No not a bodies floating in the Manhattan River, an annoying small moving black opacity in the visual field of my left eye. Floaters are deposits that are located in the vitreous humor of the eye. Normally the vitreous humor is colorless, and light passes through the eye to the retina allowing us to see what we are looking at. A floater blocks a tiny part of the visual field and casts a shadow on the retina or refracts light that passes through the eye. Typically floaters move about in the vitreous, i.e. float, hence their name. Technically floaters can be variably sized, but are generally fairly small. Most people who have floaters find that they come and go, move when they move their head or eyes, and are more annoying at first, and as we become used to them are less frustrating.

For the first few days my floater, a tiny black spot in the left eye visual field seemed like a piece of sand on my glasses, or something on my computer screen, but I suspected because it moved it was a floater. Like what many people describe my first inclination was to try to look directly at the opacity to figure out where it is located. This was a weird sensation because the floater would usually immediately disappear when I tried to look at it. Intellectually I understand that this is because with movement of the eye the floater itself moves, and because its location in the eye causing the shadow on my retina is not where it appears to be. Still the first few times I thought I was imagining the speck. Then I closed my right eye and it persisted, closed my left eye and it went away, and I knew I had yet one more sign of my age. Floaters can occur in young people, and can even be congenital, but are more common with aging.

Other people describe floaters as spots, thread or cobweb like shapes, or other descriptions that float slowly through their eyes. These are not an optical illusion, but are real phenomena. Most floaters are caused by gradual shrinking of the vitreous body as some of the molecules in the vitreous dry out and become solid. These degenerate further into fibrils that can be seen as floaters. This vitreous shrinkage that occurs with age can sometimes lead to pulling away of the retina, a.k.a. a retinal detachment. Shrinking of the vitreous can lead to flashing lights across the vision due to mechanical stimulation of the retina, and retinal detachment can cause either a large floater-like area, a type of scotoma, or a sudden appearance of numerous floater-like opacities as blood from the retina disperses in numerous droplets of blood in the vitreous. If you notice a sudden occurrence of multiple floaters you should have a dilated eye exam by an ophthalmologist right away as a retinal detachment is a potentially treatable cause of vision loss.

In general floaters are considered a nuisance, and are not treated. For severe cases treatment may be appropriate, either through a vitrectomy or by use of a YAD Laser. Neither is commonly performed due to the risks of the procedures and controversy over the efficacy treatment. For me I just smile, thank God I can still see well, and try not to let my floaters bother me too much.

Leave a comment below to tell us about your floaters, or any personal experiences you have with this phenomenon.

Resolving Subconjunctival Hemorrhage (3 days old)

Today in the office I saw the patient with the subconjunctival hemorrhage, or broken blood vessel in the eye,  in this photo.  It is always fun to see subconjunctival hemorrhage in the office because it is so easy to diagnose and the news is universally good.  Nothing else really looks like a subconjunctival hemorrhage, but it certainly gets your attention if you have one.  If you think of it as just a broken blood vessel in the eye you can imagine how it will look.

The part of the eye that can be seen from the outside consists of the iris and the pupil which are covered by the cornea, and the white part of the eye, the sclera, which is covered by a very thin layer of clear tissue called the bulbar conjunctiva.  The conjunctiva covers the white part of the eyeball and wraps under the eyelids where it is called the palpebral conjunctiva.  The tiny blood vessels that course through the conjunctiva are usually barely visible.  When the conjunctiva is inflamed from allergy, viral or bacterial infection, or other causes of irritation these vessels become engorged and the eye appears pinkish.  This is sometimes called pink eye.

When one of these tiny blood vessels in the bulbar conjunctiva breaks a tiny drop of blood leaks into the space between the conjunctiva and the tough leathery white of the eye.  This blood spreads into a very thin but bright red layer making it look like the whole eye is covered with blood. It looks just like what it is, a broken blood vessel in the eye.  The blood can spread to the whole white area of the eye, or just involve either the inner aspect or the outer aspect of the eye.   This condition is called a subconjunctival hemorrhage.  The “sub” prefix means beneath or under the conjunctiva.

There are several common causes of subconjunctival hemorrhage, but often a person has no idea how the blood vessel was broken.  The most classic of the causes of subconjunctival hemorrhage is labor in pregnant women.  The violent pushing required to expel the fetus commonly causes a broken blood vessel in the eye.   Other fairly common reasons people get a broken blood vessel in the eye are minor trauma, i.e. being poked in the eye, blunt trauma, i.e. being punched in the eye, and sneezing, coughing or rubbing an eye that itches from allergies.

A subconjunctival hemorrhage gradually clears up over a few days to a few weeks time.  The initial bright redness disperses and the blood is reabsorbed.  Usually within 3-5 weeks the redness is completely gone and recovery is complete.  In situations where a person is on an anticoagulant like warfarin or Pradaxa, or an anti-platelet agent like aspirin or Brilinta the bleeding from the broken blood vessel in the eye may be more extensive than usual, but even in these cases the blood usually is reabsorbed fairly quickly.

It is important to differentiate subconjunctival hemorrhage from hyphema.  Hyphema is bleeding into the anterior chamber of the eye behind the cornea, and appears like blood is filling up the space behind the cornea.  Hyphema is an ophthalmologic emergency and needs opthamologic consultation.  Subconjunctival hemorrhage does not affect vision, whereas hyphema usually blocks the visual field.  It is not usually difficult to tell the difference but if there is any question you should definitely see your physician to have your eye examined.

The bright redness of a subconjunctival hemorrhage is not at all like the pinkness of conjunctivitis.  Conjunctivitis on close examination looks like the blood vessels in the conjunctiva are more noticible or injected looking.  With subconjunctival hemorrhage it looks like a pool of blood is covering the eyeball, and looks just like what you would expect from a broken blood vessel in the eye once you understand the anatomy of the conjunctiva and the eye.

Check out this related resource on aspirin side effects.