Sudden onset single floater symptom in one eye: is urgent dilated fundal examination by an ophthalmologist warranted?
Report by Jaheed Khan, Clinical Research Fellow
Checked by Genevieve Larkin
A shortcut review was carried out to establish whether patients with only symptom of a sudden onset uniocular floater warrant urgent referral to an ophthalmologist for specialist retinal examination to exclude retinal tears or detachment. Altogether 316 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The clinical bottom line is that patients who complain of a sudden onset single floater with no photopsia or change in visual acuity in one eye should merit urgent referral to an ophthalmologist for a detailed fundal examination.
Clinical scenario
A 60 year old lady presents to the emergency department complaining of a 3 day history of a sudden onset single floater in her left eye with no history of flashing lights or other visual problems. Her visual acuity is 6/6 aided in each eye. Dilated fundal examination of her retina with a direct ophthalmoscope is unable to exclude peripheral retinal pathology. You wonder whether she needs specialist dilated fundal examination by an ophthalmologist to exclude a retinal tear or detachment.
Three part question
In [patients with an isolated floater, no photopsia, and no change in visual acuity] is [dilated fundoscopy by an ophthalmologist] required to [exclude retinal tear/detachment or other significant pathology]?
Search strategy
Medline search from 1951–08/2005 using the Dialog Datastar interface inputting the following search terms: {(vitreous detachment OR photopsia OR flashing lights OR light flashes OR flashes OR floaters OR visual disturbance OR visual acuity OR vision, low) AND (ophthalmoscopy OR mydriasis OR specialism OR referral OR emergency OR emergencies OR early management) AND (retinal detachment OR retinal perforations OR vitreous hemorrhage OR retinal disease)} limited to papers published in English.
Search outcome
Altogether 361 papers were returned; two papers were found that addressed our particular question.
Table 1 Summary of the two papers found.
| Author, date, and country | Patient group | Study type (level of evidence) | Outcomes | Key results | Study weaknesses |
|---|---|---|---|---|---|
| Diamond JP, 1992, UK | 170 patients; 147 with unilateral symptoms of flashes and floaters | Prospective case study | Patients classified into benign vitreo‐retinal disease or potentially sight threatening disease after fundal examination | 75.9% incidence of benign vitreo‐retinal disease | Small number of patients in the study and with symptom of isolated single floater |
| 23 with bilateral symptoms attending eye casualty over 6 months | Sight threatening condition found in 41 patients (24.5%), the most important being a retinal break (16.5%) | One junior investigator examining patients with potential to miss retinal breaks. | |||
| 27 with symptoms of isolated single floater | Correlate symptoms and signs to diagnosis | Only one patient of the 27 with single floater symptomology had a retinal break (3.7%) | Symptoms can vary according to patient history, especially in the elderly | ||
| Patients categorised according to symptoms and signs | No significant difference in incidence of retinal breaks in patients with single floater v asymptomatic fellow eyes (3.7% v 1.4%) | ||||
| Byer NE, 1994, USA | 350 patients with diagnosis of acute posterior vitreous detachment examined between 1975 and 1987 | Prospective case study | Correlate symptomology and prognosis of posterior vitreous detachment | Of 163 patients who had 1–2 floaters (without flashing lights) as their presenting symptom, 12 (7.3%) went on to develop retinal tears | Study starts with a cohort of patients with posterior vitreous detachment and not patients with the symptom of an isolated floater |
| Of 31 eyes that had retinal tears on initial examination, 4 (13%) had a single floater and no light flashes as their initial symptom | No subgroup analysis to elucidate whether single floater v multiple floater groups differ in their rate of retinal tear development | ||||
| Relying on subjective history of patient with recall over the previous 3 months. | |||||
| No control group with fellow asymptomatic eyes reported |
Comments
The symptom of a sudden onset single floater with or without flashing lights in one eye is a common presentation of posterior vitreous detachment. There is a small risk of retinal breaks associated with this condition. The two studies have highlighted a small risk of retinal break development in patients who have symptoms of a single floater in their vision but do not agree on the recommended management for this group of patients. The timing for development of retinal tears or detachment following posterior vitreous detachment can be variable. As a result there is no consensus as to whether this group of patients can be reviewed safely on a routine outpatient basis.
Clinical bottom line
Patients who complain of a sudden onset single floater with no photopsia or change in visual acuity in one eye should merit urgent referral to an ophthalmologist for a detailed fundal examination.
Footnotes
Funding: none.
Competing interests: none declared.
The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd to permit this article (if accepted) to be published in EMJ and any other BMJPGL products and sublicences such use and exploit all subsidiary rights, as set out in our licence.
References
- 1.Diamond J P. When are simple flashes and floaters ocular emergencies? Eye 1992;6( Pt 1):102-4. [DOI] [PubMed] [Google Scholar]
- 2.Byer N E. Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment. Ophthalmology 1994;101(9):1503-13. [DOI] [PubMed] [Google Scholar]