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Your eyes are more than just the window to your soul. Ophthalmologist Aleksandra Rachitskaya, MD, walks us through potential warning signs of eye flashers and floaters, why we get them and what treatment can look like. She also explains why routine eye exams and being proactive about your eye health can help detect and prevent future health problems.

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Eye Health: Flashers & Floaters with Dr. Aleksandra Rachitskaya

Podcast Transcript

Cassandra Holloway:  Hi. Thanks for joining us for this episode of the Health Essentials Podcast brought to you by Cleveland Clinic. I'm your host, Cassandra Holloway. We're broadcasting from Cleveland Clinic's main campus in Cleveland, Ohio, and we're here today with Dr. Aleksandra Rachitskaya. Thanks for being here.

Dr. Rachitskaya:  Thank you so much. It's a pleasure to be here.

Cassandra Holloway:  Before we begin, we want to remind our listeners that this is for informational purposes only and should not replace your own physician's advice. Dr. Rachitskaya is an ophthalmologist at Cleveland Clinic's Cole Eye Institute, and today we're going to be talking about eye health when it comes to flashes and floaters.

Cassandra Holloway:  So most people at some point in their lives will experience small specks or threads appearing in front of their vision. And I think when it comes to our eyes and ultimately our vision, that can be really scary, right?

Dr. Rachitskaya:  Absolutely. I think it's a very important topic actually. Because it's probably the question that I get asked the most, even by the members of my own family My mom would call and be like, "I have these symptoms. What do I do?"

Dr. Rachitskaya:  I think it's important because a lot of times it might not be dangerous, but in some circumstances it actually could be a sign of something serious going on in the eye. That's why it's important to get examined if you have new floaters and flashes.

Dr. Rachitskaya:  So just to get oriented, if we think about the eye, the way they eye is, you have the front part of the eye. Right? The clear cornea, the lens where the cataract forms, and then you have the back part of the eye where the retina is. And the retina is the tissue that captures the information that comes through the front part of the eye and translates it and sends it back to the brain. That's how we see, we see was our brains.

Dr. Rachitskaya:  In front of the retina, there is this jelly-like substance called vitreous. Okay? And the floaters form in that space. So the floater that's the most common cause of floaters is something called separation of posterior vitreous detachment. But also the floaters can form from bleeding in the eye and inflammation in the eye.

Cassandra Holloway:  So what are, when you say floaters, what are they actually in your eye? Are they tissue? What are they?

Dr. Rachitskaya:  Of course. So if we think about that jelly, with time the jelly actually changes its consistency. It's a normal process of aging. So usually people don't get floaters until their 50s and 60s. As the jelly changes its consistency, it liquefies in some spots and condenses and other spots. And as it pulls away from the retina, that generation of posterior vitreous separation, that's when people see the floaters.

Dr. Rachitskaya:  And the floaters, as you mentioned, can be different. It can be little specks, it can be clouds, it can be spiders and Medusas. I heard all kinds of different descriptions. It's up to a person's imagination of how they describe it. So that's when it's jelly separating.

Dr. Rachitskaya:  When it's bleeding, it's actually the blood itself that creates a floater. When it's inflammation, its inflammatory cells that create the floater.

Cassandra Holloway:  So when people are experiencing floaters, it's not actually on the front of their eye. Right? It's kind of more in the back?

Dr. Rachitskaya:  Correct. And a lot of times, it's funny you mentioned because people come in and they say, "I saw this thing and I thought it was like my mascara or an eyelash and I tried to rub, or I was swatting at these flies and nobody else was seeing the flies." So yes, it is inside the eye. But the way it gets projected on the retina it appears as if it's in front of your vision.

Cassandra Holloway:  So that is the floater aspect of this.

Dr. Rachitskaya:  Correct.

Cassandra Holloway:  So let's talk a little bit about the flashes aspect. How would you describe that to a patient?

Dr. Rachitskaya:  So flashes usually, out of all these conditions that I mentioned, flashes are most commonly associated with posterior vitreous detachment. The flash is generated as the jelly kind of pools on the retina, and people see fireworks. Usually it's more pronounced in the dark environment. So a lot of times when patients come in they say, "I woke up, I saw these floaters and as the day went on, when I went into a dark room, I saw flashing."

Cassandra Holloway:  Gotcha. Is it common to have both flashes and floaters?

Dr. Rachitskaya:  Yes. You can experience floaters alone. You can experience flashes alone or you experience both.

Cassandra Holloway:  And in both eyes, I think?

Dr. Rachitskaya:  So usually when it's posterior vitreous separation, it's usually one eye at a time. But most commonly what happens, one eye goes through posterior vitreous separation. Like I said, it's a normal process of aging. Then the other eye usually does the same in about a year period.

Cassandra Holloway:  Kind of follows.

Dr. Rachitskaya:  Follows, yeah.

Cassandra Holloway:  Gotcha. So let's talk about causes then I guess with both flashes and floaters. What are some of the most common causes of these?

Dr. Rachitskaya:  Okay. So when we talk about the posterior vitreous separation, that probably accounts I would say for the majority of patients who have flashes and floaters. It actually happens to most of us, but some people notice it more and some people notice it less.

Dr. Rachitskaya:  In and of itself, the posterior of vitreous separation is not dangerous, but why is it important to be seen? It's important to be seen because as the jelly moves away from the retina, it can pull on the retina, create a retinal tear, and a retinal tear could lead to retinal detachment. And retinal detachment could be, if untreated, a blinding condition. So that's why it's so important to be evaluated.

Dr. Rachitskaya:  So when somebody comes in and sees an ophthalmologist, an eye doctor for flashes and floaters, they get their eyes dilated. We put drops in, makes your vision blurry, but it allows us to look inside the eye and see, A, what are the floaters mean? Is it posterior vitreous separation? Is it blood? Is it inflammation? Then we'll look at the peripheral retina very carefully to make sure that there is no tears or retinal detachment.

Dr. Rachitskaya:  If you have a tear, we treat it the same day with laser. If you have a retinal detachment, then a person might need surgery.

Cassandra Holloway:  Is that the more serious possibility?

Dr. Rachitskaya:  That's very serious.

Cassandra Holloway:  Gotcha.

Dr. Rachitskaya:  Yes, and retinal detachment, if the retina separates completely people can lose vision. Now in majority of posterior vitreous detachment, I would say over 80 percent, people don't have tears. In majority of vitreous separation they don't have tears or retinal detachments. But you can't tell unless you get your eyes dilated.

Dr. Rachitskaya:  It can happen without any risk factors, but we also know that some people are particularly susceptible to develop retinal tears and retinal detachments. It's usually patients who have a history of being nearsighted, meaning that they can't see distance without glasses or contact lenses because their eye tends to be longer than the average eye. So the periphery of the retina where the tears usually form is a little weaker.

Dr. Rachitskaya:  Also, people who have history of trauma, people who are born early as babies, premature, formerly premature babies, people who have family history of retinal tears and retinal detachments, and also people who have had any eye surgery. Those patients are at particular risk of developing retinal tears and retinal detachments.

Cassandra Holloway:  So it is hereditary then essentially.

Dr. Rachitskaya:  There is a component to it.

Cassandra Holloway:  That's all. Yeah.

Dr. Rachitskaya:  To be honest with you, majority of people don't have any of those risk factors. But when somebody does, we take it even more seriously.

Cassandra Holloway:  Gotcha. So when you talk about this posterior vitreous detachment, is age, just getting older a risk factor for this happening?

Dr. Rachitskaya:  Yes.

Cassandra Holloway:  Okay.

Dr. Rachitskaya:  So usually it doesn't happen in people younger than 50, usually. Now if somebody has some other eye problems it might happen sooner. But it's usually a normal process of aging, just the way our body ages.

Dr. Rachitskaya:  But the important thing I think, we all might see a floater once in awhile. Maybe you have seen a floater. I've seen random floaters. But this is not subtle. You notice that there is a problem. I think the important message is if something changes like that, a lot of us think, "Well I'm just going to wait it out. Things are going to get better." This is something you want evaluated. Because if there is some problem, the sooner we catch it and are able to treat it the better are the visual outcomes.

Cassandra Holloway:  Gotcha. Yeah, definitely makes sense. So what about migraines and headaches? I feel like there's a lot of kind of correlation between if you experience migraines and you get these floaters and flashers or both.

Dr. Rachitskaya:  Yeah. So the visual symptoms that people get with migraines are slightly different. You usually don't get the floaters, but you can get flashes and usually they're slightly different flashes than the flashes of posterior vitreous detachment. They're more geometric in kind of shape. A lot of people describe seeing zigzag lines or they see a comment. Usually that can happen in younger patients.

Dr. Rachitskaya:  So when somebody comes in, we evaluate to make sure the retina is fine. But a lot of times if somebody suffers from migraines and ocular migraines, and ocular migraine can actually happen without the headache. You can just get the ocular symptoms. And then we work with their primary care doctor if it's something that bothers them a lot.

Cassandra Holloway:  I'm curious, you mentioned about shapes. I have a friend who said she's seen the same shaped floater for years and years. Is that common?

Dr. Rachitskaya:  Yes. So what happens is if you have a posterior vitreous detachment, initially you see a lot of floaters and flashes and as the time goes on, the symptoms get better. But a lot of times the floater persists. If you're lucky the floater kind of migrates out of the center of the vision and it's not as bothersome. But sometimes people continue seeing floaters and they know exactly the shape of that floater.

Dr. Rachitskaya:  In most patients, our brains actually perceive this as useless information and ignore it. So what happens is initially you notice this floater. It really bothers you. As time goes on, and this can take months, the floater kind of fades and you don't notice it unless you look for it. But yes, a lot of patients will talk about their friendly floaters, the same guy kind of floating around.

Cassandra Holloway:  Yeah. Is there any correlation between diabetes and eye health and seeing these flashers or floaters?

Dr. Rachitskaya:  So that's a very important point. When the patient has diabetes, they can get floaters, but it's usually not from the jelly itself like in posterior vitreous detachment, but due to diabetic eye disease.

Dr. Rachitskaya:  And similar also in inflammation in patients who have what's called uveitis. It's happens in the same space but it's due to a different cause.

Dr. Rachitskaya:  So a patient with diabetes, it's so essential to be checked by an eye doctor if you carry a diagnosis of diabetes, even if you have no symptoms. Because what happens is that when we look inside the eye, we're able to see diabetic eye disease before patients develop symptoms. By the time, if you are diabetic and you start bleeding inside the eye, you already have a very advanced level of diabetic retinopathy. Because what happened, abnormal blood vessels have grown and they have bled. When patients with diabetes come in and they have bleeding in the eye, a lot of times they need injections in the eye, laser in the eye, and even surgical intervention.

Cassandra Holloway:  So I guess if you are prediabetic or you have diabetes, it's advice to see a eye doctor and make sure this is under control

Dr. Rachitskaya:  Absolutely. Absolutely. Especially if you're being treated for diabetes, and usually the primary care colleagues do recommend annual exams. You don't necessarily need to see a retina specialist like myself, but any eye doctor just for a general checkup to make sure that there's no signs of diabetic retinopathy. If somebody does have signs of diabetic retinopathy, then they get to see a retina specialist.

Cassandra Holloway:  Sure. Makes sense. Keep that in your toolbox. Okay. Do you want to play a quick game of true and false?

Dr. Rachitskaya:  Oh, let's do it.

Cassandra Holloway:  Lots of questions on the internet about what causes these kind of flashes and floaters.

Dr. Rachitskaya:  Sure.

Cassandra Holloway:  So do stress or anxiety cause flashes and floaters?

Dr. Rachitskaya:  So it's hard to do true or false. I think stress and anxiety don't cause the posterior vitreous detachment. But stress and anxiety are known to provoke migraines.

Cassandra Holloway:  Which can cause that.

Dr. Rachitskaya:  Which can cause the symptoms of flashes. Correct.

Cassandra Holloway:  Gotcha. How about being tired or having dry eyes?

Dr. Rachitskaya:  Not really. I think dry eyes can cause other visual symptoms, and I think patients who have floaters and have dry eyes, their vision is more compromised. So dry eye is usually a chronic problem and there is good solutions in terms of artificial tears. I always tell my patients with floaters if they're bothered by the dry eye, if they kind of clear that window of eye, remember we were talking in the beginning, it just makes their vision better.

Cassandra Holloway:  Sure. Makes sense. What about eye strain from looking at a computer screen or a phone screen? Does that cause it?

Dr. Rachitskaya:  It doesn't cause it, but I think if you have a floater it sometimes is challenging, especially when you have a new onset of floaters. Because you're looking at the white background and you can see little things floating there. But it doesn't cause it.

Cassandra Holloway:  Gotcha. And then the last one, what about sun or bright lights?

Dr. Rachitskaya:  So I think if you're in a bright environment, the floaters once again would be more pronounced when you already have them, but it wouldn't cause it. We always advise our patients to be careful with sun exposure, to wear sunglasses to prevent other eye conditions. Obviously don't stare at the sun and don't look the eclipse.

Cassandra Holloway:  Yes. Great advice. I want to talk about diagnosis and treatment. You kind of touched on this a little bit. If someone starts experiencing these symptoms, it's your advice to be seen right away, correct?

Dr. Rachitskaya:  Correct. Usually what happens is if you have an established the eye doctor, you should call your eye provider. And if you don't, you can call Cole Eye Institute. We have actually a clinic where we see patients with acute emergencies or things like that. So be seen, and then it's important to know what happens when you come in. Like I mentioned, we do dilate the eyes because that's the only way for us to look inside the eye.

Cassandra Holloway:  And then after that you can kind of make a treatment plan-

Dr. Rachitskaya:  Correct.

Cassandra Holloway:  For any treatments you need?

Dr. Rachitskaya:  Yeah. And it depends what we find. If it's just the posterior vitreous detachment, we usually tell the patients to watch for any new symptoms. If the floaters get worse, if you see a shadow that doesn't go away because that could mean retinal detachment, if you see new flashes to be seen right away. Because even after the first exam, you're still at risk to develop retinal tears and retinal detachment as the jelly moves inside the eye. We also advise against super strenuous activity in the immediate time period.

Dr. Rachitskaya:  Then we bring them back, usually in about a month or so, to double check and make sure nothing new developed. If we find something else, like a patient has diabetes, then they might need intervention even the same day or a patient if they have inflammation and the eye condition called uveitis. They might need treatment for that and trying to find the cause for that.

Cassandra Holloway:  You touched on a little bit of treatment here and there. So I guess if the main cause is this posterior vitreous detachment, fixing that is first and foremost. Is there any other treatment that's available?

Dr. Rachitskaya:  So there's no way ... Once the jelly separates, it doesn't go back. Okay? So if the person just has a posterior vitreous detachment, we follow them and make sure they don't have any complications such as retinal tear and retinal detachment. But there is no way to fix it. There's no way to put it where it used to be. So that's kind of a management for that.

Dr. Rachitskaya:  Then if there's a retinal tear, then we usually laser it and it's a procedure that's done in the clinic. So what it is, is there is a lot of bright lights and we kind of create a laser barricade around the tear and it scars down so that the fluid can't get through the tear under the retina and detach it. If somebody has a retinal detachment, most commonly they need surgery and that's surgery in the eye where it's done in the operating room.

Cassandra Holloway:  So in some cases the flashers or floaters will always be there and it's just you have to learn to manage that.

Dr. Rachitskaya:  Right. It's usually the flashes go away and then the floaters they can persist to some degree, but usually it does get better as the time goes on.

Cassandra Holloway:  Gotcha. So the last thing I want to touch on here is prevention. So if someone is listening to this podcast and they've experienced a couple flashes or floaters, obviously make an appointment with your eye doctor, get that checked out. But what about other things in terms of keeping your eyes safe? I know previously you mentioned wearing sunglasses. Are there any other kind of preventative measures that we should be taking?

Dr. Rachitskaya:  Sure. I think when we talk about eye health, eye is not separated from the rest of the body. So make sure that if you have a chronic condition, whether it's high blood pressure, whether it's diabetes, whether it's cholesterol, make sure that is all under control. Because we can see manifestations of all of those diseases in the eye. If you have any eye problems, chronic eye problems, make sure you see your provider, follow up and adhere to treatment.

Dr. Rachitskaya:  I think also trauma is one of the risk factors. So if you're in situations, either work related or even home. If you're doing some construction at home make sure you wear protective goggles. It's surprising how many times we see patients with eye problems and the story is, "I was wearing the goggles and I took them off for one second and then this piece of metal flew into my eye."

Dr. Rachitskaya:  So all of those things are important and I think making sure that you have routine eye exams. Because like I mentioned, a lot of times we can see things in the eye before they manifest in terms of visual symptoms and it's good to catch that at an early stage.

Cassandra Holloway:  That's great advice. Awesome. So that's all the time we have today. Thanks for joining us.

Dr. Rachitskaya:  It's been such a pleasure. Thank you so much for having me.

Cassandra Holloway:  To learn more about eye health and minimizing your risk for flashes and floaters, visit clevelandclinic.org/eye. If you want to listen to more Health Essentials Podcasts featuring Cleveland Clinic experts, subscribe wherever you get your podcasts or visit clevelandclinic.org/hgpodcast.

Cassandra Holloway:  And don't forget, follow us on Facebook, Twitter, and Instagram @clevelandclinic, all one word, to stay up to date on the latest health tips, news, and information. Thanks for listening.

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