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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

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flashes and floaters2
Flashes and Floaters

Flashes AND Floaters occurring together

  • Virtually pathognomic for Posterior Vitreous Detachment
flashes and floaters3
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


Choroidal melanoma

CMV retinitis


Digoxin toxicity

Optic nerve compression

Optic neuritis


Pituitary tumour

Migraine Aura

Charles Bonnet Syndrome

Vitreous syneresis


Vitreous haemorrhage

Asteroid hyalosis

Posterior uveitis

Entopic phenomenon

CMV retinitis

Flashes or Floaters
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
Posterior Vitreous Detachment (PVD)
  • Anatomy of vitreous
  • Mechanism of PVD
  • Epidemiology
  • Symptoms
  • Signs
  • Complications
anatomy of vitreous
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
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 Detachment
  • Posterior vitreous detached from retina
    • Accumulation of lacunae
    • Fluid escapes into retrohyaloid space
  • Large floater
    • Weiss’ ring
    • Posterior hyaloid membrane
pvd predisposing factors
PVD: predisposing factors
  • Age
  • Myopia
  • Cataract surgery
  • Trauma
  • Posterior uveitis
pvd natural aging change
PVD: natural aging change

Percent with PVD

  • If PVD present 73% chance of PVD in fellow eye if greater than 60 years of age

Age yrs

symptoms of pvd
Symptoms of PVD
  • None
  • Flashes alone
  • Floaters alone
  • Flashes and Floaters
  • Symptoms of complication
    • Vitreous haemorrhage
    • Retinal detachment
photopsia from pvd
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
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
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
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 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
Symptom of Retinal Detachment
  • Shadow
  • Progressive
  • Requires urgent surgery
  • Visual prognosis best if macula not detached
symptomatic posterior vitreous detachment
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
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 headache22
Migraine aura without headache
  • Wave of depolarisation across cortex including occipital lobe
  • Slowly evolving nature of visual symptoms
forms of migraine aura
Forms of migraine aura
  • Photopsia
    • Unformed flashes of light
  • Fortification spectrum
    • White or coloured
  • Scotoma
    • Often crescent shaped and shimmering
  • Heat waves/ blurring/ hemianopsia
migraine aura
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
Other Conditions

Atypical flashes or atypical floaters or other


  • Optic neuritis
  • Photopsia and blunt trauma
  • Toxic, inflammatory or inherited retinal conditions
  • CMV retinitis
  • Vitreous syneresis
  • Asteroid hyalosis
  • Posterior uveitis
optic neuritis
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
Photopsia following blunt trauma
  • Indicates VR traction
  • Can develop retinal tears without full PVD
  • Must examine retinal periphery
toxic inflammatory inherited retinal conditions
Toxic, inflammatory, inherited retinal conditions
  • Small, shimmering, blinking lights
  • In affected field of vision
  • Persistent
cmv retintis
CMV retintis
  • Flashes
  • Floaters
  • Vision not affected until macular involved
  • Only in HIV or immunosuppressed patients
vitreous syneresis
Vitreous syneresis
  • Small multiple floaters
  • Lines / tadpoles
  • Seen best against bright background
  • Move with eye
  • Increased with myopia
asteroid hyalosis
Asteroid hyalosis
  • Uncertain pathogenesis
  • Degeneration
    • Age > 60 yrs
    • Calcium laden lipids
  • Usually unilateral
  • Remarkably few symptoms
posterior uveitis
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
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 floaters
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
why refer pvd
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
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
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
  • 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