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Floaters & Flashes

Checked: 23-04-2022 by Rob Adams Next Review: 23-05-2023

Overview

Floaters and Flashes are very common symptoms and are largely due to an age-related change in the vitreous, however they can indicate a retinal detachment. It is difficult to discern from symptoms which patients have age-related change in their vitreous (typically a posterior vitreous detachment) and which have retinal damage.

Symptoms include:

Floaters: these are black dots floating in the eye, often described as a cobweb or a swarm of flies in the vision.
Flashes: these are typically very short-lived flashes of light in the side of the vision that last less than a second, often described as a flash of light over their shoulder. They tend to be worse with head movement and in the dark.
Shadow in vision: this will be observed in the affected eye and be coming from the periphery of the vision, the patient will not be able to see around the shadow.

Who to refer

Referral for Diagnosis

Patients presenting within 6 weeks of onset of symptoms - Any patient with acute onset of symptoms (within the last 6 weeks) should be seen urgently (within 24 hours) in the BEH emergency department. See also Red Flags below.

Patients presenting after 6 weeks of onset of symptoms - Patients presenting after 6 weeks can be referred urgently via eRS to the vitreoretinal clinic.

Referral for Treatment

Do not routinely refer patients for treatment if a concerning cause has been excluded and symptoms are stable, as funding restrictions for treatment apply - see the BNSSG Vitreous Floaters Exceptional Funding Request Policy.

Red Flags

Patients with acute onset of floaters/ flashing lights/ shadow in vision within the last 6 weeks should attend the BEH emergency department within 24 hours.

In addition, please discuss with the on call ophthalmologist immediately if any of the following red flags are present:

Loss of vision - diffuse or focal
Recent eye surgery or eye trauma
Eye pain
Loss of red reflex
Abnormal findings on examination e.g. Schaeffer’s sign/Tobacco dust (Only visible on slit lamp examination)

Before referral

Perform an examination of the eye and vision to exclude red flags.

There is no immediate treatment which can be given in primary care so refer appropriately for diagnosis as detailed above.

Referral

Patients who have developed symptoms acutely (within the last 6 weeks) should be asked to attend the BEH Emergency Department within 24 hours (not out of hours).

Patients who have longer standing symptoms (>6 weeks) can be referred urgently via eRS to the vitreo-retinal clinic, but the patient should be given safety-netting advice and advised to attend BEH emergency department if they experience any acute deterioration of symptoms or develop red flags.

If a concerning cause has been eliminated and symptoms are stable then treatments such as vitrectomy, laser vitreolysis or eye drops and medication are subject to restrictions as layed out in the Vitreous Floaters Exceptional Funding Request Policy and will only be funded in exceptional circumstances.

Resources

These guidelines have been written by Rhys Harrison, consultant ophthalmologist at Bristol Eye Hospital, with thanks to the patients who have kindly given consent to use their photos.

For full ophthalmology guidelines see: Primary Care Ophthalmology Guidance Document

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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