Acute-onset visual floaters and flashes is linked to retinal detachment

Clinical question Are adults with acute-onset visual floaters and flashes at risk for retinal detachment?

Bottom line The prevalence of retinal tears in adults with acute-onset floaters or flashes is 14% (95% CI, 12%-16%). There is no significant association between older age or myopia and increased risk of retinal tear. The presence of subjective vision reduction significantly increases the likelihood of retinal tear (positive likelihood ratio [LR+] = 5.0; 3.1-8.1; negative likelihood ratio = 0.60; 0.49-0.73). (Level of evidence = 2a)

Synopsis Acute-onset visual floaters and flashes are usually caused by posterior vitreous detachment (PVD). PVD is an age-related event that is most often a benign occurrence without any visual complications. However, some patients with acute PVD have an associated retinal tear that can result in permanent vision loss if left untreated. These investigators searched MEDLINE, EMBASE, and relevant references of retrieved articles for studies reporting outcomes and related elements of the history or physical examination for patients referred from their primary care physicians or optometrists with an acute onset of floaters or flashes of suspected ocular origin. The overall prevalence of retinal tears in patients with acute-onset floaters or flashes is 14% (12%-16%). There is no significant association between older age or myopia and increased risk of retinal tear. The presence of subjective vision reduction significantly increases the likelihood of retinal tear. On slit lamp examination, the presence of vitreous hemorrhage (LR+ = 10; 5.1-20) or pigment (LR+ = 44; 2.3-852) also increases the likelihood of retinal tear. Patients initially diagnosed with uncomplicated PVD have a 3.4% chance of retinal tear within 6 weeks. The risk of subsequent retinal tear is increased with the sudden appearance of at least 10 floaters (LR+ = 8.1-36) or subjective visual reduction (LR+ = 2.3-17).

Hollands H, Johnson D, Brox AC, et al. Acute-onset floaters and flashes: is this patient at risk for retinal detachment? JAMA 2009;302(20):2243-2249.