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Consultant Ophthalmologist, Cataract & Refractive Surgeon
BMedSci BM BS MRCS MRCSEd MRCOpth FRCOphth MMedLaw PgD Cataract & Refractive Surgery

Your patient has flashes and/or floaters

This is difficult. Flashes and floaters are common and rarely indicate significant pathology. The key question is whether the patient has a retinal tear or hole, or retinal detachment. Optometrists are usually good at examining the fundus. The decision to refer and the urgency of the referral should be guided by the confidence of the optometrist in making the diagnosis of, or excluding the presence of, significant pathology.

If the optometrist is confident that the patient has an isolated posterior vitreous detachment and no retinal breaks, there is no need to refer. The patient should be warned about the symptoms of retinal detachment –a sudden new hail of floaters, an increase in flashes or a solid curtain across the peripheral vision – and advised to attend their ophthalmology service immediately if they get any of these.

If the optometrist has seen a retinal detachment or a retinal tear or hole, the patient should be referred urgently.

If the optometrist had a good look at the retina and could not see any pathology, but still feels that referral is warranted for assessment, the patient should be referred routinely/soon via letter.

If patients have risk factors such as pseudophakia, aphakia, a previous history of retinal detachment or high myopia, then the suspicion of pathology should be greater.

If the optometrist has seen 'pigment in the vitreous' or evidence of a vitreous haemorrhage, the patient has a retinal tear until proven otherwise and should thus be referred urgently/soon.