Flashes and Floaters Emergency Triaging Protocol Accurately Delineates Urgent Cases

A Doctor performing an Eye Examination
A doctor performing an eye examination in a hospital.
A 4-year study shows a hospital’s triage protocol missed no cases requiring urgent care.

“Flashes and floaters” triage protocol can successfully determine which cases require emergent care and which are safe for deferred evaluation, according to a study published in the American Journal of Ophthalmology.

Data was collected from the electronic medical records of the Mayo Clinic Saint Marys, in Rochester, MN from October 2014 until May 2018 using the search terms “flashes” and “floaters.” The participants were all triaged using the hospital emergency department’s “flashes and floaters” protocol, which the facility instituted in 2014. That protocol was designed to identify emergent ocular conditions requiring expedited workup or intervention, such as rhegmatogenous retinal detachment, retinal artery occlusions, or cerebrovascular events. It deemed patients eligible for a prompt (within 48 hours) deferred outpatient ophthalmic examination if they had no personal history of retinal detachments or breaks, no history of recent (within 1 month) ocular trauma or intraocular surgery, no visual field defects subjectively or on confrontation visual field testing, and no significant difference in visual acuity testing between the two eyes (2 Snellen visual acuity line difference using current spectacle or contact lens correction). If the patient answered ‘yes’ to any of those 4 questions, the emergency department was instructed to contact the ophthalmology department for guidance on whether a consult was necessary.

For this study, the researchers recorded the emergency department’s chief complaint, demographic characteristics, “flashes and floaters” eligibility criteria based on ED documentation and ophthalmology documentation (separately), time to ophthalmology visit, and final diagnosis. The rate of diagnoses for cases that required ED intervention was calculated within “flashes and floaters” protocol to determine a need for triage protocol.

471 unique medical records were included. 287 cases qualified for deferred care and 175 cases qualified for emergency care according to the triage protocol. Of the 287 (61%) that qualified for outpatient care, 269 (94%) were given that care within 48 hours. Researchers found that there was no case requiring emergent care that was not identified by the triage protocol.

Deferred examination cases resulted in 197 posterior vitreous detachments (73%), 26 retinal breaks (10%), 14 migraines (5%), and 27 cases were categorized as “no cause” or “new cause found” (10%). 

Emergency cases resulted 43 posterior vitreous detachments only (25%), 33 retinal breaks (19%), 22 macula-involving retinal detachments (13%), 19 macula-sparing retinal detachments (11%), 3 retinal arterial occlusions (2%), and 1 stroke (0.6%). Agreement for deferment eligibility between the physicians and ophthalmologists was 0.85.

“Continued development of evidence-based triage protocols offers significant promise with respect to optimization of health care resource utilization while maintaining or improving real-world patient care outcomes,” researchers conclude.

This study is limited by its examination of a single emergency department, the requirements to use the triage protocol, and the possible variability of the physician and ophthalmologist agreement in different settings. 


Shen BY, Salma AR, Shah SM, et al. Clinical outcomes following implementation of a formalized “flashes and floaters” emergency department triage protocol. Am J Ophthalmol. Published online June 21, 2022. doi:10.1016/j.ajo.2022.06.007