Posterior Vitreous Detachment: Everything You Need to Know About Flashes and Floaters

Do You Have Floaters?

As we age, the intricacies of our eyes can undergo significant changes, and one common occurrence that may cause concern is a Posterior Vitreous Detachment (PVD).

The vitreous humor, a gel-like substance that fills the eye, can pull away from the retina during this natural process, leading to flashes of light and floaters in the visual field. While often harmless, these symptoms can be alarming to experience, prompting questions about their origins, implications, and potential treatments.

In this article, we delve into the world of Posterior Vitreous Detachment, exploring its causes, associated visual disturbances, and crucial information to help you better understand and manage this age-related phenomenon.

What is Posterior Vitreous Detachment (PVD)?

Posterior Vitreous Detachment, commonly referred to as PVD in ophthalmology, is a natural and age-related phenomenon that occurs within the eye's vitreous humor, a gel-like substance that fills the space between the lens and the retina, also called the posterior chamber.

The vitreous gives the eye its rigidity and keeps the retina pressed against the back wall of the eye. It gets its consistency from being 99% water. The other one percent is comprised of vitrosin (a type of collagen), phagocytes, hyalocytes of Balazs, and hyaluronic acid.

Phagocytes are white blood cells (part of the immune system) that clean the vitreous of any foreign debris, and the hyalocytes of Balazs recycle the hyaluronic acid. There are no blood vessels feeding the vitreous. All blood vessels in the back of the eye are contained within the retina, specifically the choroid.

The vitreous is attached to the retina in two places: the optic nerve and the ora seratta, but it may stick to the retina in other places, as well. This is what causes potential problems in a posterior vitreous detachment.

The Aging Eye: Understanding the Process of Posterior Vitreous Detachment

As we grow older, vitreous syneresis occurs. This means the vitreous becomes more like a liquid than a gel due to the breakdown of vitrosin (collagen) and hyaluronic acid. Eventually, it can separate or pull away from the retina, leading to a posterior vitreous detachment. This detachment process can cause various visual disturbances, such as flashes of light and floaters, which may raise concerns about eye health and potential complications.

When the collagen breaks down, it sometimes forms chunks in the form of strings, worms, blobs, cobwebs, and other shapes that float in the watery vitreous. These chunks can be clear, or completely black and everything in between. These chunks can float in front of your vision, hence the term “floater.” Depending on its consistency, a floater can temporarily block vision, or distort it until it floats out of the way. Because our eyes move constantly, these floaters can be seen frequently, or may float out of the way only to reappear seconds later, which is frustrating for many patients.

Floaters are most noticeable against a white or solid, typically light-colored, background like the sky. They are sometimes accompanied by flashes of light, resembling a camera flash, in the periphery of the vision.

Flashes are caused by the vitreous collapsing and tugging at the retina when it detaches. This tugging causes the retinal neurons to fire, registering a flash of light in the brain. Occasionally, the vitreous can pull too hard on the retina, causing a tear. If not treated, a tear will allow fluid to build up behind it (the typical immune response to injury) and cause the retina to detach.

However, the sudden onset of flashing lights and floaters does not necessarily mean you have a retinal detachment. But if you have these symptoms, you should see your ophthalmologist as soon as possible. They will be able to find a retinal tear before it becomes a detachment.

Causes and Risk Factors of Posterior Vitreous Detachment

The main cause of PVD is aging. However, a PVD can be caused prematurely for several reasons:

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1. Myopia (nearsightedness) – PVD is common in people with myopia because their eyes are longer than someone with normal vision. The longer the eye (the more nearsighted a person is) the more likely it is for someone to have structural changes in the eye, particularly the retina and vitreous. This can lead to premature PVDs.
2. Traumatic Injury – Someone who has suffered a blunt trauma to the eye is much more likely to suffer a PVD. Blunt trauma can cause the vitreous to separate from the retina. It can also cause the vitreous to condense and thicken in certain areas. This is the result of the vitreous acting like a shock absorber for the eye. The thickened areas can lead to opacities in the vitreous. These opacities can become floaters as a result of the loosening of the vitreous humor in the posterior chamber, allowing them to float in the jelly.
3. Family History – someone with a family history of PVD may experience the early onset of floaters and detachment. This is often the case when vitreous syneresis (liquefaction) occurs in teenagers and young adults with no other etiology such as myopia or blunt trauma.
4. Ocular Surgery – procedures like cataract removal can cause premature PVD. These procedures also increase the risk of developing glaucoma or experiencing a retinal detachment.
5. Ocular Pathology – Having a pre-existing condition like chronic iritis, glaucoma, retinal tears, or uveitis can increase the risk of PVD.

Is it Serious? When to Seek Medical Attention

Many patients call their ophthalmologist when they start seeing floaters. But floaters aren’t a problem. In fact, floaters by themselves simply meant the vitreous is starting to liquefy. If you’re only seeing one or two floaters every now and then, you don’t need to see your ophthalmologist. Although if you have an upcoming appointment with them, mention it to the tech when you go in for your exam.

However, if you are seeing flashes of light, like a camera flash going off in your peripheral vision, give your eye doctor a call. Flashes can be one of two things: the vitreous tugging on the retina as it detaches, or an ocular migraine, both of which warrant further investigation. Doctors will typically see a patient with just flashes within 24-48 hours.

If you have a sudden shower of floaters, and lots of flashes, call your doctor right away. You should be seen the same day or the next day at the latest. If you see a veil or curtain coming over part of your vision, just walk into your doctor’s office and tell them what has happened, and they should see you right away.

A curtain or veil typically means the retina has detached and needs to be seen and treated ASAP. Most ophthalmology offices are general ophthalmology and do not have a retinal specialist on site, so you’ll need to be referred. The faster this can be done, the more likely you are to save vision.

Diagnosing PVD: Eye Exams and Tests

To diagnose a posterior vitreous detachment, you’ll need a comprehensive eye exam. This means you’ll need to have your eyes dilated for the doctor to be able to visualize the entire retina to ensure that everything is intact. There are a few tests that are standard in a comprehensive eye exam including:

• Checking your vision
• Checking pupil function with a penlight
• Measuring your IOP (intraocular pressure)
• Dilating your eyes
• Indirect ophthalmoscopy

The fundus exam, or examination of the retina is conducted with indirect ophthalmoscopy. The doctor will put a device on his head called an indirect ophthalmoscope which has a very bright light attached to it. He will then use a lens to magnify the retina while he shines the light into your eye. This can be uncomfortable, but it’s necessary to check for any retinal tears or detachments.

A few other tests might be ordered by your ophthalmologist depending on your symptoms, his exam protocol and what he sees during the fundus exam:

• OCT (Optical Coherence Tomography) – a non-invasive imaging test that gives the doctor a detailed cross-section of the retina. This test can show vitreomacular adhesions and traction that your doctor may not be able to see with the naked eye.
• Fluorescein Angiogram – this test involves injecting a dye into your arm and then taking pictures of the retina with a specific filter on the camera as the dye begins to fill the blood vessels of the retina. It’s used to find leaking blood vessels, hemorrhages, and occlusions. This isn’t routinely done for a posterior vitreous detachment from a general ophthalmologist, but a retinal specialist will require it. If you are allergic to any dyes like iodine, be sure to tell your doctor before this test as you may be allergic to fluorescein as well.
• B-Scan Ultrasound – Similar to the ultrasound done for pregnancy, this test uses ultrasonic waves to visualize the retina and see if it is still attached. It is not routinely performed unless the view of the retina is obstructed, as in the case of a vitreous hemorrhage.

Treatment Options for Posterior Vitreous Detachment

There are two treatments currently available for floaters. The first is a vitrectomy. This procedure is done on patients who have a retinal detachment, or large floaters that completely obstruct a portion, or all, of their vision when it floats into view.

The vitreous is removed and the vitreous cavity is filled with silicon oil. In the case of retinal detachment, a gas bubble is placed in the eye. The patient then must hold their head in a certain position to force the retina to lay flat until it reattaches. The head position is dependent on where the detachment is located and needs to be held for at least 23 hours per day.

This surgery is not recommended for minor or annoying floaters as there is a long recovery time, and vision may not improve for three to six months after surgery if it improves at all.

The procedure is also quite invasive, carrying a large risk for infections such as endophthalmitis, a nasty infection that can cause permanent vision loss in less than 24 hours. Most surgeons will only perform a vitrectomy on a patient with a vitreous hemorrhage or retinal detachment due to the surgery's invasive nature and risks of permanent vision loss.

The second treatment for floaters is laser treatment. A technique developed by Dr. John Karickhoff in Virginia that uses a YAG (Yttrium, Aluminum, and Garnet) laser to break up large floaters. The technique takes about 20 minutes, and two treatments are usually needed. However, the procedure can lead to many smaller floaters since the laser only breaks up floaters and does not vaporize them.

Potential Complications: Retinal Tears and Detachments

The problem with PVDs is that they can result in complications like retinal tears and detachments which can cause permanent vision loss. Retinal tears are the result of the vitreous tugging too hard on the retina as it separates. Some patients report seeing a very bright flash of light when this happens, but many patients don’t even notice that their retina is torn.

Retinal tears typically become detachments if not treated quickly. Detachments can lead to permanent vision loss, especially if the detachment is categorized as “mac off,” meaning the macula has also become detached.

The macula is the part of the retina that gives us our central vision. Things like tiny details and color vision are the result of the specialized cone cells found in the macula. When this area becomes detached, vision is difficult to recover even if treatment is promptly administered.

These cells are more like the neurons in the brain which can’t be regenerated. So, while the macula can reattach like the rest of the retina, vision is rarely the same after this type of detachment. It is typically distorted or blurred.

Signs and Symptoms of Retinal Tears and Detachments

It’s important to know the signs and symptoms of tears and detachments so that you can seek prompt medical attention. The most common symptoms include:

• A sudden increase in floaters, often described as a shower of floaters
• Sudden onset or increase of flashing lights
• Suddenly seeing a veil, curtain, or shadow over your vision
• Blurred vision

If you notice any or all these symptoms, it’s important to see your ophthalmologist right away. The faster treatment can be administered, the more likely it is you will retain your current vision.

Treating Retinal Tears and Detachments

Treatment for retinal tears is a simple laser procedure or cryotherapy, both of which can be done in the doctor’s office as an outpatient procedure. These techniques are used to “tack down” the tear, sealing it so that it doesn’t result in a detachment. Unfortunately, these procedures cause the vision in the treated area to be permanently lost.

There are three treatments available for a retinal detachment:

• Vitrectomy
• Pneumatic Retinopexy
• Scleral Buckle

Vitrectomy and pneumatic retinopexy are similar in that they both involve a gas bubble placed in the eye. Vitrectomy involves removing the vitreous and replacing it with silicone oil and a gas bubble. It is a long procedure, typically done in a hospital or ambulatory surgical center (ASC) setting.

Pneumatic retinopexy is an outpatient procedure done in the doctor's office and involves injecting a gas bubble into the vitreous after removing a small amount of fluid from the vitreous. After inserting the bubble, the doctor will usually use laser or cryotherapy to seal any holes or tears in the retina.

The bubble in both procedures is used to keep pressure on the detached portion of the retina to keep it pressed against the back wall of the eye. This allows the retina a chance to reattach but requires that the patient hold their head in a specific position for lengthy periods of time. Patients are allowed to lift their head to eat meals and go to the bathroom, but the rest of the time is spent in the position required to reattach the retina. This position is dependent on the location of the detachment.

The scleral buckle is a little different. This procedure is done in a hospital or ASC and involves putting a small but flexible permanent band around the outside of the eye on the sclera. This causes the walls of the eye to be compressed inward allowing the detached retina to reach the back wall and reattach. A laser or cryotherapy is used after the band is placed to seal any holes or tears.

Many patients report the surgical eye feeling painful or “sore” after a scleral buckle. The eye is typically patched for 24 hours and removed at the one day post operative appointment. This type of surgery does not require any head positioning.

The healing time for these three surgeries is about two to four weeks. During this time, you will have to avoid heavy lifting and exercise. Doctors recommend taking this time off work to avoid driving and any excess stress that may slow the healing process. It can take up to six months for vision to recover and stabilize.

Can PVD be Prevented? Lifestyle and Care Tips

Since posterior vitreous detachment is the result of the aging process in most people, there’s not a lot you can do to prevent it. However, there are things you can do to prevent premature PVD and complications:

1. Regular Eye Exams: Yearly eye exams are the best defense against any ocular disease. People under the age of 40 can go every two years, but every year is best. For those over 40, yearly is strongly recommended since this is when cataracts start to develop and changes in the macula begin.
2. Protect Your Eyes: Always wear protective eyewear when engaging in any activity that may pose a threat to your eyes like gardening, working on a car, or playing sports with a potential projectile.
3. Stay Hydrated: The vitreous is 99 percent water. Staying hydrated can help prevent premature PVD and contribute to the overall health of the vitreous and other ocular structures.
4. Eat a Healthy Diet: A diet rich in leafy green and colorful veggies, nuts and seeds and quality fats and proteins can help protect your eyes (and your body!) from the degenerative effects of the aging process.
5. Quit Smoking: Smoking decreases the amount of oxygen in your blood stream, reducing how much oxygen actually reaches your brain and eyes (as well as all other tissue in the body). Oxygen deprivation increases the amount of free radicals in the body which increases the likelihood of retinal and vitreal degeneration. This also applies to alcohol consumption.
6. Keep Chronic Disease Under Control: If you have diabetes, high blood pressure, or any other chronic condition, keep your numbers in normal range. For example, constant blood sugar spikes in diabetes should be avoided, and the goal should always be a relatively stable blood sugar level.

Living with PVD: Coping Strategies and Visual Adaptation

Living with floaters and flashes can be very frustrating for many people. But there are things you can do to make these visual disturbances less likely to interrupt your life.

1. Education and Understanding: For many people, just knowing what those black things are that are floating around in their vision is enough to put their minds at ease. Learning about the condition can really help alleviate anxiety about the condition.
2. Get Regular Eye Exams: Another way to put your mind at ease is to get an eye exam every year so that your eye doctor can catch problems early.
3. Protect Your Eyes: Be cautious when participating in activities that may pose a risk of eye injury. Wearing appropriate protective eyewear during sports and other potentially hazardous tasks can prevent blunt trauma which can cause a PVD.
4. Allow Time for Adaptation: For most people, after a few months, the floaters become much less noticeable as the brain begins to filter them out.
5. Pay Attention to Flashing Lights: If you have flashes but suddenly start seeing more of them than usual, be sure to see your doctor as soon as possible. If you’ve never had flashes and suddenly notice them, even if they are occasional, make an appointment to see your ophthalmologist.
6. Be Careful When Driving: It’s important to realize that floaters can frequently make you think there is something in your periphery. Be aware of this when driving since it may cause an accident if you aren’t prepared.
7. Try to Minimize Stress: This is much easier said than done, but stress can increase the frequency and intensity of any visual disturbance, including flashes and floaters. Even a slow inhale and exhale for 30 seconds can work miracles for alleviating your stress levels.
8. Join a Support Group: Sometimes it helps to talk with others who have the same problem. Knowing you aren’t alone can help with anxiety and offer reassurance.

Embracing Visual Changes as We Age

Sadly, the aging process causes a lot of changes in the body, and the eyes are no exception. While we can’t avoid getting older, being aware of the changes that may occur as we age can help us prepare for and adapt to them as they occur. Learning more about flashes and floaters, what to expect if you start to experience them and what to do about them can help prevent anxiety and even loss of vision.

This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2012 Mel Flagg COA, CPT, CHC, CNC

Comments

Mel Flagg COA, CPT, CHC, CNC (author) from Rural Central Florida on March 30, 2012:

That device with the probe is called a B-scan, it's basicaly an ultrasound of the eye that lets the doctor look at the retina and see if it is detached or not. Most retina specialists don't do this as a routine procedure, so you must have had a PVD that the doctor thought might rip the retina, especially if he saw you every week for four weeks. They can be scary! Are you nearsighted (myopic) by chance?