Blepharitis, flashers and floaters

Blepharitis, flashers and floatersIf like me, Ophthalmology training in medical school seemed like a blur (and that was just the view through the fundoscope!), you’ll hopefully find this update on blepharitis and flashes and floaters helpful.


Taken from the BMJ 10 minute consultation series (BMJ 2012;345:e3328), this useful reminder summarises management of this common condition.


  • Look for bilateral, usually symmetrical scaly/crusty/erythematous eyelids, possibly with conjunctival injection and small yellow plugs on meibomian glands.
  • Rule out other pathology including:
    • Dermatological conditions around the eyes.
    • Chalazion (meibomian cyst).
    • Mis-directed eyelashes (trichiasis) or missing lashes (madarosis).


Blepharitis can be chronic, so ensure the patient understands that treatment may only control rather than cure symptoms.

  • Use warm water compresses to soften crust and scale.
  • Clean eyelids with cotton bud soaked in baby shampoo or bicarbonate of soda.
  • In resistant cases, use chloramphenicol/fusidic acid for presumed Staphylococcus infection.
  • Treat persistent meibomian cyst infections with oral doxycycline (100mg daily for 6w).

Flashes and floaters

Floaters are not uncommon, but when do we need to worry about flashes and floaters and how should we manage them? This helpful BMJ clinical review provides a framework for assessing those with such symptoms (BMJ 2013;347:f6496).


Salient points are:

  • Character of flashes
    • Intermittent white flashes are usually caused by a shrinking vitreous humour tugging on the retina and can be triggered by eye movements.
      Coloured lights or zig-zagging lines are more likely to be neurological, e.g. migraine, and often last minutes or hours.
  • Presence of floaters
    • These are best seen when looking at a bright uniform background, e.g. computer screen, and move away when look at them. The general consensus is that stable longstanding floaters are not worrying, but seeing new ones should raise concern.
  • Visual loss?
    • A progressive enlarging shadow starting peripherally and moving centrally is typical in retinal detachment.
  • Any risk factors
    • e.g. myopia, cataract surgery or blunt ocular trauma?
  • Relevant past medical history
    • Such as diabetes or inflammatory conditions, which can cause debris in the vitreous humour.


  • Check visual acuity bilaterally using a Snellen chart (and record it!).
  • Assess visual fields looking for small defects. The authors suggest we use a hat pin and ask patients when they first see the pin head. Note: most retinal detachments occur in the superior quadrants, giving inferior field defects.
  • Check fundi looking for asymmetrical red reflexes (vitreous haemorrhage/retinal detachment). You may see a Weiss ring (if you’re an ace with the fundoscope!) which is pathognomonic of posterior vitreous detachment (a prominent ring near the optic nerve). Correspondence in BMJ suggested absence of this sign should not reassure you (BMJ 2013;347:f7572).


  • 85% of flashes and floaters are due to simple posterior vitreous detachments, and need minimal if any intervention. Spotting the ones that do is the key.
  • If any visual loss, same day referral to ophthalmology is indicated.
  • If no visual loss, patients should receive a detailed retinal examination within 2 weeks (this could be with a competent optician).
  • Warn all patients to seek urgent advice if any symptom of progression.

First published in the NASGP's The Sessional GP magazine.

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