Vitreous Floaters


Article Author:
Reece Bergstrom


Article Editor:
Craig Czyz


Editors In Chief:
Rhonda Coffman
Lindsay Iverson
Heather Templin


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/10/2019 12:17:18 AM

Introduction

Vitreous floaters are microscopic collagen fibers within the vitreous that tend to clump and cast shadows on the retina, appearing as floaters to the patient. The most common cause of vitreous floaters in ophthalmology is posterior vitreous detachment (PVD), a separation of the posterior hyaloid face from the retina. Often this condition is a not visually threatening. Patients that present with signs and symptoms of vitreous floaters need to be evaluated by an ophthalmologist.[1][2]

Etiology

The etiology of a vitreous floater or PVD is due to vitreous syneresis (liquefaction) and contraction with age. Additionally, trauma or injury to the globe can cause vitreous floaters.

Epidemiology

A vitreous detachment typically affects patients older than the age of 50 and increases in prevalence by age 80. Individuals who are myopic or nearsighted have an increased risk of vitreous floaters. Additionally, eyes with an inflammatory disease after direct trauma to the globe or have recently undergone eye surgery have an increased chance of developing a vitreous floater. Men and women appear to be affected equally.[3][4][5][6]

Pathophysiology

There are three chambers in the eye: the anterior chamber, the posterior chamber, and the vitreous chamber. The anterior chamber consists of ocular content behind the cornea. The posterior chamber consists of content from the iris to the anterior aspect of the lens. The vitreous chamber consists of eye content behind the lens and is the location of the vitreous floaters.

The vitreous gel, which consists of collagen fibers, fills the vitreous chamber undergoing syneresis and contraction (shrinking) due to age and mechanical factors. Fibers are intertwined within the vitreous and are attached to the surface of the retina. Over time, the vitreous shrinks and these fibers pull on the retinal surface. Often these fibers break and allow the vitreous to separate and continue shrinking. Eventually, the vitreous cannot fill the volume of the cavity it sits within. This leads to the separation of the vitreous from the retina, creating vitreous floating in its chamber. If this process happens gradually, the symptoms are typically mild and can go unnoticed. If the process of separation is violent, on an isolated portion of the retina, or there is the presence of abnormal adhesion between the vitreous and retina, the PVD can tear retinal vessels or the retina itself.

Histopathology

The vitreous is composed of 99% water and a few type II and type IX collagen fibers with many mucopolysaccharides and hyaluronic acid holding water within the vitreous. The vitreous is attached to the peripheral retina and pars plana. Additionally, it is attached to the macula, optic nerve, and vessels. The strongest attachment is at the vitreous base while the weakest attachment is along the retinal vessels. Thus, detachments and floaters are most common along the vessels and can lead to vitreous hemorrhage that coincides with the vitreous floater. Vitreoretinal junctions arise from the footplates of Muller’s cell at the internal limiting membrane.

History and Physical

Patients often will report seeing floaters, bubbles, bugs, cobwebs, or dark spots that move during eye movement that are most common with dim illumination and the temporal visual field. The displaced vitreous during eye movement scatters incoming light and casts a shadow on the retina that the patient perceives as a grey structure such as hair, bugs, or webs. Photopsias also are reported due to stimulation of the retina from vitreoretinal traction and pulling.

The work-up should include distinguishing retinal photopsias from visual changes associated with migraines which can be associated with new floaters. Important questions to consider should include: How long have these symptoms been occurring? Have these previously happened before? Have there been recent eye surgeries? Does the family have a history of retinal detachment?

A slit lamp exam is needed to examine the anterior vitreous of pigmented cells (Shaffer sign), and an indirect ophthalmoscopy with scleral indentation can rule out a retinal tear or break. Visualization of the PVD at the slit lamp with a 90-diopter lens can be done by identifying a gray-black strand floating in the vitreous. It can help to have the patient look up, down, and straight ahead to locate the floater. Shaffer's sign and vitreous hemorrhage increase the likelihood of a retina tear over a posterior vitreous detachment.

Evaluation

If the PVD cannot be viewed or a vitreous hemorrhage obscures the view, ultrasonography is indicated to rule out retinal detachments and to identify the PVD.

Treatment / Management

No treatment is indicated for a PVD or vitreous floater. If a retinal break is found, follow treatment guidelines for the break or tear.

The management of the patient should include educating the patient on retinal detachment symptoms such as the following: increase in floaters, flashing lights, worsening vision, or the appearance of a curtain or shadow anywhere in the visual field. If these symptoms develop, an immediate evaluation by an ophthalmologist is needed.

If no break or hemorrhage is found on examination, a repeat dilated exam with scleral depression needs to occur in 2 to 4 weeks. If at 2 to 4 weeks no detachment is seen, then repeat dilated exam at 3 months and 6 months from the original onset of symptoms. If no retinal break is seen, but mild vitreous hemorrhage or peripheral punctate retinal hemorrhages are present, a dilated exam needs to be performed one week, 2 to 4 weeks, 3 months, and 6 months from the onset of symptoms. If no retinal break is found, but significant vitreous hemorrhage or anterior pigmented vitreous cells are present, repeat examination should be performed the following day by a retina specialist because of the high chance of a retinal break.

Differential Diagnosis

The differential diagnosis includes:

  • Vitreous floater/posterior Vitreous detachment
  • Vitreous hemorrhage
  • Retinal tear or detachment

Prognosis

Vitreous floaters or PVDs have a good prognosis. Prognosis is worse when a patient presents with vitreous hemorrhage or retinal detachments. Within 3 months, symptoms of the floater will subside. Some patient symptoms may not subside. If symptoms do not subside and greatly affect the patient's vision, an evaluation by a retinal specialist can be discussed.

Pearls and Other Issues

The greatest concern with vitreous floaters is the potential for related retinal pathology that is sight-threatening. Two examples are a macular hole or retinal detachment. These occur when the fibers in the vitreous do not break as it is shrinking and pull violently on the retina. If left untreated, both of these problems can lead to significant, permanent loss of sight.

It is best to be evaluated by an ophthalmologist urgently if vitreous floaters develop to minimize the risk of permanent vision loss.

Enhancing Healthcare Team Outcomes

Healthcare workers and nurse practitioners may come across patients with vitreous floaters. While the condition is benign it is important to know that it can also be associated with retinal pathology. Vitreous floaters are microscopic collagen fibers within the vitreous that tend to clump and cast shadows on the retina, appearing as floaters to the patient. The most common cause of vitreous floaters in ophthalmology is posterior vitreous detachment (PVD), a separation of the posterior hyaloid face from the retina. Often this condition is a not visually threatening. Patients that present with signs and symptoms of vitreous floaters need to be evaluated by an ophthalmologist.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Vitreous Floaters - Questions

Take a quiz of the questions on this article.

Take Quiz
A 72-year-old male complains of bugs continually appearing in his vision, and he reports he keeps trying to swat them away but cannot. He appreciates them more with white backgrounds or when he looks up at a blue sky. He is very annoyed and is desperate for them to go away. An ophthalmoscopic examination with a +10 lens reveals small, motile, dark flecks. Which of the following is the most likely cause?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 66-year-old female comes to the emergency department for new onset of black objects floating in her vision. This began today and started as one or two, and now there are 10-100 of these objects in her vision. She endorses occasional flashing lights. She reports these objects are worse if she looks around or moves her head. She denies other ocular symptoms. She denies any similar past medical history or ocular surgeries. She inquires the physician that these objects are often associated with what dreaded complication?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
How do vitreous floaters develop?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 45-year-old female presents to the clinic for new onset of black, gray objects that continually move around her vision. They began yesterday with occasional flashes of light. She reports her vision has become increasingly blurry and more difficult to see. A complete dilated examination is performed and evidence much of the fundus is obstructed by vitreous hemorrhage. What is the most appropriate next in management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Vitreous Floaters - References

References

Gishti O,van den Nieuwenhof R,Verhoekx J,van Overdam K, Symptoms related to posterior vitreous detachment and the risk of developing retinal tears: a systematic review. Acta ophthalmologica. 2019 Jan 11;     [PubMed]
Tram NK,Swindle-Reilly KE, Rheological Properties and Age-Related Changes of the Human Vitreous Humor. Frontiers in bioengineering and biotechnology. 2018;     [PubMed]
Singh IP, Novel OCT Application and Optimized YAG Laser Enable Visualization and Treatment of Mid- to Posterior Vitreous Floaters. Ophthalmic surgery, lasers     [PubMed]
Brasse K,Schmitz-Valckenberg S,Jünemann A,Roider J,Hoerauf H, [YAG laser vitreolysis for treatment of symptomatic vitreous opacities]. Der Ophthalmologe : Zeitschrift der Deutschen Ophthalmologischen Gesellschaft. 2019 Jan;     [PubMed]
Luo J,An X,Kuang Y, Efficacy and safety of yttrium-aluminium garnet (YAG) laser vitreolysis for vitreous floaters. The Journal of international medical research. 2018 Nov;     [PubMed]
Chong SY,Fhun LC,Tai E,Chong MF,Sonny Teo KS, Posterior Vitreous Detachment Precipitated by Yoga. Cureus. 2018 Jan 24;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of NP-Adult Acute Gerontology. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for NP-Adult Acute Gerontology, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in NP-Adult Acute Gerontology, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of NP-Adult Acute Gerontology. When it is time for the NP-Adult Acute Gerontology board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study NP-Adult Acute Gerontology.