View source for Acute onset flashers and floaters

==Background==
[[File:Schematic diagram of the human eye en.png|thumb|Eye anatomy.]]
*Photopsia is defined as a visual phenomenon characterized by the perception of flashes of light or flickering in the visual field<ref>Hollands H, et al. Acute-onset floaters and flashes: is this patient at risk for retinal detachment? JAMA. 2009 Nov 25;302(20):2243-9. PMID 19934426</ref><ref>Powell SK, et al. Presentations to eye emergency departments with flashes and floaters differ dependent on incident solar radiation. Ir J Med Sci. 2023 Oct;192(5):2527-2532. PMID 36658378</ref>
*Acute onset flashers and floaters is a common ED complaint, especially in older adults
*The critical EM concern is ruling out [[retinal detachment]] and vitreous hemorrhage, which are sight-threatening
*Most common cause is posterior vitreous detachment (PVD), which is benign but has ~10-15% risk of associated retinal tear
*Risk factors for retinal detachment: myopia (nearsightedness), prior cataract surgery, prior retinal detachment in other eye, trauma, family history, increasing age

==Clinical Features==
===Floaters===
*A sensation of gray or dark spots, cobwebs, or strands moving in the visual field
*Caused either by light bending at the interface of fluid pockets in the vitreous jelly or cells/blood located within the vitreous
*May persist for months to years
*New onset of many floaters ("shower of floaters") or sudden increase in existing floaters is more concerning than a single new floater

===Flashes (Photopsia)===
*Monocular, repeated, brief flashes of white light in the peripheral visual field
*Related to traction on the peripheral retina from areas of tightly adherent vitreous jelly
*Flashes occurring with movement or position change suggest mechanical traction (vitreous on retina)
*Distinguish from migraine aura: migraine visual symptoms are typically binocular, with scintillating scotoma lasting 15-30 minutes, and often followed by headache

===Red Flags for Retinal Detachment===
*"Curtain" or "shadow" coming across visual field (indicates retinal detachment in progress)
*Dense new floaters or shower of floaters (may indicate vitreous hemorrhage from retinal tear)
*Decreased visual acuity (suggests macular involvement)
*Visual field deficit
*Loss of red reflex on fundoscopy
*Pigmented cells ("tobacco dust" / Shafer's sign) in anterior vitreous on slit lamp

==Differential Diagnosis==
{{Acute onset flashers and floaters DDX}}

===Posterior Vitreous Detachment (Most Common)===
*Age-related separation of vitreous from retina
*Benign but 10-15% risk of associated retinal tear

===Sight-Threatening===
*[[Retinal detachment]]: flashes, floaters, visual field curtain, decreased acuity
*[[Vitreous hemorrhage]]: sudden dense floaters, decreased acuity, absent or diminished red reflex
*Retinal tear (without detachment): may progress to detachment if untreated

===Other===
*Migraine with visual aura (binocular, scintillating, lasts 15-30 min)
*Ocular migraine (monocular, but transient)
*Posterior uveitis (cells in vitreous, pain, redness)
*Endophthalmitis (post-surgical, painful, decreased vision)

==Evaluation==
===Bedside Exam===
*Visual acuity (each eye separately) — decreased acuity suggests macular involvement
*Visual field confrontation test — detect curtain or field defect
*Pupillary exam: RAPD suggests significant retinal pathology
*[[Direct ophthalmoscopy]]: look for blood in vitreous (obscured view = vitreous hemorrhage), retinal tears, detached retina
*Slit lamp exam: look for pigmented cells ("tobacco dust") in anterior vitreous — highly suspicious for retinal tear
*Intraocular pressure: may be low with retinal detachment

===Bedside Ultrasound (POCUS)===
*Ocular ultrasound is highly sensitive for detecting retinal detachment and vitreous hemorrhage
*Retinal detachment appears as a bright membrane tethered to the optic disc
*Vitreous hemorrhage appears as swirling echogenic material in posterior chamber
*Can be performed at bedside when direct fundoscopy is limited (e.g., by vitreous hemorrhage obscuring view)

{{Retinal images}}

==Management==
===Retinal Detachment===
*'''Macula-on detachment''' (macula still attached): ophthalmologic emergency — same-day or next-day repair for best visual outcomes
*Macula-off detachment: urgent but not emergent (macula already detached); repair within 24-72 hours
*Position patient with detachment side down (gravity helps keep retina in place)
*Emergent ophthalmology consultation

===Vitreous Hemorrhage===
*Ophthalmology consultation within 24 hours
*Head-of-bed elevation (allows blood to settle inferiorly, clearing visual axis)
*Identify and treat underlying cause (diabetic retinopathy, retinal tear)

===Posterior Vitreous Detachment (No Tear or Detachment)===
*Reassurance that floaters typically improve over time
*Ophthalmology follow-up within 1-2 weeks (retinal tear can develop days to weeks after PVD)
*Strict return precautions

==Disposition==
{{Presumed posterior vitreous detachment management}}

===Emergent Ophthalmology Consultation===
*Macula-on retinal detachment
*Retinal tear identified on exam
*Vitreous hemorrhage with suspected retinal detachment

===Urgent Ophthalmology Referral (24-48 Hours)===
*Vitreous hemorrhage without retinal detachment
*Macula-off retinal detachment
*High-risk features (many new floaters, visual field changes, decreased acuity)

===Routine Ophthalmology Follow-Up (1-2 Weeks)===
*Isolated posterior vitreous detachment with normal exam and acuity
*Single new floater without associated flashes, visual field changes, or decreased acuity

===Return Precautions (All Patients)===
*New or worsening floaters
*New flashes of light
*"Curtain" or shadow in peripheral vision
*Decreased vision

==See Also==
{{Eye algorithms}}
*[[Retinal detachment]]
*[[Acute vision loss (noninflamed)]]
*[[Eye Exam]]

==References==
<references/>
#Hollands H, Johnson D, Brox AC, Almeida D, Simel DL, Sharma S. Acute-Onset Floaters and Flashes: is this patient at risk for retinal detachment? JAMA. 2009;302(20):2243-2249.

[[Category:Ophthalmology]]
[[Category:Symptoms]]