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Tuesday, August 19, 2025

Floaters and flashes in the eyes


Introduction

Floaters and flashes are common visual phenomena that many people experience, particularly as they age. While often harmless, they can occasionally indicate serious eye disease requiring urgent treatment.

What Are Floaters?

Floaters are small shapes or shadows that drift across the visual field. They may appear as:

  • Black or gray dots

  • Squiggly lines or cobwebs

  • Rings or threads

They are most noticeable when looking at a bright, plain background (such as a clear sky or a white wall). Floaters move with eye motion and seem to dart away when directly looked at, since they actually "float" inside the vitreous humor of the eye.

Causes of Floaters

  • Vitreous syneresis (age-related changes): With aging, the vitreous gel liquefies and contracts, leading to clumping of collagen fibers.

  • Posterior vitreous detachment (PVD): Common in older adults, where the vitreous separates from the retina.

  • Myopia (nearsightedness): Increases risk of floaters and retinal detachment.

  • Ocular trauma or surgery: Disturbances in the vitreous can produce floaters.

  • Inflammation (uveitis): Inflammatory cells can manifest as floaters.

  • Retinal tear or detachment: A serious cause that requires emergency evaluation.

  • Hemorrhage: Blood in the vitreous (from diabetic retinopathy or vein occlusion) may appear as new floaters.

What Are Flashes?

Flashes (photopsia) are sudden brief bursts of light in the peripheral vision, often described as lightning streaks or flickering lights. They are caused by traction on the retina, typically from the vitreous pulling against it.

Causes of Flashes

  • Posterior vitreous detachment: A common benign cause, though associated with retinal tears in some cases.

  • Retinal tear or detachment: The most urgent cause, as untreated retinal detachment can lead to permanent blindness.

  • Migraine with aura: Flashes may accompany visual auras even without headache.

  • Ocular trauma: Mechanical stimulation of the retina may cause flashing lights.

Risk Factors

  • Age over 50 years

  • High myopia

  • Eye trauma

  • Previous eye surgery (e.g., cataract extraction)

  • Family or personal history of retinal detachment

  • Diabetes mellitus

When to Seek Immediate Medical Attention

Floaters and flashes are often benign, but urgent assessment is required if:

  • There is a sudden onset of multiple new floaters

  • Flashes are persistent or frequent

  • A "curtain" or shadow is noticed across the vision (suggesting retinal detachment)

  • Vision becomes blurred or reduced

  • Associated eye pain or redness occurs

Diagnosis

Evaluation is typically performed by an ophthalmologist and includes:

  • Dilated fundus examination: Direct inspection of the retina for tears, detachment, or hemorrhage.

  • Ocular ultrasound (B-scan): Useful if the retina cannot be visualized due to hemorrhage.

  • Optical coherence tomography (OCT): To evaluate vitreous and retinal structure.

Treatment

1. Benign Floaters

  • Observation: Most floaters become less noticeable with time as the brain adapts.

  • Reassurance: If no retinal pathology is found, no treatment is needed.

2. Posterior Vitreous Detachment (PVD)

  • No specific treatment is required unless complicated by a retinal tear.

  • Patients should be counseled to seek immediate care if symptoms worsen.

3. Retinal Tears or Detachment

  • Laser photocoagulation: Seals retinal tears to prevent detachment.

  • Cryotherapy: Freezes tissue around a tear to create a sealing scar.

  • Vitrectomy: Surgical removal of vitreous gel, often used if there is hemorrhage or detachment.

  • Scleral buckle or pneumatic retinopexy: Procedures to repair detachment.

4. Vitreous Hemorrhage

  • Observation if mild and underlying cause is controlled.

  • Vitrectomy may be necessary if persistent or vision-threatening.

5. Inflammatory Causes (Uveitis)

  • Corticosteroids (Prednisolone eye drops or oral Prednisone): 10–40 mg/day orally depending on severity.

  • Immunosuppressants (Methotrexate, Azathioprine, Cyclosporine): Used for recurrent or resistant uveitis.

6. Pharmacological Management of Associated Symptoms

  • No direct medication eliminates benign floaters.

  • Analgesics like Paracetamol 500–1000 mg every 6 hours may be given if eye pain is present (usually in inflammatory causes).

  • NSAIDs (Ibuprofen 400 mg every 6–8 hours) can be used in uveitis-related discomfort, unless contraindicated.

Prevention and Patient Counseling

  • Regular eye exams, particularly for individuals with myopia or a family history of retinal detachment.

  • Protective eyewear to reduce trauma risk.

  • Good diabetic control to minimize risk of vitreous hemorrhage.

  • Patient education on red-flag symptoms (sudden increase in floaters, flashes, or curtain-like shadow).

Prognosis

  • Benign floaters often diminish in prominence over time.

  • Posterior vitreous detachment without complications is generally harmless.

  • Early treatment of retinal tears and detachment can preserve vision, but delayed treatment carries a high risk of permanent vision loss.

  • Management of underlying systemic conditions (e.g., diabetes, hypertension, autoimmune disease) reduces recurrence and severity.




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