This Guidance does not change what you must do under the law.

If you are unable to carry out an adequate examination when you examine a patient who presents with flashes and/or floaters, you must refer the patient to a practitioner who is competent to do this.

You should ensure that front line or support staff are trained to deal with such a patient who contacts the practice. Patients should be told a diagnosis cannot be reached without an examination.

If you carry out an examination, you should continue until you detect a problem and can make a diagnosis or have sufficient evidence to decide what action to take.

If you suspect a retinal break or tear, you should, as a minimum: 

1. take a detailed history and symptoms, looking for particular risk factors
2. examine the anterior vitreous to look for pigment cells
3. perform a dilated fundal examination, using an indirect viewing technique
4. give appropriate advice to the patient, which you back up with written information.

You should follow local protocols for the management and referral of these patients.

You should keep full and accurate records of all patient contact.

The majority of patients presenting with flashes and/or floaters will not have a retinal detachment. If you do not feel competent to manage a patient presenting with flashes and/or floaters, you should refer them to an appropriate colleague. Emergency referrals include: 

1. retinal detachment
2. pigment in the anterior vitreous (tobacco dust)
3. vitreous, retinal or pre-retinal haemorrhage
4. lattice degeneration or retinal break, with symptoms.

A retinal hole or tear does not always lead to retinal detachment. However, you should refer the patient if they are having relevant symptoms and any of the signs in paragraph A261 are present.

Most cases of floaters are due to posterior vitreous detachment (PVD) or vitreous degeneration. You can manage a patient in your practice if you confirm they have a PVD after dilated ocular examination and:  

1. vision is unchanged
2. no retinal tear or detachment is present
3. no pigment is present in the anterior vitreous
4. the patient is well informed about what symptoms to expect if the retina does break or detach subsequently
5. you issue the patient with written information to support your diagnosis and advice.