FLASHES AND FLOATERS AS PREDICTORS OF VITREORETINAL PATHOLOGY: IS FOLLOW-UP NECESSARY FOR POSTERIOR VITREOUS DETACHMENT? M. R. DAYAN, D. G. R. JAYAMANNE, R. M. ANDREWS and P. G. GRIFFITHS Newcastle upon Tyne SUMMARY group are usually followed up in outpatients approxi­ Purpose. The aim of the study was to determine mately 6 weeks after the onset of symptoms, to allow whether patients presenting with an isolated posterior the identification of retinal breaks which may have vitreous detachment require follow-up to identify developed after the first visit. retinal breaks not apparent at presentation and Our aims were to determine whether significant whether some histories are more predictive of asso­ pathology associated with posterior vitreous detach­ ciated serious posterior segment pathology. ment was being detected at the follow-up visit and to Methods. The notes of 295 patients presenting to eye identify characteristics of the history which were casualty with flashes andlor floaters were reviewed. more strongly indicative of the presence of retinal Results. One hundred and eighty-nine patients (64%) breaks or detachments. had isolated posterior vitreous detachments, 49 (16.6%) had retinal detachments and 31 (10.5%) had PATIENTS AND METHODS flat retinal tears. Three new breaks (3.3% of all tears We retrospectively studied 295 consecutive patients found, 1.9% of review appointments) were identified who presented to eye casualty in 1993 and 1994 with only at follow-up. Although a subjective reduction in symptoms of floaters and/or flashes due to posterior vision and a history of less than 6 weeks' duration were vitreous detachment. Patients who were referred strongly predictive of retinal breaks, the large group of directly to outpatients, or who had a history of (124/295, 42%) patients presenting with floaters alone trauma or concurrent posterior segment disease such still harboured a significant proportion (26.7%) of the as diabetic retinopathy and vascular occlusions, were retinal breaks. excluded. All had been examined at the first visit by Conclusions. A follow-up visit for patients with an the senior house officerin casualty and a diagnosis of isolated posterior vitreous detachment can be justified to detect the small percentage of asymptomatic retinal separation of the posterior vitreous face from the breaks. Although a subjective reduction of vision is the retina was made using slit lamp biomicroscopy with symptom most predictive of serious posterior segment the 90 dioptre lens or Goldmann 3-mirror contact pathology, it would be unsafe to identify particular lens. Indirect ophthalmoscopy with scleral indenta­ subgroups of patients alone for careful examination. tion was also performed to identify any peripheral retinal pathology and patients were then treated Patients complaining of flashes and floaters make up immediately as necessary or given a retinal detach­ a significantproportion of the cases presenting to eye ment warning and followed up in clinic. Patients' casualty departments. Of these, between 10% and symptoms, pathology, timing of follow-up and find­ 30% 1-3 will have retinal breaks requiring immediate ings on follow-up were recorded. treatment and approximately half will have an isolated posterior vitreous detachment.!,4 The latter RESULTS One hundred and twenty-four (42%) patients with From: Department of Ophthalmology, Newcastle General pathology presented with floaters alone, 53 (18%) Hospital, Newcastle upon Tyne, UK. with flashes, 60 (20.3%) with floaters and flashes and Correspondence to: Miss Margaret R. Dayan, Department of Ophthalmology, Royal Victoria Infirmary, Queen Victoria Road, 58 (19.7%) with floaters and/or flashes with a Newcastle upon Tyne NEI 4LP, UK. Fax: +44 191 227 5246. subjective reduction in vision. The complaint of Eye (1996) 10, 456-458 © 1996 Royal College of Ophthalmologists FLASHESIFLOATERS AS PREDICTORS OF VITREORETINAL PATHOLOGY 457 reduced vision did not always correspond to a poor symptoms and had not returned prior to their visual acuity on testing on the Snellen chart. appointment. One hundred and eighty-nine patients (64%) were found to have a posterior vitreous detachment alone at presentation. Thirty-one (10.5%) had flat retinal DISCUSSION tears, 49 (16.6%) had retinal detachments, 3 (1%) Eye casualty departments see many patients with had vitreous haemorrhage with visible tears and 18 flashes and floaters. Although up to a third of these (6.1%) had dense vitreous haemorrhages preventing patients have retinal breaks or detachments at an adequate fundal view, of whom 2 patients were presentation, over half will be identified as having subsequently found to have flat retinal tears when an isolated posterior vitreous detachment and the haemorrhage cleared. One patient was found to reviewed at 6 weeks after the onset of symptoms, have an area of lattice associated with a small round as most symptomatic breaks which are going to hole and an operculum. Four patients (1.4%) were detach will do so during this period.5,6 found to have other ocular pathology to account for In our study we looked at 295 patients with their symptoms. posterior vitreous detachments who presented with Thirty-nine (67%) of the patients with subjective flashes and floaters. Our results are comparable with visual loss had retinal tears or detachments, com­ those reported previouslyl--4 in that 188 (63.7%) had pared with 14 (23%) of those with flashes and isolated posterior vitreous detachments and 84 floaters, 10 (18.9%) of those with flashes and 23 (28.5%) had retinal breaks or detachments on (18.5%) of those with floaters alone. However, due presentation. Two patients (0.7%) had breaks to the large number of patients presenting with which were found later when their vitreous haemor­ floaters alone and the much smaller numbers rhage cleared and 1 had a hole which was suspected presenting with additional visual loss, 45.4% of the in casualty and confirmed at follow-up the next day. tears and detachments occurred in patients with Fifty-five patients (29.3%) with a diagnosis of subjective visual loss but over a quarter (26.7%) posterior vitreous detachment returned to casualty with new symptoms prior to their follow-up appoint­ occurred in patients with floaters alone, 16.3% in ment, of whom only 1 had new pathology - a flat those with floaters and flashes and 11.6% in those round hole which was lasered. with flashes. The length of history was also linked to Following up patients with posterior vitreous the presence of serious pathology, with all but 1 detachments involves considerable resources - in (98.8%) of the retinal breaks and detachments our department serving a catchment population of presenting within the first 6 weeks (95% within the 1.1 million we gave follow-up appointments to 169 first 4 weeks) compared with only 95% of the patients with posterior vitreous detachments during isolated posterior detachments. 1993 and 1994. However, of the 157 who attended At presentation 84 patients (28.4 %) had retinal their appointment, 3 were found to have breaks breaks or detachments of which 51 required surgery, which had not been seen or suspected at their 30 laser and 2 cryotherapy, with 1 patient with casualty visit: 1 with a horsehoe tear which definitely carcinoma of the lung being too ill to undergo retinal required treatment and 2 patients with a round hole detachment repair. Forty-three patients (14.6%) with in an area of lattice and an operculated hole who posterior vitreous detachment alone and onset of both received laser treatment, although the need for symptoms more than 6 weeks previously were treatment in these cases is rather more controver­ discharged from casualty at the firstvisit. sia1.5-7 These three breaks therefore comprise 3.3% Fifty-five patients (19.2%) returned to casualty of the total breaks and detachments identified, and prior to their scheduled follow-up appointment, but occurred in 1.9% of the patients given follow-up new pathology (a round hole requiring laser) was appointments. It can be argued that only 1 of these found in only 1 case. A total of 169 patients were patients (with a symptomatic horshoe tear) was at given follow-up appointments of which 12 (7%) definiterisk of retinal detachment and that the return failed to attend. Six retinal breaks were found at in terms of pathology identifiedfor the investment of follow-up: 3 of these were suspected - 2 were flat clinic time in follow-up is very small. The decision of breaks visualised as vitreous haemorrhage cleared whether to follow up these patients is an individual and 1 was a retinal hole which was provisionally judgement, but in our department we have chosen to identified at the initial assessment and confirmed at continue the 6 week review of patients with isolated review the next day. However, one horsehoe tear, posterior vitreous detachment on the basis of the one operculated break and one round hole in an area findings of thIS study. oflattice were identifiedat follow-up by a consultant, The association between the presence of serious a registrar and a different senior house officer (3.3% pathology and the type and duration of symptoms of all the tears found, 1.9% of follow-up appoint­ found in this study is similar to that reported in the ments) in patients who had suffered no further literature,1.2,4,8.9 although in our study the presence 458 M. R. DAYAN ET AL. of a subjective reduction in vision was found to be a subjective reduction in vision are more likely to highly predictive of the presence of both retinal harbour retinal breaks, any complaint of flashes or detachments and flat breaks - a link which has not floaters should prompt a very careful clinical been reported previously to the best of our knowl­ examination at presentation.