What is the primary care approach to a patient complaining of floaters in the eye?

Primary Care Approach to Eye Floaters

Patients with acute-onset floaters should be urgently referred to an ophthalmologist for same-day evaluation to rule out sight-threatening conditions such as retinal tears or detachment. 1

Initial Assessment in Primary Care

Key History Elements

• Onset and duration of floaters (sudden vs. gradual)
• Associated symptoms:
  • Flashes of light
  • Visual field defects or "curtain" over vision
  • Decreased visual acuity
  • Pain
• Unilateral vs. bilateral symptoms
• History of trauma
• Risk factors:
  • Myopia (nearsightedness)
  • Previous eye surgery
  • Family history of retinal tears/detachment
  • Previous retinal tears/detachment

Basic Examination

• Visual acuity assessment (using eye chart)
• Pupillary examination (equal, round, reactive)
• Red reflex examination
• Penlight inspection of anterior eye 1

Risk Stratification

High-Risk Features Requiring Same-Day Ophthalmology Referral

• Acute-onset floaters with subjective visual reduction (7.9× higher risk of urgent retinal pathology) 2
• Floaters accompanied by flashes of light
• Floaters with visual field defects
• Recent eye trauma
• History of retinal tears/detachment
• Vitreous or retinal hemorrhage visible on examination

Moderate-Risk Features Requiring Prompt (Within 1-2 Weeks) Referral

• New-onset floaters without visual reduction or flashes
• High myopia with new floaters
• Persistent floaters causing significant visual disturbance

Low-Risk Features (Routine Referral Acceptable)

• Chronic, stable floaters without other symptoms
• Minimal impact on daily activities

Patient Education

Primary care physicians should educate patients about:

1. The significance of floaters (often due to posterior vitreous detachment)
2. Warning signs requiring immediate attention:
   • Sudden increase in number or size of floaters
   • Flashes of light
   • Curtain or shadow in peripheral vision
   • Decrease in visual acuity 1
3. Self-monitoring techniques:
   • Regular assessment of visual acuity by reading newsprint
   • Awareness of visual field changes 1

Management Options

Conservative Management

• Observation is appropriate for most patients with benign floaters
• Reassurance that most isolated floaters are not sight-threatening
• Floaters typically become less noticeable over time as the brain adapts

Interventional Options (to be discussed by ophthalmologist)

• Pars plana vitrectomy: Most definitive treatment but carries risks of retinal tears, retinal detachment, and cataract formation 3
• YAG vitreolysis: Less invasive alternative with variable success rates 4

Follow-up Recommendations

• Patients with acute floaters who have been cleared by ophthalmology should be advised to return immediately if they experience new symptoms
• Patients with chronic floaters should have regular ophthalmologic examinations
• Patients with high-risk conditions (high myopia, history of retinal pathology) may benefit from periodic funduscopic examinations 1

Common Pitfalls to Avoid

1. Dismissing acute-onset floaters as benign without ophthalmologic evaluation
2. Failing to recognize the association between subjective visual reduction and retinal pathology
3. Not providing clear instructions about warning signs requiring immediate re-evaluation
4. Overlooking the psychological impact of persistent floaters on quality of life
5. Attempting to perform direct ophthalmoscopy without adequate training or equipment (this is unlikely to be useful for diagnosis of retinal issues when performed by non-ophthalmologists) 1

Remember that while most floaters are benign and related to age-related vitreous changes, the primary care physician's most important role is to identify patients who need urgent ophthalmologic evaluation to prevent vision loss from retinal pathology.