Make the Diagnosis: Does This Patient With Floaters and/or Flashes Have a Retinal Tear?
Among patients with acute flashes and/or floaters who seek ophthalmological care or are referred for an evaluation, the prevalence of a retinal tear is 14%. Most of these patients will have uncomplicated posterior vitreous detachments, and over the ensuing 6 months they have a 3.4% chance of developing a retinal tear.
Population in Whom Flashes and/or Floaters Suggest Retinal Tear
Most people will develop posterior vitreous detachment at some point in their lives, manifested by visual symptoms of flashes and floaters. However, most patients do not seek urgent attention as the onset is gradual and may be more annoying than alarming. When patients do present with flashes and/or floaters, the evaluation has 3 steps: (1) elicit the patient's history of visual symptoms and assess for nonocular causes, (2) test visual acuity and perform an eye examination, and (3) consider ocular causes of visual symptoms of floaters and flashes and identify high-risk features for retinal tears.
Assessing the Likelihood of Retinal Tear
Men are slightly more likely to experience retinal tears (likelihood ratio (LR), 1.5; 95% confidence interval (CI), 1.1-2.0). However, older age (>60 years), having myopia, or having both flashes and floaters rather than 1 of the symptoms has little effect on the likelihood with the LRs approaching 1.0. By far, the most important finding from the patient's history is subjective visual loss (Table 75-1). There are no published data to describe the accuracy of the symptom of the patient's perception of a “sudden gray curtain” obscuring vision. While a primary care clinician may perform direct ophthalmoscopy and identify abnormalities (Table 75-1), the better examination will be through slitlamp biomicroscopy and indirect ophthalmoscopy with scleral depression performed by an ophthalmologist. Thus, the role of the primary care clinicians is frequently to determine the urgency of referral to a specialist (Table 75-2). Once a patient has a posterior vitreous detachment as evidenced by ocular flashes and/or floaters, a sudden increase in floaters suggests a retinal tear.
Table 75-1Clinical Findings for Identifying Retinal Tear in Patients With Flashes and/or Floaters ||Download (.pdf) Table 75-1 Clinical Findings for Identifying Retinal Tear in Patients With Flashes and/or Floaters
|Finding ||LR+ (95% CI) ||LR- (95% CI) |
| ||Symptoms |
|Subjective vision loss1 ||5.0 (3.1-8.1) ||0.60 (0.49-0.73) |
|Sudden increase in floaters (≥10) in patients with prior posterior vitreous detachment ||8.1-36 ||0.53-0.55 |
|Sudden increase in flashesa in patients with prior posterior vitreous detachment ||1.9-7.9 ||0.96-0.98 |
| || |
|Vitreous pigment ||44 (2.3-852) ||0.23 (0.12-0.43) |
|Vitreous hemorrhage ||10 (5.1-20) ||0.49 (0.38-0.64) |
Table 75-2Suggested Approach for Referral of Patients With Presumed ...