Flashes and Floaters
3) Guideline for the Investigation and Referral of Flashes, Floaters, PVD and Retinal Detachment
3.1 Patients complaining of recent onset flashes and floaters frequently present in optometric practices or telephone for advice. This is an area of practice fraught with danger and potential for litigation and should be taken seriously in all cases.
There are two possible courses of action, as follows:
a) If it is at all possible to fit the patient in on the same day, carry out a full, dilated examination of the eye using every instrument at your disposal, these might include:
- Direct ophthalmoscope
- Slit-lamp bio with 90D Superfield Volk lens
- Slit-lamp bio with 3 mirror contact lens
- Indirect (headset) ophthalmoscopy with scleral indentation
- Full field visual field test
Look very carefully for Schaffer’s sign (pigmented cells in the anterior third of the vitreous) observed with the slit lamp by asking the patient to look up and then straight ahead. 100% of patients with a positive Schaffer’s sign will have a retinal break.
Should a retinal tear, detachment or Schaffer’s sign be observed refer the patient straight to BMEC, after phoning the triage nurse in the casualty department (0121 554 3801) and give a leaflet on PVD and retinal detachment to the patient.
If no tear, detachment or Schaffer’s sign is seen, carefully explain the signs and symptoms of a retinal detachment to the patient with strict instructions to proceed straight to BMEC should they occur. Also give a leaflet on PVD and retinal detachment to the patient.
If you have any doubts about whether there is a retinal tear or not always refer.
b) If it is absolutely impossible to see the patient on the same day, issue a leaflet on PVD and retinal detachment (if patient in attendance at the practice) and advise him/her to proceed straight to BMEC casualty department.
3.2 If flashes and floaters have been noticed for the "past few months" it is probably safe to arrange to see the patient for a full, dilated examination as soon as possible, when option 1 above should be exercised.
All practice staff should be made aware of this advice.
3.3 A suitable leaflet for use on these occasions is available for download from the Good Hope Hospital Eye Department web site; www.goodhope.nhs.org/departments/eyedept. All optometrists may access these leaflets free of charge and print them out for distribution to patients. In fact there are a number of useful leaflets available from the Good Hope site, all of which could usefully be introduced into any optometric practice. Also RNIB produce a leaflet entitled “Understanding Retinal Detachment” in large print – available from RNIB customer services on 0845 702 3153.
One tip, for those able to download onto a computer equipped with Microsoft Publisher, the Good Hope PVD leaflet is a little off centre and can be adjusted in Publisher although care should be taken to ensure that none of the words are lost.
For those who do not have internet access one copy of the Good Hope leaflet (which can be photocopied) may be obtained by contacting the LOC secretariat on 0121 357 1748.
3.4 The LOC believes that optometrists following the foregoing advice and making adequate notes on the patient's record will be in a good position to defend any action brought against them by patients who, having been seen because of flashes and floaters and given advice but not referred, subsequently suffer a retinal detachment.
3.5 The contents of this guidance are not intended to be prescriptive and it is the duty of the individual optometrist to ensure that he is fully aware of the College of Optometrists emergency referral guidelines.
3.6 As another alternative to the leaflet available from the Good Hope web site practitioners may wish to use the following document issued by the AOP in January 2005
AOP Jan 2005
Flashes and Floaters
The following information sheet may be used to provide written backup
following a verbal explanation of the symptoms and risks of posterior vitreous detachment. The text can be transferred to your own headed paper.
The text is written so as to be easily understood by the general public, so we advise that it is not altered. It should be laid out using a clear font in a reasonably large size, as in the example below.
This information sheet is intended for use by the optometrist to augment
verbal information and explanations given to the patient in the consulting
room. It is not intended as a general waiting room information leaflet and it should not be used as an alternative to appropriate verbal explanations and warnings.
It is always wise to fully document your actions on the patient’s record card and this should include a note that you have issued written advice to the patient.
AOP Jan 2005
Flashes and Floaters
Patient Information Sheet
What are floaters?
Often, people who have healthy eyes see floaters. They appear as
spots, lines or cobweb effects, usually when you look at a plain surface
such as a white wall or a clear blue sky. They often appear when the
clear jelly in the main part of your eye gets older.
What are flashes?
Sometimes the jelly in the main part of your eye shrinks a little and tugs
on the retina (the light-sensitive layer) at the back of your eye. This can
cause flashes of light at the edge of your vision. These differ from the
disturbance of vision that can occur with migraine
When should I be concerned?
If you suddenly notice a shower of new floaters, or floaters along with
flashes or a dark shadow or “curtain” in your vision, then you should
seek advice urgently. These symptoms can mean that the retina is
tearing. Go to an Accident and Emergency Department if necessary.
What will happen if the retina tears?
The retina is at the back of your eye. It receives the images and sends
them to the brain. This is one of the things that enable you to see. If the
retina tears, it may come away from the back wall of the eye. This is
called retinal detachment. It can result in partial or complete loss of
How is retinal detachment treated?
A tear may be treated by using a laser. If treated quickly, you may have
a better chance of full recovery. However, if your retina has become
detached, you will need surgery. The operation may restore most of
your vision but may come too late for a full recovery.
Look out for:
· flashes or floaters getting worse
· a black shadow in your vision
· a sudden cloud of spots
· a curtain or veil over your vision
· any sudden loss of vision.
Go to an Accident and Emergency Department without delay
if you notice any of these symptoms.
In Birmingham go to:
Birmingham and Midland Eye Centre
City Hospital NHS Trust