What should I do if I'm experiencing floaters in my vision?

Management of Floaters in Vision

If you are experiencing floaters in your vision, you should be urgently referred to an ophthalmologist for same-day evaluation to rule out sight-threatening conditions such as retinal tears or detachment. 1

Understanding Floaters

Floaters are visual phenomena caused by particles or debris in the vitreous gel of the eye that cast shadows on the retina, especially noticeable against bright backgrounds. They commonly result from:

• Posterior vitreous detachment (PVD) - most common cause in adults
• Vitreous hemorrhage
• Inflammatory conditions
• Age-related degenerative changes in the vitreous body

When to Seek Immediate Medical Attention

Urgent Warning Signs (Require Same-Day Evaluation):

• Sudden increase in number or size of floaters
• Floaters accompanied by flashes of light
• Curtain or shadow appearing in peripheral vision
• Decrease in visual acuity
• Floaters after recent eye trauma

Risk Assessment

The risk of retinal tear in patients presenting with acute-onset floaters and/or flashes is approximately 14% 2. Risk factors that increase concern include:

• Subjective visual reduction (5x higher likelihood of retinal tear) 2
• Vitreous hemorrhage (10x higher likelihood of retinal tear) 2
• Myopia (nearsightedness)
• Previous eye surgery
• Family history of retinal tears or detachment
• Previous retinal tears or detachment

Diagnostic Approach

An ophthalmologist will typically perform:

1. Best-corrected visual acuity testing
2. Pupillary examination
3. Intraocular pressure measurement (unless corneal trauma is suspected)
4. Slit-lamp biomicroscopy to examine:
   • Vitreous for hemorrhage, detachment, or pigmented cells
   • Anterior chamber for hyphema or inflammation
5. Dilated fundus examination with indirect ophthalmoscope using scleral depression
6. Visual field testing by confrontation

Additional diagnostic tests may include:

• B-scan ultrasonography (if media opacity prevents adequate fundus examination)
• Optical coherence tomography (OCT) to evaluate posterior vitreous detachment

Management Options

1. Observation

Most cases of uncomplicated floaters due to PVD can be managed with observation. However, patients initially diagnosed with uncomplicated PVD have a 3.4% chance of developing a retinal tear within 6 weeks 2.

2. Procedural Management (for persistent, visually significant floaters):

• Pars plana vitrectomy (PPV) - most definitive management but carries risks of infection, cataract formation, and retinal detachment 3
• Nd:YAG laser vitreolysis - less invasive alternative with varied success rates 3

Self-Monitoring

Patients should be educated to:

• Regularly assess their visual acuity
• Be aware of visual field changes
• Return immediately if experiencing:
  • New onset of at least 10 floaters
  • Subjective visual reduction
  • Flashes of light
  • Peripheral vision changes

Special Considerations

HIV-Infected Patients

Floaters in HIV-infected patients, especially those with low CD4+ counts (<50 cells/μL), may indicate cytomegalovirus (CMV) retinitis. These patients should be educated about the significance of increased floaters and advised to assess their visual acuity regularly 4.

Follow-Up

If no retinal breaks are found at initial examination, follow-up examination is recommended within 6 weeks, or sooner if new symptoms develop 4.

Remember that while most floaters are benign, they can be the first sign of serious retinal conditions that require prompt treatment to prevent vision loss.