ot Alan G. Kabat OD, FAAO and Joseph W.

Sowka OD, FAAO

A clinician’s guide to flashes and floaters

How to differentiate dangerous warning signs from normal, physiologic ocular findings
A patient complaint that we hear quite often is that of seeing floating spots in the field of vision.
Occasionally, when a patient experiences these ‘floaters’, he or she may mention that flashes of light are
also occurring. In this article, we briefly review and examine the causes of floaters and flashes.
Floaters coalesce into collagen fibrils, causing further of the posterior pole may be difficult due to
While most causes of floaters reside in the breakdown of the vitreous gel structure. This accumulation of vitreal cells.
vitreous gel, it is important not to overlook a process is known as vitreous degeneration and Another common cause of vitritis is pars
simple and superficial aetiology – namely, debris syneresis. planitis. Here, the patient is typically well
within the tear layer. It is not uncommon for The fibrils may ‘float’ within the liquid systemically, but complains of multiple floaters
patients to accumulate make-up or other vitreous, giving the patient a sensation of and decreased vision, often due to cystoid
material within their tears. These patients may floaters. The floaters here will be small, few in macular oedema. The vitritis can be so
have a mild foreign body sensation, or may be number, and may have a linear appearance. They significant that it disrupts the vitreous
asymptomatic. Patients with oily tears and will move coincidentally with eye movements. framework causing a collapse with posterior
inpissated meibomian glands may also These floaters are particularly noticeable against vitreous detachment. Discounting trauma,
accumulate debris within the tear layer, which a bright background – a sunny sky, a white posterior uveitis and vitritis is the typical cause
can be reported as floaters. This phenomenon is page, or a bare white wall. Patients rarely see of PVD in younger patients.
transient and the patient may report that the vitreal floaters in dim illumination. A relatively common vitreous anomaly that
floaters move significantly upon blinking. There With the accumulation of lacunae, the occasionally causes floaters is asteroid hyalosis.
typically are no other associated symptoms, such vitreous body loses support, and the vitreous Asteroid bodies are calcium soaps that attach to
as foreign body sensation, that could provide a framework contracts. Liquefied vitreous escapes the vitreous framework. The bodies move slightly
diagnostic clue. to the retrohyaloid space and the vitreous with eye movement, but always return to their
Patients with ocular allergies may also be completely separates from the sensory retina, original position. This condition is typically
prime candidates for this phenomenon, since the resulting in posterior vitreous detachment (PVD). unilateral or asymmetric and is encountered in
eye produces excess mucus in order to soothe An annular ring corresponding to the attachment older patients. There is arguably a relationship
the eye from the allergic assault. It is important of the posterior vitreous will be seen floating between asteroid hyalosis and systemic vascular
to remember that true vitreous floaters may over the posterior pole. The shadow from this disease, though conclusive proof does not exist.
seem to move upon blinking, and the patient annulus will be perceived as a large floater, and Asteroid bodies are white, but may appear
may mistakenly assume that this represents may resemble a smoke ring or an insect. golden or glittering during ophthalmoscopy. The
debris within the tear layer. Another cause of floaters is vitreous clinical picture can be quite dramatic, even to
A tear film aetiology should only be haemorrhage. A PVD that encounters an area of the point of completely obscuring the posterior
entertained once true vitreous floaters and vitreoretinal adhesion can cause a tractional tear pole. Still, vision is rarely significantly affected.
degeneration have been eliminated as a possible in the retina. If a retinal blood vessel is In most cases, complaints of floaters with
cause. involved, subsequent leakage into the vitreous asteroid hyalosis are uncommon, since the
By far, the main cause of symptomatic cavity and retrohyaloid space will occur. asteroid bodies demonstrate minimal movement.
floaters resides within the vitreous cavity. A Patients with vitreous haemorrhage initially Asteroid hyalosis must be quite dense before
caveat to remember: when patients complain of report a multitude of small floating spots in floaters are noted.
floaters that they can localise to one eye or the their vision, which subsequently enlarge and A similar condition to asteroid hyalosis is
other, they are typically correct. Vitreous may take on a red or purple hue. A precipitous synchisis scintillans. This is a rare bilateral
abnormalities present symptomatically as floaters decrease in vision may be encountered, vitreous disorder involving an accumulation of
due to shadows that they cast upon the retina. depending upon the extent of the haemorrhage. cholesterol crystals. The crystals settle in the
Thus, the patient can correctly determine which In addition to tractional tears, a very inferior vitreous while the eye is at rest and
eye is experiencing the phenomenon. common cause of vitreous haemorrhage is float freely in the liquid vitreous as the eye
In contradistinction, patients experiencing spontaneous leakage of a neovascular membrane moves.
flashes of light can not always determine in proliferative retinopathy (e.g. diabetic, sickle Unlike asteroid hyalosis, synchisis scintillans
accurately in which eye the phenomenon is cell, venous occlusion or Eale’s disease). is rarely encountered in clinical practice, since it
occurring. The patient may report that flashes Occasionally, a vitreous haemorrhage can occur is believed to be an end-stage disease seen only
are in the right visual field and may incorrectly from a choroidal neovascular membrane in in blind, severely damaged eyes.
conclude that the phenomenon is occurring in macular degeneration.
the right eye. In reality, this may ensue from When attempting to differentiate the cause Flashes
stimulation of either the right nasal retina or the of a vitreous haemorrhage, it is crucial to Flashes, or photopsiae, typically result from a
left temporal retina. consider the underlying medical and ocular mobile vitreous mechanically tugging on
The vitreous gel is transparent due to the history of the patient. portions of the retina. These areas of
fact that it is 99% water and 1% solid elements. Patients with posterior uveitis and vitritis vitreoretinal adhesion include the optic disc,
Of the solid portion, there are proteins, collagen will frequently complain of multiple floaters, macula, along retinal vessels, along areas of
filaments, and hyaluronic acid molecules. The often with associated decreased vision. chorioretinal scarring and RPE hyperplasia, at
relationship between the formed elements and Biomicroscopic evaluation of the vitreous will the vitreous base, at vitreoretinal tufts,
the ability of hyaluronic acid molecules to retain show a significant accumulation of white blood and along the border of lattice retinal
water molecules gives the vitreous its gel cells adherent to the framework of the vitreous degeneration.
consistency. gel. A common cause of this clinical picture is When the vitreous pulls upon areas of
With age, there is a depolymerisation, active toxoplasmosis. Here, there will be a vitreoretinal adhesion, the photoreceptors are
causing the hyaluronic acid molecules to release ‘headlights in a fog’ appearance corresponding mechanically stimulated. Keep in mind that the
their water molecules and form lacunae, pockets to an inflamed retina and choroid with a dense retina is a ‘dumb’ animal when it comes to
of liquefied vitreous. The collagen filaments overlying vitritis. Ophthalmoscopic observation recognizing stimuli; retinal cells are incapable of

36 March 23, 2001 OT www.optometry.co.uk

Figure 1 Recent PVDs are readily observable Figure 2 A vitreous haemorrhage involving Figure 3 Active toxoplasmosis can present
to ophthalmoscopy. the optic disc. Visual acuity was not affected with a dense vitritis, demonstrating a
in this patient. ‘headlights in the fog’ appearance.

Figures 4a and 4b Figure 5 (retinal flap tear) Tractional retinal

Densely packed asteroid bodies may obscure the posterior pole in some cases. tears, like the one shown here, are a
common cause of ‘flashes’.
identifying pain, pressure, or temperature. The
only stimulus that the retina acknowledges is
light. So when the photoreceptors experience
mechanical stimulation, they send a signal to the
brain in the form of disorganized light, which is
perceived by the occipital cortex as a ‘flash’.
Photopsia is an ominous symptom of
vitreoretinal traction, since it may indicate a
tear in the retina. The presence of photopsia
with a tractional retinal tear denotes that the
mobile vitreous is pulling the retina away from
the RPE, allowing liquefied vitreous to
accumulate beneath the edges of the tear.
Ultimately, this can lead to rhegmatogenous Figure 6 Pigment accumulation in the Figure 7 The patient presented with a history
retinal detachment. The advancing detachment anterior vitreous, sometimes referred to as of flashes and a ‘veil’ over the inferior
will further physically stimulate the retina, with ‘Shaffer’s sign’, often accompanies portion of her vision. Note the white, billowy
additional or continued complaints of flashes. rhegmatogenous retinal detachment. retinal detachment superiorly.
Migraine phenomena are often described by
patients as beginning with flashing lights in the other symptoms, though in our experience this About the authors
peripheral visual field. This ‘aura’ is likely due to is seen less commonly.
an ischaemic phenomenon spreading across the One final clinical entity bears mention. Drs Kabat and Sowka are faculty members at the
various regions of the brain, including the Papillophlebitis, a central retinal vein occlusion Nova Southeastern University College of
occipital cortex. The lights typically take on a occurring in a young adult, has anecdotally been Optometry in Fort Lauderdale, Florida.
herringbone pattern, surrounding an area of dim associated with flashing lights during the active Dr Kabat is an Associate Professor and serves
or missing vision (fortification scotoma). The bleeding phase. The flashes have specifically as an Attending Physician in the Primary Care
scotoma increases in size as it migrates across been described as golden or purple lights. The Service, as well as Director of Externships for the
the visual field. The aura usually lasts about aetiology of this phenomenon is unknown, but College. Dr Sowka is also an Associate Professor
20-30 minutes, and may be associated with may represent a mechanical disturbance of the as well as Chief of both the Primary Care Service
vertigo, tremors, weakness in the extremities, photoreceptors by the blood leaking from the and the Glaucoma Service. Drs Kabat and Sowka
and difficulty speaking. retinal capillaries. are widely published and lecture internationally
In the classic form of migraine, a severe This phenomenon has not been reported in on topics of ocular disease.
headache with associated nausea ensues. Other the literature on papillophlebitis, but we, as well
symptoms may include extreme sensitivity to as others managing patients with
light and noise, profuse sweating and vomiting. papillophlebitis, have frequently heard this Acknowledgements
It is possible to encounter the visual aura of patient complaint (Dr Andrew Gurwood, personal Article reprinted by kind permission from
migraine without the associated headache or communication). Review of Optometry, a Jobson publication.

www.optometry.co.uk 37