Retinal detachment - Symptoms

Symptoms of retinal detachment consist of subjective and objective signs.

Patients complain of sudden loss of vision (referred to by the patient as a "curtain" or "veil" before the eyes). The disturbances progressively increase and lead to an even deeper decrease in visual acuity. These symptoms of retinal detachment may be preceded by a feeling of "flashes and lightning", distortion of objects, and floating opacities. These symptoms, characteristic of retinal detachment, depend on the location and extent of retinal detachment and the involvement of the macular region in the process. Loss of vision usually occurs on the side opposite to the location of the retinal detachment.

During an ophthalmoscopic examination, retinal detachment is characterized by the disappearance of the normal red reflex in one or another area of the fundus, which becomes grayish in the area of retinal detachment, and the retinal vessels are darker and more tortuous than normal. Depending on the prevalence, height and duration of retinal detachment, the retinal detachment protrudes more or less into the vitreous body, retaining almost complete transparency in the early stages. With a small height of retinal detachment (the so-called flat retinal detachment), the presence of the process can only be judged by the change in the course of the vessels and less clarity of the choroid pattern, as well as by a decrease in the bioelectric activity of the retina. With high and vesicular retinal detachment, the diagnosis is beyond doubt, since a swaying whitish-grayish bubble is visible. With a long-term existence of a detached retina, coarse folds and stellate scars appear in it. The detached retina becomes slightly mobile, rigid. Eventually it takes on a funnel-shaped form and maintains contact with the underlying membranes only around the optic disc.

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Symptoms of Primary Retinal Detachment

Classic precursor symptoms, observed in 60% of patients with spontaneous rhegmatogenous retinal detachment, are photopsies and vitreous floaters. After some time, patients notice relative visual field defects, which may progress and involve central vision.

Photopsies with acute posterior vitreous detachments may be caused by retinal traction in the area of vitreoretinal adhesions. Cessation of photopsies is associated with detachment of adhesions, including complete detachment of the adhesion area along with a portion of the retina. In eyes with posterior vitreous detachments, photopsies may be caused by eye movements and are more evident in low light. They are mainly temporal and, unlike floaters, do not tend to lateralize.

Vitreous floaters are mobile and are perceived when a shadow falls on the retina. Vitreous opacities in eyes with acute posterior vitreous detachments can be of three types:

1. single round opacities representing a detached ring located along the edge of the optic nerve disc (Weiss ring);
2. arachnoid opacities resulting from the accumulation of collagen fibers within the destroyed cortical part of the vitreous body;
3. tiny clusters of red or dark spots usually indicate secondary vitreous hemorrhage following rupture of peripheral retinal vessels.

Visual field changes secondary to retinal detachment are described as a "dark curtain." Some patients may not have this symptom upon awakening from sleep due to spontaneous reabsorption of subretinal fluid, but may develop it later in the day. Initial changes in one or another quadrant of the visual field are diagnostic for determining the location of the primary retinal tear (which will be in the opposite quadrant). Central visual impairment may be due to subretinal fluid leaking into the fovea and, less commonly, to occlusion of the visual axis by extensive bullous retinal detachment above.

General signs

• Marcus Gunn pupil (relative afferent pupillary defect) is noted in eyes with extensive retinal detachments regardless of their type.
• Intraocular pressure is usually about 5 mmHg below normal.
• Often accompanied by moderate uveitis.
• In the anterior part of the vitreous body, the so-called “tobacco dust” is determined.
• Retinal tears appear as irregular red spots on the surface of the retina.
• Retinal manifestations depend on the duration of retinal detachment and the presence or absence of proliferative vitreoretinopathy, as described below.

Fresh retinal detachment

• The detached retina has a convex shape, is somewhat cloudy and uneven due to intraretinal edema. It undulates freely when the eyes move.
• The underlying choroidal structure is noted to disappear, the retinal vessels appear darker than in the flat part of the retina, while the venules and arterioles differ little from each other in color.
• Subretinal fluid extends superiorly to the serrated line, except in rare cases with macular holes, in which subretinal fluid initially accumulates in the posterior pole region.

Pseudoruptures are more often detected when the detachment is localized in the posterior pole.

Pseudo-breaks should not be mistaken for true macular holes, which may progress to retinal detachment in highly myopic eyes or after blunt ocular trauma.

Old retinal detachment

The main signs of old rhegmatogenous retinal detachment, which are characteristic of other types.

• Secondary retinal thinning in response to atrophy that should not be mistaken for retinoschisis.
• Secondary intraretinal cysts may develop if retinal detachment persists for more than 1 year.
• A subretinal demarcation line (with a high level) is noted with proliferation of RPE cells at the border of the flat and detached parts of the retina and develops over 3 months.

Proliferative vitreoretinopathy

Proliferative vitreoretinopathy occurs when membranes on the inner surface of the retina (epiretinal membranes), on the posterior surface of the detached hyaloid membrane, and sometimes on the outer surface of the retina (subretinal membranes) proliferate and contract. Significant postoperative contraction of these membranes is the most common cause of failure in retinal detachment surgeries. The main clinical signs of proliferative vitreoretinopathy include retinal folds and rigidity, with the degree of retinal tremor during eye movement or sclerocompression depending on the severity of the process. The classification of proliferative vitreoretinopathy is as follows.

1. Grade A (minimal) is characterized by diffuse clouding of the vitreous body (in the form of “tobacco dust”), sometimes the presence of pigment cells in the lower parts of the retina.
2. Grade B (moderate) is characterized by retinal breaks with inverted jagged edges, wrinkling of the inner surface of the retina and tortuosity of the vessels, compaction and decreased mobility of the vitreous body. The main role in this belongs to epiretinal membranes, which can only be seen with indirect non-contact ophthalmoscopy on a slit lamp and which are not detected with conventional indirect ophthalmoscopy.
3. Degree C (pronounced) is characterized by thickened rigid folds of the retina with compaction and destruction of the vitreous body. It can be anterior or posterior, with an uneven dividing line corresponding to the equator of the eyeball.
   • the severity of proliferation is determined by the volume of retinal pathology, expressed by the number of hour meridians (1-12) even in non-adjacent proliferations;
   • The type of membrane contraction is in turn divided into: type I (local), type 2 (diffuse), type 3 (subretinal), type 4 (circular) and type 5 (with anterior displacement).

Symptoms of traction retinal detachment

Photopsies and floaters are usually absent because vitreoretinal traction develops insidiously and is not accompanied by acute posterior vitreous detachment. Progression of visual field changes is slow and may be established over several months or even years.

Signs

• The detached retina has a concave shape, without breaks.
• The level of subretinal fluid is lower compared to rhegmatogenous retinal detachment and rarely extends to the "serrated" line.
• The retina is most elevated in the area of vitreoretinal tractions.

Retinal mobility is significantly reduced, and there is no fluid movement.

If tractional retinal detachment leads to the formation of tears, it acquires the properties of rhegmatogenous retinal detachment and progresses very quickly (combined tractional-rhegmatogenous retinal detachment).

Symptoms of exudative retinal detachment

There are no photopsies because there is no vitreoretinal traction, although floaters may be present if there is concomitant vitreitis. Visual field changes develop suddenly and progress rapidly. In some cases of Harada disease, both eyes are affected.

Signs

• The detached retina has a convex shape without breaks.
• The surface is often smooth rather than uneven.
• Sometimes the subretinal fluid level is so high that retinal detachment can be seen at the slit lamp without a lens; the retina may even be in contact with the back surface of the lens.
• The detached retina is very mobile, and the phenomenon of "fluid displacement" is observed, in which the subretinal fluid, under the action of gravity, detaches the area of the retina under which it accumulates. For example, when the patient is in an upright position, the subretinal fluid accumulates in the inferior parts of the retina, but in a supine position, the inferior part of the retina flattens and the subretinal fluid shifts posteriorly, detaching the macula and the superior part of the retina.
• Scattered areas of subretinal pigment lumps, such as "leopard spots," are found after the retinal detachment has resolved. Fundus examination may reveal the cause of the retinal detachment, such as a choroidal tumor.