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Detachment (detachment) of the retina
Last reviewed: 23.04.2024
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Retinal detachment - separation of the layer of rods and cones (neuroepithelium) from pigment epithelium of the retina, which is caused by the accumulation of subretinal fluid between them. Detachment of the retina is accompanied by a disruption in the nutrition of the outer layers of the retina, leading to rapid loss of vision.
The detachment of the retina is due to the structural features of this structure. An important role in detachment of the retina is played by dystrophic processes in the retina and traction actions from the vitreous humor.
Symptoms of retinal detachment are a narrowing of the peripheral and a decrease in central vision, often described as a "veil before the eyes." Concomitant symptoms include painless visual disturbances, including photopsy and numerous floating opacities. The diagnosis is made with indirect ophthalmoscopy; the extent of detachment of the retina can determine ultrasonography. Immediate treatment is indicated when there is a threat of loss of central vision to restore the integrity of retinal layers. Treatment of retinal detachment involves the use of systemic glucocorticoids, laser coagulation around the retinal ruptures, diathermy or cryotherapy of retinal ruptures; scleral depression, transconjunctival cryopexy; photocoagulation, pneumatic retinopexy; Intravitreal surgery and enucleation, depending on the cause and localization of the lesion. In the early stages of the disease, loss of vision is reversible, with the removal of the macula and reduced vision, treatment is less successful.
[What causes retinal detachment?
There are the following types of retinal detachment: dystrophic, traumatic and secondary retinal detachment.
The dystrophic retina detachment, also called primary, idiopathic, rhematogenic (from the Greek rhegma - a rupture, breakdown), arises in connection with rupture of the retina, as a result of which subretinal fluid from the vitreous body penetrates it. Regmatogenic retinal detachment occurs again in response to a deep defect in the sensory retina, which increases the access of subretinal fluid from the liquefied vitreous body to the subregional space.
Traumatic detachment of the retina develops as a result of direct trauma to the eyeball - contusion or penetrating injury.
Secondary retinal detachment is a consequence of various eye diseases: neoplasms of the choroid and retina, uveitis and retinitis, cysticercosis, vascular lesions, hemorrhages, diabetic and renal retinopathy, central retinal vein thrombosis and its branches, retinopathy of prematurity and sickle cell anemia, Hippel's angiomatosis - Lindau, retinitis Coates, and others.
Non-hematogenous retinal detachment can be caused by vitreoretinal traction (as in proliferative retinopathy in diabetes mellitus or sickle-cell anemia) or by fluid drainage into the subretinal space (for example, severe uveitis, especially in Vogt-Koyanagi-Harada syndrome or in primary or metastatic choroidal tumors).
Non-haematogenous retinal detachment can be:
- Traction, when the sensory retina detaches from the pigment epithelium due to the tension of vitreoretinal membranes; the source of the subretinal fluid is unknown. The main causes include proliferative diabetic retinopathy, retinopathy of prematurity, sickle-cell anemia, penetrate the rear segment;
- exudative (serous, secondary), in which the subretinal fluid from the chorio capillaries increases access to the subretinal space through the damaged pigment epithelium. The main causes include choroid tumors, exophytic retinoblastoma, Harada disease, posterior sclerites, subretinal neovascularization and severe arterial hypertension.
The main pathogenetic factor in the development of dystrophic and traumatic retinal detachment is retinal rupture.
The reasons for the formation of ruptures of the retina are not completely established. However, in the pathogenesis of ruptures and detachment of the retina, undoubtedly, the dystrophic changes in the retina and the choroid, the traction from the vitreous humor and the weakening of the connections between the photoreceptor layer of the retina and the pigment epithelium are important.
Among the peripheral vitreochorioretinal dystrophies, one can conventionally identify the most common forms.
In accordance with the localization, it is necessary to distinguish between equatorial, paraoral (in the dentate line) and mixed forms of peripheral vitreochorioretinal dystrophies, which reveal in 4-12% of the eyes in the general population. The most dangerous in terms of the appearance of ruptures and detachment of the retina is latticular dystrophy.
Latticular degeneration of the retina is usually located equatorially or anterior to the equator of the eyeball. Its characteristic feature is a network of intertwining white lines (obliterated vessels of the retina), between which reveal areas of thinning, retinal ruptures and vitreoretinal fusion. With the progression of latticed dystrophy, not only perforated but also valvular lesions can be formed, as well as large atypical ruptures along the entire length of the lesion ("giant" discontinuities). Favorite localization is the uppermost quadrant of the fundus, but there are also circular variants of latticular dystrophy.
Regmatogenic retinal detachment implies the presence of a retinal rupture. It often occurs with myopia, after cataract surgery or eye trauma.
Symptoms of retinal detachment
The detachment of the retina proceeds painlessly. Early symptoms of retinal detachment may include the appearance of dark or irregular forms of floating opacities in the vitreous, photopsy and blurred vision. As the progression progresses, the patient marks the "curtain" or "shroud" before the eyes. If the macula is involved, central vision is significantly reduced.
Diagnosis of retinal detachment
Direct ophthalmoscopy can demonstrate the uneven surface of the retina and its bubble-like elevation with darkened retinal vessels. Retinal detachment is indicated by symptoms and ophthalmoscopy data. To detect peripheral ruptures and detachment, indirect ophthalmoscopy with scleral impression is performed.
If the vitreous hemorrhage from the retinal rupture interferes with visualization of the retina, its detachment should be suspected and Scanning ultrasonography should be performed.
What do need to examine?
How to examine?
Treatment of retinal detachment
In the presence of retinal ruptures, retinal detachment can be spread without treatment, involving the entire reticular membrane. Any patient with suspected or established retinal detachment should be urgently examined by an ophthalmologist.
Regmatogenous retinal detachment is treated by laser, cryo or diathermocoagulation rupture. A scleral depression can be performed during which the fluid drains from the subretinal space. Anterior rupture of the retina without detachment can be blocked by transconjunctival cryopexy; posterior tears - photocoagulation. More than 90% of rhegmatogenous layers can be treated surgically with the achievement of their adhesion. If ruptures occur in the upper 2/3 of the eye, simple detachments can be treated with pneumatic retinopexy (outpatient procedure).
Non-malignant retinal detachment, due to the presence of vitreoretinal traction, can be treated with vitrectomy; transudative detachments with uveitis can respond to systemic glucocorticoids. Primary choroid tumors (malignant melanomas) may require enucleation, although radiation therapy and local resection are sometimes used; Choroidal hemangiomas can respond to local photocoagulation. Metastatic choroid tumors, most commonly from the breast, lung or gastrointestinal tract, can respond well to radiation therapy.