Abstract
Aim
The aim of this retrospective review was to analyse the frequency of patients presenting with flashes and/or floaters (F/F) on bright versus dark days to the eye emergency department of a tertiary referral hospital (the Mater Misericordiae University Hospital) over a 3-year period. The diagnostic and clinical outcomes of F/F presentations were also analysed.
Methods
This retrospective study assessed eye casualty attendances between January 2018 and December 2020. Solar irradiation (j/cm2) at ground level was retrieved from the records of Met Eireann (Irish National Meteorological Service) via their open access records. A review of electronic patient medical records using the in-house database patient centre was carried out of all patients who attended EED of during the study timeline on the 5 ‘brightest’ and 5 ‘darkest’ days of each year.
Results
Seven hundred forty patient presentations were analysed in total. Overall, 16% (n = 119) of all patients that attended EED during the timeframe of the study presented with F/F. One hundred six patients (89%) presented with floaters, 40 patients (34%) presented with flashing lights/photopsia, and 35 patients (29%) presented with both F/F. More patients presented to EED with F/F on bright days when compared with dark days (74 vs 45, p < 0.05). Eighty-nine percent of all patients with F/F presented with monocular floaters. There were more floater presentations during bright when compared with dark days (70 vs 36, p < 0.05). More patients were diagnosed with PVD on bright days when compared with those diagnosed with PVD on dark days (43vs 15, p < 0.05). More RDs were diagnosed on dark days compared with bright days (7 vs 3, p < 0.05).
Conclusion
This study established that F/F presentations were more likely to present during bright days when compared with dark days. The diagnosis of PVD was more common during bright days, and RDs were diagnosed significantly more frequently on dark days. Although incident solar radiation was correlated with greater floaters/PVD presentation, causation is unlikely, and the duration of PVD may have been longer in patients presenting on bright days (i.e. pseudo-sudden symptoms).
Supplementary Information
The online version contains supplementary material available at 10.1007/s11845-023-03281-1.
Keywords: Floaters, Ophthalmic emergency, Photopsia, Posterior vitreous detachment, Retinal detachment, Retinal tear
Introduction
Flashing lights (photopsia) and floaters (myodesopsia) are visual phenomena which can occur individually or together and commonly lead to patient attendances to emergency ophthalmic services. Common aetiologies behind monocular flashes/floater (F/F) symptoms include posterior vitreous detachment (PVD), retinal tear (RT), rhegmatogenous retinal detachment (RD), or combinations thereof, as well as other ocular pathologies such as vitreous haemorrhage (VH), pathologic myopia, and proliferative retinovascular occlusive disease including diabetic retinopathy, uveitis, and rarely, retinal migraine [1, 2]. F/F symptoms require both prompt and accurate assessment for an underlying treatable pathology. Timely treatment interventions, such as laser or surgery for RT or RD, and anti-inflammatory therapy for uveitis are necessary to reduce the risk of progressive visual impairment and blindness associated with these disorders.
Floaters are generally caused by age-related biochemical alterations in the optical clarity of the vitreous body and most commonly occur due to degenerative collagen remodelling and liquefaction of the vitreous, which ultimately leads to vitreous body collapse [3]. Biochemically, the vitreous body, a virtually acellular structure, is composed primarily of water (98%), as well as macromolecules including cations, anions, hyaluronic acid, glycosaminoglycans, proteoglycans, and type 2 collagen [4, 5]. Under normal physiological conditions, the inner and outer blood ocular barriers prevent exudation of red blood cells or white blood cells into the vitreous body; however certain disease states such as uveitis and diabetes mellitus may impair this barrier function, thereby causing reduction in the optical clarity of the vitreous, leading to the development of vitreous haze which may present as subjective floaters [6]. Photopsia, which are less common than floaters, occur due to stimulation of the neurosensory retina secondary to vitreoretinal traction (e.g. PVD) or mechanical stretch due to intraretinal or subretinal accumulation of fluid, blood, or lipid exudate) [7].
F/F are more common on bright, sunny days versus dark days [1], and our hypothesis is that this may result in increased EED patient presentations. To our knowledge, there are no other reports or studies in the literature analysing weather patterns and F/F presentations to EED. The aims of this retrospective review were to analyse the frequency of patients presenting to the eye emergency department (EED) with flashes and/or floaters (F/F) on ‘bright’ versus ‘dark’ days over a 3-year period (2018–2020 inclusive). Furthermore, we sought to elicit the both the diagnostic and clinical outcomes of F/F presentations and discussed reasons for differences in presentation.
Methods
This retrospective review of the EED department of the tertiary referral centre at the Mater Misericordiae University Hospital, Dublin, was conducted between January 2018 and December 2020. A review of electronic patient medical records using the in-house database Patient Centre was carried out of all patients who attended EED of during the study timeline.
Solar irradiation (j/cm2) at ground level was retrieved from the records of Met Eireann (Irish National Meteorological Service) via their open access records (https://www.met.ie/climate/available-data/historical-data). Solar radiation at ground level accounts for cloud cover and thus equates to the degree of incident light present on a given day to enter a person’s eye. With the hypothesis that greater incident light causes greater symptoms of floaters, the five brightest and five darkest days for each year from 2018 to 2020 were assessed.
Patient demographics and clinical outcomes
Baseline patient demographic data collected from patient records included age, gender, reason for presentation to EED (signs and symptoms), clinical diagnosis, and clinical outcome. Five main clinical outcomes were measured during this study: (1) the total number of patient with F/F that presented to EED, (2) comparison of F/F presentations in bright versus dark days, (3) F/F diagnoses in bright versus dark days and their resultant clinical outcomes, and (4) the proportion of PVDs, RT, and RD diagnoses that presented as F/F in bright and dark days.
Statistical analysis
All statistical analyses were performed using Microsoft® Excel for Mac version 16.16.27. Chi-squared test (χ2) was utilized in to determine statistical significance of categorical variables. Differences were considered as statistically significant when p < 0.05. This study abides by the Declaration of Helsinki and local data protection legislation including the General Data Protection Regulation articles 6 and 9.
Results
Patient demographics
Across the 30 days (15 bright and 15 dark days) included in the study, 740 patients were seen in total, 51% (n = 355) of which were female. The breakdown of gender was comparable between bright and dark days; 51% of patients seen during bright days were female versus 49% during dark days. The overall mean age of patients presenting to EED was 54.76 ± 5.16 years, which was also similar on bright and dark days (55.48 ± 2.72 vs 52.27 ± 2). Fifty-two percent (n = 387) of patients presented to EED during sunny days compared to 48% (n = 353) of patients who presented during dark days. Patient demographic data is described in Table 1.
Table 1.
Overall patient demographics and breakdown of F/F by bright versus dark days
| Total | Bright | Dark | p value (bright vs dark) | |
|---|---|---|---|---|
| Total number of patients presenting to eye casualty (n =) | 740 | 387 | 353 | |
| % female (n =) | 51% (n = 355) | 51% (n = 197) | 49% (n = 177) | |
| Mean age, y (SD) | 54.76 (5.16) | 55.48 (2.72) | 52.27 (2) | |
| % with flashes or floaters (n =) | 16% (n = 119) | 19% (n = 74) | 12.7% (n = 45) | < 0.05 |
| % with flashes (n =) | 5.4% (n = 40) | 6.7% (n = 26) | 4% (n = 14) | p = 0.65 |
| % with floaters (n =) | 14.3% (n = 106) | 18% (n = 70) | 10.2% (n = 36) | < 0.05 |
| % with flashes & floaters (n =) | 4.7% (35) | 5.9% (n = 23) | 3.4% (n = 2) |
Comment on incident light
The complete data regarding the highest and lowest global radiation (j/cm2) can be found in Supplementary Table 1. However, days with lowest global radiation at sea level (mean 48.1 ± 19.1j/cm2) fell between October and December, while days with the highest global radiation (mean 2863.0 ± 116.4j/cm2) at sea level fell in May to July. This takes into account cloud cover and approximates the incident light to the eye at sea level in Dublin, Ireland, the location of the clinical site in questions.
F/F presentations to EED
The breakdown of F/F presentations to EED on bright versus dark days are described in Table 1. Overall, 16% (n = 119) of patients that attended EED during the timeframe of the study presented with F/F, the first most common reason for attendance. One hundred six patients (89%) presented with floaters, 40 patients (34%) presented with flashing lights/photopsia, and 35 patients (29%) presented with both F/F. Significantly more patients presented to EED with F/F on bright days when compared with dark days (74 vs 45, p < 0.05).
A breakdown of F/F presentations according to symptoms are outlined in Table 2. Overall, 89% (n = 106) of all patients with F/F presented with monocular symptoms. There were significantly more floaters presentations during bright when compared with dark days (70 vs 36, p < 0.05). Thirty-four percent (n = 40) of patients presented with photopsia, but there was no statistically significant difference between the frequency of photopsia in bright versus dark (days (26 vs 14, p = 0.65).
Table 2.
The clinical features of patients presenting to EED with F/F
| Symptoms | Total number of patients | Bright | Dark |
|---|---|---|---|
| Floaters | 106 (89%) | 70 (66%) | 36 (34%) |
| Flashes | 40 (34%) | 26 (65%) | 14 (35%) |
| Both flashes and floaters | 35 (29%) | 23 (66%) | 12 (34%) |
Clinical diagnosis and clinical outcomes of F/F
The clinical diagnoses and clinical outcomes of F/F patient presentations are described in Table 3. Overall, 49% (n = 58) of all patients who presented to EED with F/F were diagnosed with PVD, which was by far the most prevalent diagnosis, followed by no acute findings on examination. Of note, there were no patients with a diagnosis of uveitis presenting with F/F. Significantly more patients were diagnosed with PVD on bright days when compared with those diagnosed with PVD on dark days (43 vs 15, p < 0.05). All patients with a PVD diagnosis were given instructions on symptoms to monitor and advised when and how to seek further ophthalmic advice (i.e. ‘retinal detachment warning’) prior to leaving EED.
Table 3.
The frequency of F/F clinical diagnosis and clinical outcomes
| Clinical diagnosis of F/F presentations | Patient number (total cohort n = 119) | Clinical outcome |
|---|---|---|
| Posterior vitreous detachment | 49% (n = 58) | Retinal detachment warning, review as required |
| No acute pathology | 13% (n = 15) | Discharged |
| No clinical notes | 8% (n = 10) | Unable to assess |
| Retinal detachment | 8% (n = 10) | Retinal detachment surgery |
| Neovascular age-related macular degeneration (nARMD) | 6% (n = 8) | Intravitreal anti-VEGF injections |
| Vitreous haemorrhage/PDR | 3% (n = 4) | Referral to retina clinic for follow-up B scan |
| Retinal tear | 3% (n = 4) | Laser retinopexy |
| Central serous retinopathy | 2% (n = 2) | Retina outpatient clinic referral |
| Diabetic retinopathy | 2% (n = 2) | Diabetic retina service referral |
| Postural/orthostatic hypotension | 1% (n = 1) | Referral to General Practitioner |
| Optic neuritis | 1% (n = 1) | MRI brain/orbits, commenced on 1 g IV methylprednisolone, neurology and neuro-ophthalmology referral |
| Hypertensive retinopathy | 1% (n = 1) | Referral to retina clinic |
| Retinitis pigmentosa | 1% (n = 1) | Referral to retina clinic |
| Migraine | 1% (n = 1) | Referral to outpatient clinic and GP |
Of the 119 patients presenting with F/F, 3% (n = 4) were diagnosed with RT and 8% (n = 10) with RD. The subtype and location of RD were not recorded in this study. Significantly more RDs were diagnosed on dark days compared with bright days (7 vs 3, p < 0.05). Eighty percent (n = 8) of RDs presented with F/F, while 20% (n = 2) of RDs presented with different symptoms (e.g. superior hemifield defect, sudden loss of vision following blunt ocular trauma). Sixty percent (n = 6) of RD patients presented with both F/F, and 20% (n = 2) presented with photopsia alone.
Of the F/F patients with photopsia exclusively (34%, n = 40), 42% (n = 17) were diagnosed with PVD, 18% (n = 7) with RD, 7.5% (n = 3) with a RT, and 5% (n = 2) with VH/proliferative vitreoretinopathy, and 2.5% (n = 1) each were diagnosed with neovascular age-related macular degeneration (nARMD) and optic neuritis, respectively. No acute ophthalmic pathology was noted in four patients, and there were no clinical notes or clinical outcomes documented for two patients that presented with photopsia.
Discussion
A total of 740 patients attended EED during the course of the study timeframe and were included in data analysis. F/F were the most common patient presentation to EED, representing 16% (n = 119) of all patient presentations. In this study, we identified statistically significant increase in presentations of F/F on days with higher incident solar radiation compared to darker days. Overall, only 11% of these conditions required urgent treatment (RT/RD), and 88% were due to non-vision threatening pathology and were either referred for further investigation or discharged. These data may have implications for triaging of referrals and allocation of staff resources relative to the Irish climate.
Undoubtedly, there is increasing demand for all urgent and emergency care in Ireland, including ophthalmic care. This is secondary to changing demographics and disease prevalence, increased population size, and changes in how patients access care. Extreme weather changes are forecast in several climate change models, which will certainly impact healthcare service and provision. Cashman et al. examined the trauma orthopaedic workload in a trauma centre in Ireland and demonstrated that workload levels were significantly higher on days with lower temperatures, thereby having direct implications in terms of hospital staffing and resource allocations [8]. It is vital that, going forward, hospitals are properly equipped to adequately deal the effect extremes of temperatures will have on healthcare.
Furthermore, the severe acute respiratory syndrome coronavirus-2 (COVID-19) pandemic saw the rise of telemedicine to prominence as the most effective method by which to provide ophthalmic care. Telemedicine has remained an effective, post-pandemic method of triaging patients, thereby reducing the number of face-to-face consultations required while simultaneously increasing virtual management of ophthalmic conditions [9, 10].
This retrospective study sought to describe F/F presentations to EED during a 3-year period, comparing the frequency of presentations between bright and dark days and analysing diagnostic and clinical outcomes. Finally, we described the ten most common conditions that presented to EED during the study timeframe. Our overall hypothesis centred around the concept that symptoms of floaters are exacerbated by greater incident light, and thus, we expected to see a greater number of F/F presentations in bright days when compared with dark days. While certain diagnoses have been linked with seasonal changes in weather patterns, such as multiple sclerosis [11], no definitive link has been reported between floaters and greater incident sunlight exposure.
Lumi et al. reported that the most common diagnosis in a presentation of acute floaters is PVD with a prevalence of 24% in patients aged between 50 and 59 years, rising to 87% in patients > 80 years [3]. It is well-known that possible downstream sequelae of PVD include the development of more serious retinal pathologies including retinal tears and rhegmatogenous retinal detachment [3]. In terms of our data, we report that PVD was the most common diagnosis that presented as F/F, representing 49% of all F/F presentations. Furthermore, significantly, more patients were diagnosed with PVD on bright days versus dark days (p < 0.05). Hollands et al. sought to determine the clinical risk of retinal tears in patients presenting with F/F or PVD. They reported that 3.4% of patients diagnosed with an uncomplicated PVD developed a retinal tear within 6 weeks and concluded that patients with risk factors such as having more than ten floaters or reduced visual acuity should be referred for urgent ophthalmological review [12]. Unfortunately, the design of this study assessed a single attendance at EED and thus did not include follow or subsequent EED presentations after their initial EED attendance.
In terms of more serious pathologies, we analysed the frequency of RT and RD presenting as F/F. We report that 3% (n = 4) of all patients with F/F received RT diagnosis and 8% (n = 10) were diagnosed with RD. Overall, 11% of patients presenting with F/F required an immediate intervention for RD/RT repairs, and a further 6% patients were diagnosed with nARMD, requiring urgent intravitreal anti-VEGF injections. Importantly, significantly more RDs were diagnosed on dark days compared with bright days (p < 0.05).
Goodfellow et al. analysed diagnostic outcomes of 77 of patients that presented with photopsia and found that 35% patients had PVD, 9% had retinal tears, and 32% were diagnosed rhegmatogenous retinal detachments [13]. Of the 40 patients in our photopsia patient cohort, 42% were diagnosed with PVD, 18% with RD, and 7.5% with a RT. Kun and Aylward reported that photopsia should be treated as a more serious symptom than floaters, due to its significance in terms of retinal traction, and this may be important in terms of clinical triaging. [14]
This shift toward providing virtual care via telemedicine in the post-COVID era reduces burden on non-consultant hospital doctors (NCHDs) and enables them to address more serious sight-threatening conditions presenting to EED, alleviating staffing issues, reducing waiting times, and ultimately increasing capacity safely and effectively [15].
Although this is a small retrospective study, our data provides some evidence to suggest that the eye emergency department should be better staffed on bright days versus dark days, which would have obvious clinical ramifications in terms of clinic planning, EED resource allocations, and capacity. The clinical assessment of patients presenting to EED with F/F is time-consuming and necessitates a full dilated slit lamp examination with scleral indentation in order for an accurate assessment of the posterior segment. Of course, the clinical challenge posed is in relation to delineating whether F/F are symptoms of a benign pathology that does not require immediate assessment and treatment such as PVD or whether F/F are due to more serious, sight-threatening aetiologies that require prompt diagnosis and treatment, such as RT and RD. Diamond et al. analysed 170 patients who presented with F/F and concluded that an isolated floater was generally benign and did not warrant urgent ophthalmic assessment. Instead, they recommended routine, outpatient follow-up for this cohort patients [16]. A study by Singalavanija et al. reported that risk factors for RT in patients with floaters include multiple floaters, photopsia, and lattice degeneration [17].
Shen et al. developed a ‘F/F’ triage protocol in order to stratify patients into high-risk groups requiring urgent ophthalmic assessment and low-risk groups whose care is deemed urgent [18]. Indeed, a thorough clinical history, paying particular attention to nature and duration of F/F, whether they are monocular/binocularity in nature and elucidating clinical associations such as decreased visual acuity or alterations in visual fields may be helpful to accurately triage the patient cohort that present to EED with F/F, especially on bright days [19, 20]. Clearly, no piece of evidence can be used in isolation, and all patients with new visual phenomena require thorough ophthalmic examination; however, high-risk features such as pathological myopia, trauma, previous cataract surgery, and severity/timing of symptoms may be relevant factors in determining timing of assessment.
Limitations
Firstly, this study is retrospective in nature and is a single-centred, small cohort study. Secondly, some of the brightest/darkest days included in this study fell on weekends potentially affecting the volume of patients seen per day and influencing patients’ willingness to attend EED on a weekend. In general, significantly less patients are seen in EED on Saturday and Sunday when compared to the Monday-to-Friday weekdays. Furthermore, the introduction of telemedicine during the COVID-19 pandemic commencing March 2020 resulted in significantly less face-to-face consultations [21]. EED departmental guidelines were implemented for virtual treatment of anterior segment pathologies such as dry eye, Meibomian gland dysfunction, blepharitis, non-traumatic sub-conjunctival haemorrhage, corneal abrasion, and conjunctivitis. This cohort of patients was therefore not included in this study which only reports physical attendances at EED. As per these guidelines, patients presenting with new onset F/F were seen on the same day.
Conclusions
This study established that F/F presentations were significantly more likely to present during bright days when compared with dark days. The diagnosis of PVD was significantly more common during bright days, and sight-threatening pathologies (RT/RD) that require urgent treatment were diagnosed significantly more frequently on dark days. In terms of other common EED presentations, 25% of all presentations are now being safely and effectively managed virtually, which undoubtedly will have a positive impact in terms of staffing, resource allocations, and capacity. Although flashes/photopsias often herald urgent treatable retinal pathology, presentations with F/F warrant further larger, prospective multi-centred studies in order to definitively conclude whether F/F presentations during dark days warrant more urgent attention than patients presenting with F/F during bright days.
Supplementary Information
Below is the link to the electronic supplementary material.
Declarations
Conflict of interest
The authors declare no competing interests.
Footnotes
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This article has been retracted. Please see the retraction notice for more detail: https://doi.org/10.1007/s11845-025-03934-3"
Change history
3/24/2025
This article has been retracted. Please see the Retraction Notice for more detail: 10.1007/s11845-025-03934-3
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