What's New

A new care pathway for patients reporting symptoms of flashes and/or floaters in their vision is now in operation within Gloucestershire.

Flashes and/or floaters are very common visual symptoms and are normally benign. However very occasionally, flashes or an increase in floaters can be a sign of a retinal detachment which requires urgent treatment to prevent vision loss.

Health Professionals can now triage patients using the information below and sign-post them to the appropriate care pathway depending on the severity of symptoms or history reported.

The following pathways have been developed to filter patients into high risk or low risk categories. The high risk patients are referred directly to the Ophthalmology Casualty Department and the low risk to Community Optical Practices where they will be examined by an Optometrist.

Triage can be performed by GPs, A&E, Pharmacists, 111, MIU, non-participating Optical Practices and other health professionals.

Flashes and Floaters Care Pathway - Overview

Please click the relevant flowchart box to be taken directly to textual information.



Any patient reporting the onset of floaters and/or floaters within the last 2 months should be triaged and referred to the appropriate pathway.

Floaters appear as black spots, a hair or cobwebs in front of the vision that move in the direction of the eye if the patient tries to look at them. They can be semi-transparent or dark and appear to float in front of your vision. The number of floaters can increase with age. They can be more apparent when looking at a light coloured surface, at the sky or in bright light. Floaters are more common in short-sighted people and those who have had eye surgery .        

A sudden increase in the number of floaters or the appearance of new large floaters requires investigation by an Eye Health Professional.

Flashes can appear as small sparkles, lightning or fireworks in front of one or both eyes, often in the extreme corners of the vision. They usually come and go, and don't obscure any part of the vision. They can be more noticeable when going from a light to dark environment and they don't last for a defined length of time.

Flashes occur when the retina is being pulled by the vitreous gel. This happens when the gel becomes more liquid and collapses (Posterior Vitreous Detachment) and this is more likely to happen with ageing. Flashes can occur on and off for several months.

New flashes require investigation by an Eye Health Professional.

The vitrous gel inside the eye is attached to the retina at various points.

Over time the vitreous gel inside the eye turns into liquid and shrinks. The gel separates into a watery fluid and wavy collagen fibrils- causing floaters.

As it becomes more liquid it can collapse, pulling at the points on the retina to which it was attached- causing flashes and sometimes a large ring- shaped floater.

PVD's are usually benign, non-sight threatening events. However occasionally, as the vitreous gel collapses it can pull on the retina and cause a tear or hole. Retinal tears and holes can lead to a retinal detachment therefore all new symptoms of flashes and/or floaters should be investigated by an Eye Health Professional.

Where the retina (light sensitive layer inside the eye) pulls away from the eye.

This can cause a rapid deterioration in vision, a blank spot or curtain in the vision in addition to an increase in floaters and flashes.

If the detachment progresses to include the macula, severe vision loss can occur.

Speed in referral for treatment is essential if the vision is to be preserved.                            

Red Flags
Any one of the following indicates a high risk of retinal detachment:
  • Flashes & Floaters + Rapid Vision Loss
  • Curtain across vision + Vision Loss
  • History of Retinal Detachment/Tear in fellow eye
  • Field Loss
  • Myopia greater than 5 Dioptres
In addition to the above, any patient who is functionally monocular (the fellow eye having a VA of 6/60 or poorer) should be treated as high risk.
These patients should be referred to Eye Casualty via the Ophthalmology triage line:
0300 422 3578 for an emergency appointment.
Completion of a referral sheet to fax is advised.
Please fax to:
CGH: 0300 422 3652
GRH: 0300 422 8450
All other patients can be signposted to a participating Community Optical Practice for a consultation and examination.
Differential Diagnosis
  • Normal vitreous floaters
  • Migraine with aura
  • PVD (posterior vitreous detachment)
  • Uveitis – an intra ocular inflammation which can cause floaters
  • Central or Branch retinal vein occlusion- can cause floaters and vision loss
  • Retinal detachment
When to Refer

GPs should triage patients presenting with flashes and/or floaters. If the patient reports any symptoms or history listed in the red flags section, the GP should call eye casualty to make an urgent referral and use the fax referral template.

If the patient does NOT report any red flag symptoms or history, they can be referred to a participating Community Optical Practice for a MECs examination with an Optometrist.

Write a referral letter, include the patient's NHS number, and give this to the patient along with the list of participating Optical Practices.

Advise the patient to choose an Optical Practice from the list and contact them as soon as possible, same day and request a flashes and floaters appointment.

There is also a patient information leaflet available here.

The Optical Practice will take the patient's details and an appointment will be given within 24hours/48hours depending on the severity of the patient's symptoms/history. The patient should take the referral letter along to the appointment. The GP will receive a report from the Optometrist on the outcome.

The examination will include pupil dilation- the patient should be advised not to drive to the appointment.

Key Point

The MECs Flashes and Floaters service is an NHS service- therefore there is no charge to the patient for care received at a participating Optical Practice.

Patients may consult an Optical Practice who is not listed as a provider if they prefer to do so, however a private consultation charge may be incurred by the patient.

Patients Referred to Eye Casualty

Key Point

Patients referred into either pathway should expect to undergo dilated fundoscopy. Dilating eye drops will be instilled in both eyes.

Their pupils will remain dilated for around four hours after the examination and they may experience blurred vision. Therefore they should be advised not to drive themselves to or from their appointment and they should not drive until the affects of the drops have worn off. They may also be light sensitive.

Patients who are found to have retinal tears or a detachment and the macula has not yet detached may undergo same day surgery.

If a detachment has occurred and the macula has detached surgery may not be so urgent.

Patients Referred to a Community Optical Practice

24 hours of presenting if they have one of the following;

  • Sudden Increase in number of floaters – “too many to count”
  • Sudden shower of floaters
  • Cloud/Curtain/Veil across vision
  • Flashes < 6 weeks

48 hours of presenting if they have one of the following;

  • Stable Flashes and Floaters
  • Symptoms > 6 weeks
  • Normal Vision

  • Detailed History & Symptoms
  • Examine Anterior Vitreous to look for pigment cells
  • Perform a dilated Fundus examination, with at least the field of view of a Volk 90
  • Examination of all 8 positions of gaze + Posterior Pole

Key Point

Patients referred into either pathway should expect to undergo dilated fundoscopy. Dilating eye drops will be instilled in both eyes.

Their pupils will remain dilated for around four hours after the examination and they may experience blurred vision. Therefore they should be advised not to drive themselves to or from their appointment and they should not drive until the affects of the drops have worn off. They may also be light sensitive. 

  • Patient with only one seeing eye, reassess Posterior Vitreous Detachment in 4 to 6 weeks
  • Any uncertainty on behalf of Optometrist
  • Second opinion from colleague

If any of the following is seen following examination under the service the Triage Line should be called and a referral/appointment be completed:

  • Retinal Detachment
  • Vitreous or pre-retinal break
  • Pigment ‘Tobacco dust’
  • Retinal Tear/hole

The optomanager system will produce a report that can then be printed and given to the patient to take to their HES appointment.

If a non-urgent condition is found the Optometrist will arrange a routine referral to Ophthalmology.

Patients who are found to have normal healthy retinas will be given advice and information. They may require a follow up consultation with their Optometrist.


Patient Resources

Please see the Patient & Carer Information & Leaflets and Community Resources sections

Resources for Professionals

National Standards

Please see the National and NICE Guidance section

Other Online Resources

Record Keeping and Audit

Community Optical Practices must keep clear and contemporaneous records of any patient contacting this service.

It is recommended that any health care professional providing any form of triage or advice to patients reporting symptoms of floaters and/or flashes keep a clear and comprehensive record of the consultation.

Planned audit will be completed in collaboration with GHFT and Gloucestershire CCG. 

Pathway Leads





Dermot Keogh

Community Optometrist

Primary Eyecare Group


Graham Mennie


Gloucestershire Clinical Commissioning Group


Fadi Alkherdahji


Gloucestershire Hospitals NHS Foundation Trust


Ian Sprigmore

Transformation Programme Manager

Gloucestershire Clinical Commissioning Group


Reason for Pathway Selection

To accompany the launch of the Primary Eyecare Gloucestershire Flashes and Floaters service.

Completion Date

Oct 2016

Review Date

Oct 2017