What is the essential workup for a patient presenting with blurry vision and floaters in bilateral eyes?

Essential Workup for Bilateral Blurry Vision and Floaters

Patients presenting with bilateral blurry vision and floaters require urgent same-day referral to an ophthalmologist for a comprehensive eye examination to rule out sight-threatening conditions such as retinal tears or detachment. 1

Initial Assessment

History Elements

• Onset and duration of symptoms (acute vs. gradual)
• Characteristics of floaters (number, size, recent increase)
• Presence of flashes of light
• Presence of visual field defects (curtain or shadow)
• Diurnal pattern (worse upon waking, improving later in day)
• Associated symptoms (photophobia, redness, pain)
• Prior eye trauma 2
• History of ocular surgery, including YAG laser capsulotomy 2
• History of intravitreal injections 2
• Family history of retinal detachment or genetic disorders 2
• Myopia (increases risk of retinal tears) 2, 1

Physical Examination

1. Visual acuity testing 2, 1
2. Pupillary assessment for relative afferent pupillary defect 2
3. Confrontation visual field examination 2
4. Examination of the vitreous for:
   • Hemorrhage
   • Detachment
   • Pigmented cells (highly suggestive of retinal tear) 2, 3
5. Peripheral fundus examination using:
   • Indirect ophthalmoscope with scleral depression (preferred method) 2
   • Slit-lamp biomicroscopy with mirrored contact lens or condensing lens (alternative) 2

High-Risk Features Requiring Urgent Attention

• Subjective visual reduction (strongest symptom associated with retinal tear, LR 5.0) 3, 4
• Vitreous hemorrhage on examination (LR 10 for retinal tear) 3
• Vitreous pigmented cells 2
• Sudden increase in number or size of floaters 1
• New onset of at least 10 floaters (LR 8.1-36 for retinal tear) 3

Diagnostic Testing

If media opacity or poor patient cooperation prevents adequate examination of the peripheral retina:

• B-scan ultrasonography to search for retinal tears, retinal detachment, or other causes of vitreous hemorrhage 2
• Optical coherence tomography (OCT) may be helpful to evaluate posterior vitreous detachment 2

Differential Diagnosis

Consider other causes of vitreous cells or debris:

• Posterior vitreous detachment (most common) 1, 3
• Uveitis
• Infection
• Inflammation
• Neoplasia 2
• Leukemia (rare, can present with bilateral proliferative retinopathy) 5

Management Approach

1. For acute-onset floaters: Urgent same-day ophthalmologic evaluation 1, 3

2. If peripheral examination is limited by vitreous hemorrhage:

   • Follow closely (weekly) until hemorrhage resolves or thorough examination is possible 2
   • Consider head elevation and bilateral patching to help clear vitreous hemorrhage 2
   • Repeat ultrasonography within 1-2 weeks if retinal tear is suspected 2

3. If retinal tear or detachment is identified:

   • Immediate referral to retinal specialist 4
   • Early vitrectomy may be considered for dense vitreous hemorrhage to reduce risk of vision loss 2

Follow-up Recommendations

• Patients with benign findings should be educated about warning signs requiring immediate re-evaluation 1
• Patients with posterior vitreous detachment without tears have a 3.4% chance of developing a retinal tear within 6 weeks and should be monitored 3
• Regular follow-up examinations for patients with chronic floaters 1

Common Pitfalls to Avoid

• Dismissing acute-onset floaters as benign without ophthalmologic evaluation 1
• Failing to recognize the association between subjective visual reduction and retinal pathology 1, 3, 4
• Not providing clear instructions about warning signs requiring immediate re-evaluation 1
• Inadequate peripheral retinal examination (scleral depression is the preferred method) 2