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The Rational Clinical Examination | Clinician's Corner

Acute-Onset Floaters and Flashes:  Is This Patient at Risk for Retinal Detachment?

Hussein Hollands, MD, MSc(epid); Davin Johnson, BSc; Anya C. Brox, MD, CCFP; David Almeida, PHD, MD, MBA; David L. Simel, MD, MHS; Sanjay Sharma, MD, MSc, FRCSC
JAMA. 2009;302(20):2243-2249. doi:10.1001/jama.2009.1714.
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Context Acute onset of monocular floaters and/or flashes represents a common presentation to primary care physicians, and the most likely diagnosis is posterior vitreous detachment (PVD). A significant proportion of patients with acute PVD develop an associated retinal tear that can lead to retinal detachment and permanent vision loss if left untreated.

Objective To quantify the association between relevant clinical variables and risk of retinal tear in patients presenting with acute-onset floaters and/or flashes and PVD.

Data Sources Structured MEDLINE (January 1950–September 2009) and EMBASE (January 1980–September 2009) searches and a hand search of references and citations of retrieved articles yielded 17 relevant studies.

Study Selection Studies of high-level methods that related elements of the history or physical examination in patients presenting with floaters and/or flashes and PVD to the likelihood of retinal tear.

Results For patients with acute onset of floaters and/or flashes who are self-referred or referred to an ophthalmologist, the prevalence of retinal tear is 14% (95% confidence interval [CI], 12%-16%). Subjective visual reduction is the most important symptom associated with retinal tear (likelihood ratio [LR], 5.0; 95% CI, 3.1-8.1). Vitreous hemorrhage on slitlamp biomicroscopy is the best-studied finding with the narrowest positive LR for retinal tear (summary LR, 10; 95% CI, 5.1-20). Absence of vitreous pigment during this examination is the best-studied finding with the narrowest negative LR (summary LR, 0.23; 95% CI, 0.12-0.43). Patients initially diagnosed as having uncomplicated PVD have a 3.4% chance of a retinal tear within 6 weeks. The risk increases with new onset of at least 10 floaters (summary LR, 8.1-36) or subjective visual reduction (summary LR, 2.3-17) during this period.

Conclusions Primary care physicians should evaluate patients with acute-onset floaters and/or flashes due to suspected PVD, or patients with known PVD and a change in symptoms, for high-risk features of retinal tear and detachment. Physicians should always assess these patients' visual acuity. Patients at increased risk should be triaged for urgent ophthalmologic assessment.

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Figure 1. Normal Eye Anatomy, PVD, Retinal Tear, and Retinal Detachment
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A, Normal eye anatomy. B, Posterior vitreous detachment (PVD) involves separation of the posterior vitreous from the retina as a result of vitreous degeneration and shrinkage. C, In the acute phase of PVD, as the vitreous shrinks and detaches from the retina, tractional forces may be sufficient to cause a full-thickness tear in the retina. D, When a retinal tear occurs, fluid is allowed entry into the subretinal space, which can lead to retinal detachment (separation of the neurosensory layer from the underlying retinal pigment epithelium).

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Figure 2. Area of Peripheral Retina With 2 Horseshoe-Shaped Retinal Tears in an Area of Billowing Retinal Detachment
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Figure 3. Fundus Photograph of Vitreous Hemorrhage
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Superiorly, vitreous hemorrhage is completely obscuring retinal details. Inferiorly, some hazy retinal details (including vessels) can be observed through the vitreous hemorrhage.

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