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Flashes and floaters in visual fields

Specialties > Ophthalmology

Differential Diagnosis Schema 🧠

Retinal Causes

  • Posterior Vitreous Detachment (PVD): Sudden onset of floaters, flashes of light, usually in the peripheral visual field, and often associated with aging.
  • Retinal Detachment: Flashes and floaters, followed by a curtain-like shadow over the visual field; an ophthalmic emergency.
  • Retinal Tear: Flashes of light and floaters, with or without visual field loss; can lead to retinal detachment if untreated.
  • Vitreous Hemorrhage: Sudden onset of floaters, often described as cobwebs or clouds, possibly with vision loss; associated with diabetic retinopathy, trauma.
  • Retinal Migraine: Temporary visual disturbances including flashes and zigzag patterns, often followed by a headache.

Vascular Causes

  • Ocular Migraine: Transient visual disturbances, such as flashes, floaters, and scotomas, often associated with a throbbing headache.
  • Central Retinal Artery Occlusion (CRAO): Sudden, painless loss of vision with possible preceding amaurosis fugax; often presents with cherry-red spot on the retina.
  • Central Retinal Vein Occlusion (CRVO): Sudden vision loss, often with floaters due to retinal hemorrhages; associated with hypertension and diabetes.
  • Transient Ischemic Attack (TIA): Temporary visual loss or disturbances, including flashes and floaters, typically lasting minutes to hours.
  • Giant Cell Arteritis: Elderly patients with headache, jaw claudication, scalp tenderness, and visual symptoms; urgent ESR/CRP and temporal artery biopsy required.
  • Hypertensive Retinopathy: Chronic high blood pressure leading to retinal changes and possible visual disturbances.

Other Causes

  • Uveitis: Inflammation of the uveal tract can cause floaters and blurred vision, often associated with pain and photophobia.
  • Trauma: Blunt or penetrating trauma to the eye can cause retinal tears, vitreous hemorrhage, and subsequent flashes and floaters.
  • Optic Neuritis: Inflammation of the optic nerve causing visual disturbances, often with pain on eye movement; associated with multiple sclerosis.
  • Intraocular Tumors: Rare, but can cause floaters and visual field defects; may be associated with melanoma or retinoblastoma.
  • Ocular Infection: Conditions such as endophthalmitis can lead to floaters and vision loss, often with redness and pain.
  • Psychogenic Causes: Patients may report visual disturbances in the absence of ocular pathology, often related to anxiety or conversion disorder.

Key Points in History 🥼

Symptom Onset and Duration

  • Acute vs. Gradual Onset: Sudden onset suggests retinal tear or detachment, whereas gradual onset may indicate vitreous degeneration or chronic uveitis.
  • Duration of Symptoms: Persistent symptoms may point to retinal detachment or vitreous hemorrhage, while transient symptoms suggest migraine or TIA.
  • Preceding Events: Trauma, recent eye surgery, or systemic illness can provide clues to the underlying cause.
  • Unilateral vs. Bilateral: Unilateral symptoms often suggest a local ocular cause, while bilateral symptoms might indicate a systemic issue like migraine.

Associated Symptoms

  • Visual Field Defects: Presence of a curtain or shadow suggests retinal detachment.
  • Photophobia and Pain: Suggests uveitis or optic neuritis.
  • Headache: Associated with ocular migraine or giant cell arteritis.
  • Red Eye: May indicate uveitis, trauma, or infection.
  • Systemic Symptoms: Fever, weight loss, or jaw claudication might suggest giant cell arteritis or systemic vasculitis.
  • History of Recent Eye Surgery: Increases the risk for retinal detachment or vitreous hemorrhage.
  • Flashes with Eye Movement: Common in posterior vitreous detachment.
  • Loss of Color Vision: Suggests optic neuritis.

Background

  • Past Medical History: Include history of diabetes, hypertension, migraine, or autoimmune conditions which can predispose to retinal or vascular issues.
  • Drug History: Consider anticoagulants, which can increase the risk of vitreous hemorrhage.
  • Family History: Note any history of retinal detachment, glaucoma, or systemic vascular conditions.
  • Social History: Smoking, alcohol use, and occupational hazards can be relevant, particularly in trauma or vascular causes.
  • Eye Health History: Prior eye surgeries, myopia, or previous episodes of similar symptoms should be noted.

Possible Investigations 🌡️

Ophthalmologic Examination

  • Visual Acuity: Assessment to determine the degree of vision loss, which can help localize the issue.
  • Fundoscopy: Direct visualization of the retina to check for detachment, tears, hemorrhages, or signs of vascular occlusion.
  • Slit-Lamp Examination: Helps identify anterior chamber abnormalities like uveitis or vitreous hemorrhage.
  • Intraocular Pressure Measurement: Elevated in conditions like glaucoma, which can also present with visual disturbances.
  • Peripheral Visual Field Testing: Important in assessing for retinal detachment or other peripheral visual field defects.
  • Fluorescein Angiography: May be used to assess the retinal and choroidal circulation, especially in cases of suspected vascular occlusion.

Imaging

  • B-scan Ultrasound: Useful in cases where the retina cannot be visualized directly due to vitreous hemorrhage or dense cataract.
  • Optical Coherence Tomography (OCT): Provides cross-sectional imaging of the retina, useful in diagnosing macular conditions and retinal detachment.
  • CT/MRI Brain: Consider if neurological causes like TIA or optic neuritis are suspected.
  • Carotid Doppler Ultrasound: Assess for carotid artery stenosis in cases of amaurosis fugax or other vascular causes.
  • Temporal Artery Biopsy: Essential if giant cell arteritis is suspected, particularly in elderly patients with systemic symptoms.

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Ophthalmology