Vitreous Floaters

Bergstrom R, Czyz CN.

Publication Details

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 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 the stimulation of the retina from vitreoretinal traction and
pulling.
The work-up should include distinguishing retinal photopsia 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 now? 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 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, 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 the dilated exam at three months and six
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, three
months, and six 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 three
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

Vitreous floaters is a benign condition, however, 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 not visually
threatening. The initial evaluation is done by a primary care provider or
optometrist. Patients that present with signs and symptoms of vitreous floaters
need to be evaluated by an ophthalmologist. Ophthalmology nurses assist with
the initial evaluation and patient education. [Level 5]

Continuing Education / Review Questions

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References
1.
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 Ophthalmol. 2019
Jun;97(4):347-352. [PubMed]
2.
 Tram NK, Swindle-Reilly KE. Rheological Properties and Age-Related
Changes of the Human Vitreous Humor. Front Bioeng
Biotechnol. 2018;6:199. [PMC free article] [PubMed]
3.
Singh IP. Novel OCT Application and Optimized YAG Laser Enable
Visualization and Treatment of Mid- to Posterior Vitreous
Floaters. Ophthalmic Surg Lasers Imaging Retina. 2018 Oct
01;49(10):806-811. [PubMed]
4.
Brasse K, Schmitz-Valckenberg S, Jünemann A, Roider J, Hoerauf H.
[YAG laser vitreolysis for treatment of symptomatic vitreous
opacities]. Ophthalmologe. 2019 Jan;116(1):73-84. [PubMed]
5.
Luo J, An X, Kuang Y. Efficacy and safety of yttrium-aluminium garnet
(YAG) laser vitreolysis for vitreous floaters. J Int Med Res. 2018
Nov;46(11):4465-4471.[PMC free article] [PubMed]
6.
Chong SY, Fhun LC, Tai E, Chong MF, Sonny Teo KS. Posterior
Vitreous Detachment Precipitated by Yoga. Cureus. 2018 Jan
24;10(1):e2109. [PMC free article] [PubMed]

Publication Details
Author Information

Authors
Reece Bergstrom1; Craig N. Czyz2.

Affiliations
1
 Doctor's Hospital
2
 Ohio University

Publication History
Last Update: May 21, 2020.

Copyright
Copyright © 2020, StatPearls Publishing LLC.

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NLM Citation
Bergstrom R, Czyz CN. Vitreous Floaters. [Updated 2020 May 21]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2020 Jan-.