identified no R.F. other than distance of the tear from the fovea for progression of MORD to macula-off RD (a finding not done in the ED). In this study 26% of patients were treated out-of hours.
The 1995 AAO stance is that MORD be treated within 24 hours (American Academy of Ophthalmology. Ophthalmic procedure assessment. The repair of rhegmatogenous retinal detachment. Ophthalmology 1995; 103: ).
A growing body of literature suggests no long term difference providing that repair occurs within 3 days of symptom onset. (Anatomic and visual outcomes in early versus late macular-on primary retinal detachment repair. Retina jan; 31(1):93-8.)
“best evidence practice for MORD would indicate that surgery be scheduled no later than 7 days of symptom onset.” (Letter in Eye (2006), )
Macula-off Detachment - a recent study found that repair of macula-off detachment in the first three days after the event results in equivalent outcomes to repair in 24 hours, but repair of greater than one week had significantly worse outcomes.

11. Case 1- Resolution
62 y.o. female with OS flashers / floaters, objective visual loss, an normal eye exam.
Referred that day for opthalmology assessment
Found to have PVD with a supra- temporal retinal tear.
Referred to a retinal surgeon at a tertiary centre for definitive management.

13. Disposition ? What would you do in this case at 1pm on Monday?
What would you do in the case at 1am on Saturday?
Is this case an “emergency” or “urgency”

14. RD Summary
Patients with acute onset of either flashers &/or floaters with subjective/objective visual loss, and signs of vitreous hemorrhage need a same day referral.
RD likely represents an urgency vs. emergency based on available literature.

15. Case 2
75 y.o. male with double vision and left eyelid ptosis, previously completely well.
Awoke in the AM c/o he was seeing double esp. when looking up.
Denies any visual blurring, headache, fever, neck pain or “b symptoms.”
Remainder of R.O.S is normal.
PMHx: HTN, lipids, GERD, CAD, AF - therapeutic INR, Pacemaker - SSS

16. Physical Findings obvious droopy left eyelid right 20/25, left 20/40
PERL, no RAPD
right normal EOM
left cannot elevate, depress or adduct
IOP 13 mmHg bilaterally
SLE normal anterior chamber & cornea
Fundi exam attempted - but limited (not dilated)

18. The can’t miss diagnosis have more than just CN findings.
Differential?
Binocular Diplopia
Cranial Nerve - idiopathic (microvascular), stroke, compressive lesion, infectious (sinus thrombosis), alcohol related (WE)
Mechanical - typically assc. with proptosis and pain - i.e. Grave’s dx, orbital myositis, base of skull tumors
Neuromuscular - typicall assc. with systemic illness - i.e. botulism, GBS (Miller Fisher Variant), MG, MS
The can’t miss diagnosis have more than just CN findings.

20. Disposition? Should I order a CT/MRI, what type?
Can I safely send this patient to the family physician for follow up in 4-6 weeks?
Can I safely send this patient for opthalmology f/u tomorrow?
Do I need to call the opthalmogist now?
Do I need to call the stroke MD now?

21. Red Flags - Admit/Image
More than one cranial nerve deficit
Pupillary involvement of any degree
Any neurologic symptoms besides diplopia
Pain
Proptosis

22. Who Can I d/c without any imaging?
Unilateral
Single Cranial Nerve Palsy
Normal pupillary light response
No other signs or symptoms

23. Case 2 Patient was f/u by opthalmology 2 days post d/c.
Visit % ptosis, pupil sparing, no adduction, elevation, depression of L eye
Visit 2 (2/52) - near 100% ptosis, pupil sparing, no adduction, elevation, depression L eye
Visit 3 (4/52) - 30% ptosis, able to adduct past midline, slight elevation and depression
Visit 4 (8/52) - no ptosis, normal EOM, no double vision

24. Diploplia Summary
Patients with isolated pupil sparing 3rd, 4th and 6th CN palsies likely have idiopathic or microvascular disease.
EXTREMELY CAREFUL NEURO EXAM
In the above cases emergent management is not often necessary, although urgent opthalmology referral, with a call from the ER physician should be encouraged.