Floaters

Last week, I was asked to write about floaters, a complaint that bobs up frequently in my practice. The little black "flies" that suddenly pop up in one's vision are the subject of endless fascination, consternation, and futile swatting motions. Some describe them as strands and spots that appear under bright sunny conditions. Others see them as cobwebs that cannot be Swiffered. If a floater is large enough, it may interfere with vision and require surgery (very rarely).

There are a few different types of floaters, but the most common ones are begotten by the "vitreous body" (sound like an x-men character to you?) In normal young eyes, especially those with myopia (near-sightedness), the strings or spots may represent strands of vitreous in the posterior chamber of the eye. Vitreous is a mysterious substance that is normally attached to several points in the retina as well as the peripheral portion of the lens. Its state of matter is difficult to define, and hovers somewhere between solid and liquid, most closely resembling a blob of snot. As we age (between our 50s to 70s), our vitreous begins to liquefy and, as it does so, detach from the retina. When this happens -- bam -- a floater appears. I once treated a patient who actually drew out the new floater that distressed her. Let me just say that. . .ahem. . . the drawing was x-rated. On dilated exam, I was amused to discover that the NC-17 floater appeared exactly as she had described it -- a shapely posterior vitreous detachment. So, in most instances floaters represent benign entities: either vitreous strands (in the young) or vitreous detachments (in middle-aged individuals).

However, if you see a floater for the first time, you are usually told by your ophthalmologist to present at the office within twenty-four hours. What's the hurry? In a minority of cases, especially in myopes and/or those who recently suffered ocular injury (or surgery), floaters may be caused by retinal tears. Unattended retinal tears can lead to retinal detachments that may cause permanent visual loss. A retinal detachment in which the central portion of the retina (the macula) is still attached must be repaired within forty-eight hours!

The last class of floaters, even rarer than the first two, may be due to non-vitreous substances floating in the posterior chamber (the posterior chamber assumes characteristics of the East River). Those floaters may represent inflammatory cells and debris formed in response to an infection or autoimmune disease. Depending on their etiology, they may be referred to in sophisticated ophthalmic parlance as: "snowballs," "fungus balls," or "haze." Alternately, floaters in diabetics may be caused by bleeding into the vitreous. Those floaters are described as reddish wisps floating in and out of view.

For diagnostic purposes, all of these conditions require a complete dilated exam -- do not kill the messenger! Your pupil gives us a peep-hole view onto your vitreous and retina and the bigger we make it, the better our view of your posterior chamber (so keep it clean).