Flashes and Floaters Hong Woon SJUH Flashes and Floaters

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Flashes and Floaters

• Hong Woon
• SJUH

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Flashes and Floaters

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

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Flashes and Floaters

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

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Flashes or Floaters

• PVD
• 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

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• 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

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Posterior Vitreous Detachment (PVD)

• Anatomy of vitreous
• Mechanism of PVD
• Epidemiology
• Symptoms
• Signs
• Complications

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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

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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

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Posterior Vitreous Detachment

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

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PVD predisposing factors

• Age
• Myopia
• Cataract surgery
• Trauma
• Posterior uveitis

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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

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Symptoms of PVD

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

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Photopsia from PVD

• Peripheral arcs of light (Moores 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

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Floaters from PVD

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

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Acute complications of PVD
Vitreous haemorrhage
Retinal tear
Retinal detachment
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• 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

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Symptom of Retinal tear

• No symptom from tear alone
• 50 risk progression to Retinal detachment
• May be associated with small vitreous haemorrhage

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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.

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Symptom of Retinal Detachment

• Shadow
• Progressive
• Requires urgent surgery
• Visual prognosis best if macula not detached

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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

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Migraine aura without headache

• Any age but more common with increase age ( 1 gt
  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

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Migraine aura without headache

• Wave of depolarisation across cortex including
  occipital lobe
• Slowly evolving nature of visual symptoms

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Forms of migraine aura

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

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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

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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

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Optic neuritis

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

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Photopsia following blunt trauma

• Indicates VR traction
• Can develop retinal tears without full PVD
• Must examine retinal periphery

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Toxic, inflammatory, inherited retinal conditions

• Small, shimmering, blinking lights
• In affected field of vision
• Persistent

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CMV retintis

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

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Vitreous syneresis

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

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Asteroid hyalosis

• Uncertain pathogenesis
• Degeneration
• Age gt 60 yrs
• Calcium laden lipids
• Usually unilateral
• Remarkably few symptoms

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Posterior uveitis

• Idiopathic / toxoplasmosis
• Very large numbers of small spots individual
  cells
• larger floaters
• Similar symptoms for small vitreous haemorrhage

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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?

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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

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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

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When to refer PVD?

• Symptoms of vitreous haemorrhage
• Rain drops / dark streaks
• Symptoms of retinal detachment
• Shadow
• Recent history
• lt 6 weeks
• High myopia / history of RD in fellow eye

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What do we do with PVD?

• Dilated examination
• 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

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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