Are These Ocular Symptoms Common or Concerning?

Brianne N. Hobbs, OD


July 06, 2018

In This Article

Ocular symptoms can be difficult to evaluate without specialized equipment, but a working knowledge of both the most common and the most concerning diagnoses associated with ocular symptoms can help direct clinical thinking and determine appropriate management strategies.

This article discusses the differential diagnoses and management for five common ocular complaints that may be encountered in the primary care setting—along with red flags that should alert the clinician to suspect a more worrisome pathology.

"I see floaters and/or flashes."

Floaters are extremely common and are usually secondary to age-related changes in the consistency of the vitreous. Flashes, on the other hand, may indicate a more serious etiology, because vitreoretinal traction is often responsible for the perception of flashes of light. The retina is stimulated by the tension of the vitreous pulling on it, and this stimulation is registered as a flash of light. The combination of both floaters and flashes is most highly predictive of a more concerning etiology, such as retinal detachment.

The factors surrounding the onset of the floaters and/or flashes are key to identifying which etiology is most likely. Ask the patient whether he or she has previously experienced floaters or flashes; the longer and more stable the symptoms, the less likely that retinal detachment is present. Large retinal detachments can also cause a visual field defect, so patients may report a "shadow" or "curtain" in a portion of their vision, and confrontation visual field testing may be abnormal. Posterior vitreous detachments do not affect visual acuity, but retinal detachments can decrease acuity if the macula is affected.

In patients presenting with new-onset floaters and/or flashes, it is extremely important to refer them for a dilated fundus examination, because it is impossible to differentiate the two (posterior vitreous detachment versus retinal detachment) on the basis of symptoms alone. Whereas some large retinal detachments may be detectable on examination with a direct ophthalmoscope, many will not, owing to the limited field of view of the instrument.

Most common diagnosis: Posterior vitreous detachment

Most concerning diagnosis: Retinal detachment

Key factors

  • Acuity of onset

  • Concurrent symptoms, such as reduced vision or visual field defect

Clinical pearl

  • A patient with acute onset of floaters and/or flashes should be referred to an ophthalmologist or optometrist for a dilated fundus exam.

Figure 1. Large retinal detachment with the macula attached. The patient presented with superior-nasal field loss and floaters.
Image courtesy of Erika Anderson, OD


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