What should be done for a patient seeing vitreous floaters with no other symptoms?

Management of Vitreous Floaters Without Other Symptoms

A patient presenting with isolated vitreous floaters and no other symptoms requires urgent ophthalmologic examination with dilated fundoscopy and scleral depression to rule out retinal tears or detachment, as 8-22% of patients with acute posterior vitreous detachment symptoms have a retinal tear at initial presentation. 1

Immediate Action Required

All patients with new-onset floaters must be examined by an ophthalmologist skilled in binocular indirect ophthalmoscopy with scleral depression, even when floaters appear isolated without flashes or visual field loss. 2, 1 This is non-negotiable because:

• There are no symptoms that can reliably distinguish between a benign posterior vitreous detachment (PVD) and one with an associated retinal break, making peripheral retinal examination mandatory. 2
• Even patients presenting with floaters alone harbor 26.7% of all retinal breaks found in symptomatic patients. 3
• The amount of vitreous hemorrhage directly correlates with the likelihood of retinal tear, and early hemorrhage may present simply as new floaters. 1

Essential Examination Components

The ophthalmologist must perform:

• Visual acuity testing to establish baseline and detect any subtle vision loss. 2, 4
• Pupillary assessment for relative afferent pupillary defect. 2
• Vitreous examination for hemorrhage, pigmented cells (Shafer's sign), detachment, and syneresis. 2, 4
• Careful peripheral fundus examination using indirect ophthalmoscopy with scleral depression, which is the preferred method for evaluating peripheral vitreoretinal pathology. 2, 1

If media opacity or patient cooperation precludes adequate examination, B-scan ultrasonography must be performed to search for retinal tears, detachment, or other pathology. 2, 4

Critical Follow-Up Protocol

Even when the initial examination reveals no retinal breaks:

• Patients must return for follow-up examination within 6 weeks, as 2-5% of patients with initially normal examinations will develop retinal breaks during this period. 1, 4
• 80% of patients who later develop breaks had either pigmented cells, hemorrhage in the vitreous/retina at initial evaluation, or new symptoms prompting a return visit. 1
• Any patient with vitreous pigment, vitreous/retinal hemorrhage, or visible vitreoretinal traction requires follow-up within 6 weeks. 1

Patient Education and Red Flags

All patients must be educated about warning symptoms requiring immediate return, including:

• Sudden increase in number of floaters (possible vitreous hemorrhage or new retinal tear). 1, 5
• New flashes of light (photopsias indicating vitreoretinal traction). 1, 5
• Peripheral visual field loss (possible retinal detachment). 1, 5
• Sudden decrease in visual acuity (retinal detachment or macular involvement). 1

Long-Term Management

If no retinal pathology is found:

• Most PVD symptoms diminish over time, sometimes requiring several months, and patients should receive appropriate reassurance. 2, 1
• For persistent, debilitating floaters significantly impairing quality of life after several months of conservative management, pars plana vitrectomy is the definitive treatment option, with greater patient satisfaction than YAG laser vitreolysis. 1
• YAG laser vitreolysis is a less invasive alternative but provides only moderate symptom resolution compared to vitrectomy. 1

Common Pitfalls to Avoid

• Never assume isolated floaters are benign without proper ophthalmologic examination, as this can lead to delayed diagnosis of sight-threatening retinal pathology. 1
• Do not dismiss patients with "just floaters" for routine follow-up without urgent dilated examination, as even isolated floaters without flashes carry significant risk of retinal breaks. 3, 6
• Failing to arrange 6-week follow-up even when initial examination is normal can result in missed diagnoses of delayed retinal breaks. 1, 4
• Do not underestimate the impact on quality of life, as studies demonstrate significant reduction in contrast sensitivity function and vision-related quality of life in affected patients. 1