1. Flashes and Floaters
Hong Woon
SJUH

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

3. 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

4. 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

5. 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

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

7. 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

8. 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

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

10. PVD: predisposing factors
Age
Myopia
Cataract surgery
Trauma
Posterior uveitis

11. 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

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

13. 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

14. 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

15. Acute complications of PVD
Vitreous haemorrhage
Retinal tear
Retinal detachment

16. 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

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

18. 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.

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

20. 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

21. 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

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

23. 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

24. 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

25. 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

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

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

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

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

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

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

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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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