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Saturday, August 23, 2025

Eye floaters and flashes


Introduction

Eye floaters and flashes are frequent visual disturbances reported by patients of all ages, particularly those over 40. Floaters appear as small spots, cobwebs, or thread-like shapes drifting across the field of vision. Flashes, in contrast, present as brief flickers of light, often in peripheral vision, resembling lightning streaks.

In most cases, floaters and flashes result from benign age-related changes in the vitreous humor. However, they may also indicate potentially vision-threatening retinal tears, detachments, or vascular occlusions. Distinguishing harmless vitreous opacities from urgent retinal pathology is critical in clinical practice.

Anatomy and Pathophysiology

Vitreous Humor

  • A gel-like substance filling the posterior segment of the eye.

  • Composed of water (99%), collagen fibers, and hyaluronic acid.

  • With aging, collagen aggregates and the vitreous liquefies (syneresis).

Floaters

  • Formed when collagen fibers clump together and cast shadows on the retina.

  • May also occur due to hemorrhage (blood cells), inflammatory debris (uveitis), or retinal tears.

Flashes (Photopsia)

  • Caused by vitreoretinal traction.

  • Pulling on the retina mechanically stimulates photoreceptors, leading to perceived flashes of light.

Causes of Floaters and Flashes

1. Benign Causes

  • Posterior vitreous detachment (PVD): Most common cause, age-related vitreous shrinkage.

  • High myopia: Increases vitreous degeneration risk.

  • After cataract surgery (pseudophakia).

2. Pathological Causes

  • Retinal tear or retinal detachment: Vision-threatening, often accompanied by sudden increase in floaters, flashes, or curtain-like shadow.

  • Vitreous hemorrhage: Caused by trauma, diabetic retinopathy, retinal vein occlusion.

  • Uveitis: Inflammatory cells floating in vitreous.

  • Ocular trauma: Direct mechanical or penetrating injuries.

  • Tumors: Rare, but intraocular tumors may cause vitreous floaters.

Clinical Presentation

  • Floaters: Spots, threads, cobwebs, moving with eye movement, more visible against bright background.

  • Flashes: Brief lightning streaks, usually peripheral vision, worse in dim light.

  • Associated symptoms:

    • Sudden increase in number of floaters

    • Loss of peripheral vision (“shadow” or “curtain”)

    • Decreased visual acuity

    • Red eye or ocular pain (in uveitis, trauma, infection)

Differential Diagnosis

  • Posterior vitreous detachment (PVD)

  • Retinal tear or detachment

  • Vitreous hemorrhage

  • Uveitis

  • Ocular migraine (transient flashes, zig-zag lines, not floaters)

  • Optic neuritis (phosphenes with eye movement)

Diagnostic Approach

1. Clinical History

  • Onset, duration, frequency of floaters/flashes.

  • Associated symptoms (vision loss, curtain, trauma).

  • Past ocular history (myopia, surgery, diabetes, hypertension).

2. Physical Examination

  • Visual acuity testing

  • Pupillary reaction (afferent pupillary defect suggests retinal or optic nerve pathology)

  • Fundoscopy: Direct or indirect ophthalmoscopy

  • Slit-lamp biomicroscopy with dilated pupil

3. Investigations

  • Optical coherence tomography (OCT): Retinal layers and vitreomacular interface.

  • B-scan ultrasonography: Useful when media opacity (dense hemorrhage) prevents fundus visualization.

  • Fluorescein angiography: In vascular causes.

Management and Treatment

A. Benign Posterior Vitreous Detachment (PVD)

  • Observation: No treatment required if retina intact.

  • Reassurance: Floaters often fade or become less noticeable.

  • Regular follow-up: Fundus exam at 2–6 weeks after onset to exclude late retinal tear.

B. Retinal Tears and Detachment (Ophthalmic Emergency)

  • Immediate referral to retina specialist.

  • Treatment options:

    • Laser photocoagulation: Creates adhesive scars sealing retinal tears.

    • Cryotherapy: Freezing therapy for peripheral tears.

    • Vitrectomy: Surgical removal of vitreous in retinal detachment.

    • Scleral buckle surgery: Silicone band supporting retina.

    • Pneumatic retinopexy: Intraocular gas bubble sealing detachment.

Medications used perioperatively:

  • Topical antibiotics: Ciprofloxacin ophthalmic 0.3%, 1 drop every 6 hours postoperatively.

  • Topical corticosteroids: Prednisolone acetate 1% drops, 1 drop every 2–4 hours post-op.

C. Vitreous Hemorrhage

  • Cause: Trauma, diabetic retinopathy, vein occlusion.

  • Management:

    • Bed rest with head elevation.

    • Avoid strenuous activity.

    • Systemic therapy for underlying disease:

      • Metformin 500 mg orally twice daily (for diabetes control).

      • Aspirin or Clopidogrel for vascular occlusion (with caution under specialist advice).

    • Vitrectomy if non-clearing hemorrhage (>3 months).

D. Uveitis (Inflammatory Floaters)

  • Treatment:

    • Topical corticosteroids: Prednisolone acetate 1% drops, 1 drop every 1–2 hours initially.

    • Cycloplegic drops: Atropine 1%, 1 drop twice daily (reduces pain, prevents synechiae).

    • Systemic corticosteroids: Prednisone 40–60 mg orally once daily, taper gradually.

    • Immunosuppressive agents (for recurrent uveitis): Methotrexate 10–25 mg orally weekly.

E. Ocular Migraine (Visual Aura without Retinal Disease)

  • Management:

    • Avoid triggers (stress, caffeine, dehydration).

    • Acute therapy: Sumatriptan 50–100 mg orally at migraine onset.

    • Preventive: Propranolol 40 mg orally twice daily, or Topiramate 25–50 mg orally twice daily.

F. Symptomatic Persistent Floaters (Rarely Treated)

  • Most floaters diminish over time. If persistent and visually disabling:

    • YAG laser vitreolysis: Disrupts floaters with laser energy.

    • Pars plana vitrectomy: Removes vitreous gel completely, reserved for severe cases.

Medications Commonly Used in Eye Floater and Flashes Management

ConditionDrug (Generic)Typical Dose/Use
Infectious prophylaxis (post-retinal surgery)Ciprofloxacin ophthalmic 0.3%1 drop q6h
Post-surgical inflammationPrednisolone acetate 1%1 drop q2–4h
Pain/cycloplegia (uveitis)Atropine 1%1 drop BID
Systemic inflammationPrednisone40–60 mg PO daily
Chronic uveitis (immunosuppression)Methotrexate10–25 mg PO weekly
Migraine with auraSumatriptan50–100 mg PO at onset
Migraine prophylaxisPropranolol40 mg PO BID

Patient Education and Lifestyle Advice

  • Urgent warning signs: Sudden increase in floaters, flashes, or shadow/curtain across vision → emergency ophthalmology evaluation.

  • Regular monitoring: Especially in diabetics, high myopes, or after eye surgery.

  • Protective eyewear: Prevent trauma-induced floaters.

  • Systemic control: Diabetes and hypertension management.

  • Hydration and healthy lifestyle: May reduce frequency of ocular migraines.

Complications

  • Untreated retinal detachment → permanent vision loss.

  • Chronic vitreous hemorrhage → proliferative vitreoretinopathy.

  • Recurrent uveitis → cataract, glaucoma, macular edema.

  • Post-vitrectomy complications → infection, cataract, retinal detachment.

Prognosis

  • Benign PVD: Excellent, floaters fade with time.

  • Retinal tears/detachment: Good prognosis if treated promptly, poor if delayed.

  • Vitreous hemorrhage: Depends on underlying disease (diabetic retinopathy = guarded).

  • Uveitis: Variable; recurrent cases need long-term immunosuppression.

  • Ocular migraine: Generally benign, manageable with lifestyle and prophylaxis.




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