Floaters and Flashing Lights
Saturday, December 01, 2007
Paul Auerbach, M.D.
Medicine for the outdoors is just that – application of the healing arts in outdoor environments, where one must on occasion make do with limited diagnostic capabilities (compared to what is available in a hospital or clinic) and supplies. Often, one must make an educated guess about what might be going on with a victim, medically speaking. Without an x-ray or stethoscope, it may be difficult to confirm the presence or absence of fluid in the lungs or collapse of lung tissue. Without an ophthalmoscope or slit lamp, it is impossible to peer within the eyeballs to determine whether or not there is a problem with the lens, vitreous, or retina. Without a meter to measure the quantity of glucose in the blood, one must rely upon clinical judgment and evaluation of symptoms to estimate whether or not a person is suffering a hypoglycemic episode.
I recently suffered a new (for me) medical problem, as the vision in my right eye was suddenly and painlessly obscured by a tangle of what appeared to be threads and black dots. From my medical training, I knew that these were “floaters,” and was concerned that they might represent a tear in my retina. Fortunately, I was close to the expert care of a skilled eye doctor. At this point, my retina is intact, but I need to be very careful with my activities over the next few weeks until the process of vitreous separation, which I will describe below, subsides.
After I knew for sure what had happened, I thought, what if this had occurred during my recent visit to Mt. Everest base camp, away from sophisticated medical care? What if it happened to someone on a backcountry ski adventure, when exploring in the jungle, or at sea on a diving expedition? If any of these was the case, he or she would have to make due as best possible, worried about what might be wrong and, in the absence of someone trained and properly equipped to complete a full eye exam, unable to truly confirm a diagnosis.
Indeed, this is how most of the world lives. Most people don’t have rapid access to medical professionals, like we do. Furthermore, what I am suffering is actually quite common, and occurs with regularity to persons unable to obtain prompt evaluation. These people must make decisions – do they wait it out and hope for the best, or do they end their travels in order to play it safe and seek an evaluation? This might require expensive and potentially hazardous modes of transportation, which adds yet another layer of risk to the decision making process.
So, using information from an excellent set of patient education instructions provided to me by my ophthalmologist at the Palo Alto Medical Foundation, let’s consider “floaters and flashing lights,” and put it all in the context of what one might do and consider if faced with this problem in an outdoor, remote from medical care, setting.
Floaters are small spots, lines, clouds, cobwebs or veils that move around in your field of vision, especially when you move your eyes. They can be in one or both eyes, but usually show up in one eye at a time. As I can certainly attest, they are easiest to see when you look at the sky or against a plain white background. Floaters are caused by tiny opacities inside the vitreous, which is the gel that fills the inside of the eyes. In childhood and adolescence, the vitreous gel is clear, so that floaters are not seen. In adulthood, floaters can develop when the vitreous gel forms small clumps as part of the aging process. As light passes from the outside of the eye, through the cornea and lens, and then through the vitreous gel before it strikes the retina to record an image, the floaters can cast shadows on the retina. Floaters are annoying, but not dangerous, particularly if they have been present for a long time.
However, the sudden appearance of floaters can signify separation of the vitreous gel from the retina. This occurs because the vitreous gel shrinks as it ages. If it shrinks enough, it begins to peel away from the retina, in what is called a vitreous separation or detachment. It is more common in nearsighted people and in persons who have had cataract surgery or injuries to their eyes or head. When a vitreous separation occurs, the floaters appear suddenly. As the gel peels away from the retina, it tugs on it, which can cause a person to appreciate flashes of light, usually on the outer (ear) side of the eye. These usually last no more than a second, and are caused by the nerves within the retina (which connect to the large optic nerve) being stimulated mechanically by the tug of the vitreous gel. Flashes are difficult to appreciate in daylight, but can be easily seen in the darkness. Moving the head or eyes can cause the flashes. Since flashes mean that the vitreous is pulling on the retina, this is a warning sign, because the traction can cause a retinal tear. If this happens, then an ophthalmologist needs to perform laser surgery as soon as possible in order to prevent a full-blown retinal detachment.
The normal course for a vitreous separation is a 2 to 4 week process in which the separation is completed. This may be punctuated by intermittent addition of new floaters, but usually the burst of opacities is at the beginning of the process. Over time, most of the floaters diminish or disappear, but there may be some residual floaters. During the course of the separation, when a person first notices the floaters, and if a person suddenly develops new floaters, more frequent flashing lights, or a defect in a field of vision (often described as a "dark curtain"), then an ophthalmologist should perform an examination to be certain that there is not a retinal tear or detachment. It is important to avoid sudden eye or head movements for several weeks after the onset of a vitreous separation, in order to decrease the likelihood of developing a retinal tear or detachment.
What does a person do if faced with this situation when distant from the care of an ophthalmologist? The major risk is retinal tear(s) or detachment. If a new vitreous detachment is suspected, then it is wise to begin to head toward civilization in order to undergo a proper examination. However, if it is likely that a retinal detachment has occurred (e.g., there is a "field cut," or a darkened area of vision as if a curtain was being pulled across the field of vision from any direction), then it is prudent to evacuate immediately, including a more expensive mode of transportation if necessary, because treatment for retinal detachment is usually an operation by an opthalmologist, and time is of the essence. A progressive retinal detachment can lead to permanent loss of vision in the affected eye.
In terms of exercise, it is wise to avoid sudden head or eye movements, so no jogging or swimming with rapid head movements, wrestling, significant straining, etc. Until the vitreous separation process is complete, a person should try to turn the head to look in a direction, rather than hold the head in a fixed position and move the eyes. All of this may be difficult in a precarious situation, such as rock climbing or kayaking, but you should just do the best you can given your particular circumstances.
photo courtesy of www.maculacenter.com
Tags: vitreous separation, retinal tear, floaters, wilderness medicine, outdoor medicine, healthline
Labels: eye, eye injury, floaters, retina, retinal detachment, vitreous, vitreous detachment
10 Comments:
At Mon Jan 28, 05:02:00 AM 2008,
Anonymous said…
I am an RN, 58 y.o., suffering 4 days of peripheral "lightening bolts" and two specific types of floaters. I'm also s/p lens replacements, R & L, approx 20 months ago. Saw my eye doctor emergently early Sunday morning since the affected eye had had post-op problems not long after the implant and he deemed it prudent to see me Sun. rather than wait 'til Monday office hours for which I am grateful. My point...he was extremely close-mouthed until I started asking questions and I left his office relieved, but didn't realize I needed to be cautious in my ADL's so as not to separate the retina further. (Actually he never even used that phrase "retinal detachment" but explained it differently). Since I work in a busy ER and sometimes pull 200+ lb pt's.up by myself & I stretch, reach, and bend all shift-long...well your concise information may just have saved the vision in my left eye. For this I thank you with all my heart. Though I will not take any time off from work, I will certainly use an abundance of caution in carrying out my duties. Thanks again, sir ! Sincerely, Donna-M. Zera R
At Thu May 29, 03:07:00 AM 2008,
Anonymous said…
HI, I am a 49 y/o f. About 3 months ago, I awoke with a floater in my right eye and immed. called an eye doctor.I was diagonosed with
retinoschisis in both eyes and posterior vitreous detachment in my right eye.In a month my visual acuity decreased and I deveoped cataracts in my right eye.I feel the retinal specialist isn't being forthright with me as to the extent of the diseases I have in both eyes. I am terrified of losing my sight. I have been told there is no cure or treatment at this stage. He never intimated that my retina could detach or this might be the order of progression. Reading it here was a first and now I am even more scared. Any feedback?
At Fri Oct 03, 10:29:00 AM 2008,
jean fryer said…
Iwas recently diagnosed with post vitreouse detachment after visiting my optician who referred me to the emergency eye clinic at once as I was due to fly on holiday the following day. I was not given much information other than it was quite a common problem as one ages. I am just 66. I was given the ok to fly and a slip of paper saying no further treatment was necessary.Having read some comments on the internet I feel more informed but I am rather worried to find that during the first six weeks after it happening I am at greater risk of developing a retinal detachment.How great is this risk and is there anything I can do to prevent this happening? Prior to the diagnosis I had taken decongestant tablets for sinusitis could these have been the cause and should I avoid them in the future?I still have "cobwebs" in my eye 3 weeks later will these go away?
At Mon Oct 06, 01:47:00 PM 2008,
Paul Auerbach, M.D. said…
It is unlikely that decongestants would have anything to do with your having suffered a vitreous detachment. I have not seen a link between these two described in the medical literature. I cannot put a number on the statistical risk for a retinal detachment following a vitreous detachment - just be aware that VD is definitely a risk factor for subsequent RD. The last few comments in my post describe how you should limit your activities if you wish to be prudent in order to decrease the risk for a RD. These admonitions appear in the ophthalmology literature. With regard to the "cobwebs" in your eyes, usually these improve (e.g., diminish), but there is no guarantee. They may improve, stay the same, appear to change location in your visual field, or worsen. You may have some degree of these floaters for a long time (e.g., years).
At Thu Oct 16, 10:21:00 PM 2008,
Anonymous said…
I'm 46 and had a vitreous detachment yesterday. I was seen by an optometrist today and was told many of the same facts you have pointed out. However, I would like a second opinion on one thing: Is it okay to swiw?
I'm an avid swimmer (3-4x per week for at least one hour workouts), but I believe swimming can be jarring, not only in the constant moving of the head from side to side to breathe, but in the act of flip turning and pushing hard off the wall to continue swimming in the other direction.
I'd appreciate your opinion. Thanks,
JEK
At Sat Oct 18, 02:26:00 PM 2008,
Paul Auerbach, M.D. said…
Probably best NOT to swim until you are cleared by your ophthalmologist. I am offering the same advice that was given to me, as I also swim for exercise. I waited a full 6 weeks after the appearance of any new symptoms (flashes of light or new floaters) before I resumed recreational swimming.
At Tue Dec 23, 09:23:00 PM 2008,
Anonymous said…
I'm a 55 yr old ER Nurse, This event in my life, of sudden blurred vision with a starburst of floaters left me looking through what looked like wax paper was scarry as the dickens!! Why don't they teach folks about this. I too saw eye MD and Retinologist within 2 hours of this event, and luckilly did not have any retinal tears, yet. Had re-bleeding for two days and then again a week later.. I was interested to read about the long recovery period and what not to do like swimming, as I swim too. I guess I'll just have to stick to walking for a while. I found that puting a blinder patch on the blurred eye was very helpful in the beginning to see. and that watching TV or quietly reading, where my hear and eyes were not moving much helped too. The analogy of one's eye being like a snow globe with the floaters was really true for me as by the end of a day all was stirred up and blurry again, where as in the morning after being quiet all night things were clearer. So my question is, how long before the blurriness goes away, and how long before the big floaters go away.. if ever?? Jane Greenville, SC
At Sat Jan 03, 03:08:00 PM 2009,
Anonymous said…
This is to Jean Fryer. I was suffering from a severe cold and cough last week when my vitreous detachment happened (sorry, can't get myself to refer to it as "VD"). My eye doctor thought it could have been caused by my hard coughing and/or blowing my nose. He said any kind of "trauma" could have caused the condition. So, just wanted you to know you weren't totally off base. It wasn't the medication you were taking, but the illness itself (especially if you had a severe cough) that may have caused your vitreous detachment.
At Tue Feb 10, 09:11:00 AM 2009,
Anonymous said…
I awoke two days ago with lightning bolts and cob web like floater in my right eye. I saw my dr yesterday and was diagnosed with Posterior Vetreous Detachment.
I had a cold last week and did lots of coughing and sneezing -- I asked if that could have contributed to the detachment and he said no. However, there seems to be a common thread with others who have suffered the detachment on the heels of a cold.
At Wed Apr 01, 03:37:00 PM 2009,
Anonymous said…
On May 8th, 2008 I was driving to work and noticed a clump of new floaters. I have had lots of floaters for many years, but still was concerned about the sudden new floater in my left eye. I got in quickly to see the optometrist that afternoon and was told that my retinas both looked fine. He described the types of changes that take place in the vitreous. He also told me that if I had any further symptoms, even if it was the same night or the next day, I should call back. That same night, when standing up after watching a television show, my left eye suddenly had a glob of dark, cobwebby junk in front of it. In the dark, I had some light flashes. I barely slept that night, getting up every hour or so to see if I thought my retina had detached. In the morning, I looked up "detached retina" on the internet and found information on "post vitreous detachment with retinal tear" that closesly fit my symptoms. I called for an appointment as soon as the office was open and got in at 8:30 that morning. I had a different optometrist the next morning, as my usual one was in a different town. I was diagnosed with a small retinal tear and was immediately sent to an opthamologist in the same building. My retinal tear was fixed by laser surgery and I was home by 11:30 that morning. Months later, I had a postvitreous detachment in the other eye, with minimal symptoms, no flashing lights, and thankfully, no retinal tear. People really don't know much about retinal tears and detachments and their symptoms. Thanks you for this post and the education it provides people.
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