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The Rational Clinical Examination
David L. Simel, Drummond Rennie
Floaters and Flashes
Hussein Hollands, Davin Johnson, Anya C. Brox, David Almeida, David L. Simel, Sanjay Sharma
Confrontation visual field testing is another key element of the examination because the finding...


Topics Discussed: acephalgic migraine, diagnostic process, migraine with aura, ophthalmic examination and evaluation, ophthalmoscopy, photopsia, retinal detachment, retinal perforations, slit lamp biomicroscope, visual acuity, visual fields, vitreous detachment, vitreous floaters, vitreous hemorrhage

Excerpt: "The report of acute-onset floaters and/or flashes in a patient's field of vision represents a common scenario to primary care physicians. Most cases of acute-onset monocular floaters and/or flashes are ocular in nature and caused by posterior vitreous detachment (PVD). The role of primary care physicians is to make the diagnosis of probable PVD and to identify patients at increased risk of retinal tear and detachment based on history and physical examination to determine the urgency of ophthalmologic assessment.Posterior vitreous detachment involves separation of the posterior vitreous from the retina as a result of vitreous degeneration and shrinkage (Figure 75-1 and Figure 75-2). This is an age-related event, with prevalence in the general population increasing from 24% in adults aged 50 to 59 years to 87% among those aged 80 to 89 years.1 Other risk factors for PVD include the presence of myopia, trauma, and intraocular inflammation.2Not all floaters and/or flashes represent ocular problems, and nonocular causes can usually be differentiated by a careful history taking (Box 75-1). By far the most common condition mimicking PVD is visual aura associated with migraine, or classic migraine.15 Patients with classic migraine describe an amorphous pattern of lights or jagged lines and colors "marching" through the binocular visual field, sometimes surrounding a central area of visual field loss. Contrary to flashing lights of retinal origin, this phenomenon is bilateral, involves the sensation of colored lights (vs white lights in PVD), and evolves over 5 to 30 minutes before resolving with onset of a headache. The visual aura may occur without headache, representing a so-called acephalgic migraine. In these cases, most patients have a known history of migraine. Patients with visual aura have visual acuity that is normal (20/20) or unchanged and a normal ocular examination result...."
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