Flashes, floaters & PVD
At a glance
Acute flashes and floaters require exclusion of a retinal tear or detachment, even when acuity is preserved.
CAVE
- Vitreous haemorrhage, pigment, high myopia, trauma and previous retinal tear increase concern.
Clinical presentation
- New mobile opacities, temporal flashes or a sudden shower of spots.
- Ask about a curtain or missing field.
Diagnosis & investigations
- Ask about onset, a shower of spots, curtain, reduced vision, trauma, myopia, prior cataract surgery and fellow-eye detachment. New symptoms require prompt dilated assessment; curtain, reduced vision or haemorrhage demand same-day evaluation.
- Check acuity, pupils, anterior vitreous pigment and haemorrhage. Examine the peripheral retina through 360°, with scleral depression when appropriate, and document areas not visualised. A wide-field image or a visible Weiss ring does not replace the peripheral examination. Use B-scan if media opacity prevents a view, while arranging repeat examination.
Differential diagnosis
- Posterior vitreous detachment, retinal tear, detachment, vitreous haemorrhage and migraine aura.
Treatment
- Treat an identified retinal break according to its risk.
- Uncomplicated PVD needs explanation and explicit return precautions, not routine drug treatment.
Follow-up
- Return immediately for a new curtain, field loss, decreased vision or increased flashes/floaters, even after a negative examination or successful retinopexy. Explain these signs in writing. Schedule the next examination before discharge; use the scenarios below.
| Finding | Action | Timing / detail |
|---|---|---|
| Acute symptomatic PVD, complete negative peripheral examination, no high-risk findings | Give explicit return instructions; repeat dilated examination | Usually 4–6 weeks; earlier for new symptoms |
| Vitreous haemorrhage, pigment or incomplete view | Assume increased tear risk; retinal review and serial examination, with B-scan if the view is obscured | Haemorrhagic PVD often needs weekly review until the view clears; urgent reassessment if symptoms worsen |
| Acute symptomatic horseshoe tear | Prompt retinopexy or retinal surgical management according to associated detachment | After treatment: commonly 1–2 weeks, then 4–6 weeks; additional tears can develop |
| Asymptomatic atrophic hole or operculated break without traction or progressive subretinal fluid | Observation is often appropriate; assess fellow-eye history and other risk modifiers | Do not equate every hole with a symptomatic tractional tear |
Risk factors & context
- Ask about myopia, trauma, cataract surgery and retinal breaks or detachment in either eye.
- Record the onset and evolution of symptoms.
Complications
- Retinal tears, vitreous haemorrhage and retinal detachment can accompany vitreous separation.
- An initially normal peripheral examination does not exclude a later tear.
When to refer
- Same-day urgent assessment for a curtain, field loss, reduced vision or increasing symptoms.
References 1
- AAO · Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration Preferred Practice Pattern ↗2025 · Initial evaluation; management; follow-up
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