Photopsia: Diagnosis from patients symptoms

[RAMESH DORAIRAJAN]

Photopsias: A Key to Diagnosis

Ophthalmology

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• In a detailed description, photopsias in patients of a retina practice were correlated with the cause of the visual disturbance. In 57% of patients, the photopsias were due to vitreoretinal traction; these were predominantly quick, white flashes seen temporally. Non-temporal location was associated with higher incidence of retinal detachment, although this was a rare occurrence. Central location of photopsias was most often associated with age-related macular degeneration. Bilateral photopsias were most often associated with migraine variant. Other causes of photopsias include hypoglycemia/hyperglycemia with diabetes, vertebrobasilar insufficiency, severe coughing, retinitis pigmentosa, and central serous chorioretinopathy.

• Recognizing the most prevalent ocular symptoms linked with their underlying conditions can aid clinicians in determining the cause of photopsias. 

  – Kathy Freeman, OD, FAAO

This paper describes the different flashing lights (photopsias) experienced by patients in a clinical retina practice. Of course, photopsias are also faced in comprehensive ophthalmology and other ophthalmic subspecialist practices. In essence, all ophthalmologists encounter photopsias.

Several key points can be drawn from the information presented in the paper:

Flash location

• Temporal, if the flashes are instantaneous (96%), lightning/flash-like (96%), white (87%), come with new floaters (85%–90%), seen predominantly at night (66%), and are temporally located (think vitreous traction). Posterior vitreous detachment (PVD) accounted for 40% of the 217 eyes (169 consecutive patients) in the series. Retinal tears accounted for another 9%, and retinal detachment was associated with 7%. These latter two conditions likely had a bias toward higher incidences since the cases came from a vitreoretinal practice. Flashes were temporal in 86% of PVD eyes and 90% of eyes with retinal tears. Key point: With retinal detachment, the flashes had similar features, but only 60% were temporal.
• The most common cause of central photopsias was neovascular macular degeneration, which accounted for 11% of eyes. Typically lasting several seconds or longer, 96% were repetitive starbursts, twinkles, pinwheels, or strobes and 80% were centrally located. Other causes of central flashes were conditions involving the posterior pole, including late retinitis pigmentosa, multifocal choroiditis, Best’s disease, and papilledema.

Laterality. Flashes were unilateral in 70% of cases and bilateral in 30%.

• Bilateral simultaneous (think central nervous system or systemic). Migraine accounted for 50% of these cases and was usually acephalic. The photopsias were typically scintillating scotomas, repetitive flashes lasting 5 to 30 minutes at the edges of blurring. Half the patients thought the photopsias were unilateral but realized they were bilateral when asked the question, “Could you see clearly?” If not, they knew both eyes were affected. Other causes were vertebrobasilar insufficiency, hypoglycemia, severe coughing, retinitis pigmentosa, and one case each of metastatic adenocarcinoma to the brain, hyperglycemia >400 mg/dL, digitalis toxicity, the Charles Bonnet syndrome, and orthostatic hypotension. Key point: Do not miss vertebrobasilar insufficiency. A resultant stroke can be severe, on occasion causing the “locked-in” syndrome. Each of our patients had central photopsias lasting 10 seconds to 10 minutes, vertigo, and dizziness. Two-thirds had syncope and two-thirds had a headache, often on top of the head or occipital. Unlike with classic migraine, the photopsias did not typically come immediately before the headache.
• Bilateral, non-simultaneous. Bilateral PVD accounted for 50% in this group, PVD/retinal tear/detachment combinations bilaterally for 30%, and bilateral neovascular macular degeneration for 15%. With bilateral vitreous traction, the flashes in each eye might only be a second apart, but they were not simultaneous.
  

Color. Oral digitalis caused bilateral yellow photopsias, and retinal arterial occlusion was associated with purple/white photopsias. The entoptic phenomenon caused multiple silver, comma-like photopsias centrally, while vitreoretinal traction caused silver/white flashes in over 90% of eyes. Choroidal neovascularization was associated with white photopsias in 68% of eyes, blue in 16%, and red, green, or multicolored photopsias in 16%.

A detailed history can often give important clues as to the origin of the photopsias. With the clinical exam and diagnostic testing, the origin can be successfully identified in over 98% of cases.

[dr.rameezhussain]

Very nice article. Please let us know the source journal details

Regards

Dr Rameez

[TNOA forum]

Dear Dr Rameez

The article is published in Aug issue of  "Ophthalmology" 

pubmed summary is attached below

Ophthalmology. 2015 Aug 3. pii: S0161-6420(15)00613-2. doi: 10.1016/j.ophtha.2015.06.025. [Epub ahead of print]

Photopsias: A Key to Diagnosis.

Brown GC1, Brown MM2, Fischer DH3.

Abstract

PURPOSE:

To assess the character and cause of photopsias in vitreoretinal patients.

DESIGN:

Cross-sectional study.

PARTICIPANTS:

A total of 169 consecutive patients (217 eyes) with vitreoretinal disease presenting with a history of photopsias.

METHODS:

A total of 217 eyes with photopsias in 169 patients were evaluated. Photopsia assessment included (1) laterality (unilateral, bilateral but not simultaneous, bilateral, and simultaneous); (2) morphology (flash, zig-zag, strobe, scintillating scotoma, twinkling, other); (3) color (white, silver, yellow, combination, other); (4) location (temporal, central, other); (5) duration (quick, prolonged, constant, other); (6) frequency; (7) diurnal appearance (day, night, both); (8) stimuli (turning head or eyes, hypoglycemia, hyperglycemia, other); and (9) associated systemic or ocular signs and symptoms (headache, numbness, weakness, vertigo, syncope, diplopia, hypotension, floaters, other).

MAIN OUTCOME MEASURES:

Clinical photopsia features correlated with the causes of photopsias.

RESULTS:

Thirty-two photopsia causes were identified. The top 16 included posterior vitreous detachment (PVD) in 39.7% of eyes; retinal tear in 8.9% of eyes; neovascular age-related macular degeneration (AMD) in 7.9% of eyes; rhegmatogenous retinal detachment (RRD) in 7.5% of eyes; classic and ophthalmic migraine in 6.5% of eyes; hypoglycemia in 2.8% of eyes; vertebrobasilar insufficiency in 2.8% of eyes; non-AMD choroidal neovascularization in 2.3% of eyes; retinitis pigmentosa in 1.9% of eyes; severe cough in 1.9% of eyes; central serous chorioretinopathy in 1.4% of eyes; intraocular lens reflections in 0.9% of eyes; blue field entoptic phenomenon in 0.9% of eyes; Charles Bonnet syndrome in 0.9% of eyes; digitalis in 0.9% of eyes; and metastatic adenocarcinoma to the brain in 0.9% of eyes. The photopsias associated with PVD are typically quick (96%), with lightning/flash morphology (96%), white (87%), temporally located (86%), associated with new-onset floaters (85%), preferentially seen in dark (90%) rather than lighted environments (29%), and often initiated by head/eye movements (60%). Retinal detachment had a similar profile, but with more nontemporal photopsias (40%) (P = 0.01). The photopsias from neovascular AMD are more centrally located (83%), quick and repetitive (79%), seen in light (73%) and dark (63%) environments, have no inciting stimuli (84%), and are more likely to be nonwhite (40%).

CONCLUSIONS:

A pointed history for photopsias can reveal a cause that may not initially seem apparent. Thus, the history can play a key role in management decisions.

Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

[docrameez .]

Thank you

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