Retinitis: causes, symptoms, diagnosis, treatment

Retinitis is an inflammatory disease of the retina.

Infectious and inflammatory diseases of the retina are rarely isolated: they usually serve as a manifestation of a systemic disease. The inflammatory process involves the choroid and retinal pigment epithelium, resulting in the characteristic ophthalmoscopic picture of chorioretinitis, while it is often difficult to determine where the inflammatory process primarily occurs - in the retina or choroid. Diseases are caused by microbes, protozoa, parasites or viruses. The process can be widespread, disseminated (for example, syphilitic retinitis), localized in the central parts of the retina (central serous chorioretinitis) or near the optic disc (Jensen's juxtapapillary chorioretinitis). Localization of the inflammatory process around the vessels is characteristic of periphlebitis of the retinal veins and Eales' disease.

Various etiologic factors causing inflammatory changes in the posterior pole of the fundus cause multifocal involvement of the retina and choroid in the pathological process. Often, the ophthalmoscopic picture of the fundus plays a major role in diagnostics, since there are no specific diagnostic laboratory tests to identify the cause of the disease.

Acute and chronic inflammatory processes in the retina are distinguished. Anamnestic data are very important for establishing a diagnosis. Histologically, the division of the inflammatory process into acute and chronic is based on the type of inflammatory cells found in tissues or exudate. Acute inflammation is characterized by the presence of polymorphonuclear lymphocytes. Lymphocytes and plasma cells are detected in chronic non-granulomatous inflammation, and their presence indicates the involvement of the immune system in the pathological process. Activation of macrophages or epithelioid histiocytes and giant inflammatory cells is a sign of chronic granulomatous inflammation, so immunological studies are often essential not only for establishing a diagnosis, but also for choosing treatment tactics.

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Septic retinitis

Septic retinitis often occurs in patients with endocarditis, meningitis, and in women after childbirth. The basis of retinal changes in sepsis are inflammatory lesions of the retinal vessels - perivasculitis.

Septic retinitis indicates the severity of the process and often occurs before death. It is caused by the introduction of bacteria and toxins into the vessels of the retina.

Septic retinitis of Roth - the process is localized in the retina, vision is usually not affected. In the macular area around the disk, along the papilla - foci of yellow-white exudate, not merging, often there are hemorrhages in the form of a wreath with a white focus in the middle. Periarteritis, periphlebitis are possible. At the end of the disease, the foci can resolve. Septic retinitis can be the beginning of metastatic ophthalmia. Clinic - symptoms of irritation are noted, more in adult patients, the color of the cornea changes. On the fundus - multiple white foci located close to the vessels. Foci in the macular area are often formed in the shape of a star. Symptoms increase, edema of the optic nerve develops, opacity of the retinal vessels is noted, the vitreous body becomes dull, its purulent melting leads to endophthalmitis, and then to panophthalmitis.

Viral retinitis

Viral retinovasculitis (caused by herpes simplex, herpes zoster, adenoviruses, and influenza viruses). Changes in the retina are common with influenza. The transparency of the retina is impaired to varying degrees: from gentle diffuse opacity to the formation of saturated white spots of various shapes and sizes. The clouded areas of the retina have a "cotton wool" appearance and are located mainly around the optic nerve head and in the macular region. The vessels passing here are veiled or not visible at all. Clouding of the retina is caused by swelling or clouding of the interstitial substance. The function of the clouded area of the retina is impaired, although cell viability is reduced. The clinical picture is characterized by significant variability over time. The white spots gradually become smaller, more transparent, and finally disappear without a trace or almost without a trace. As the transparency of the retina is restored, its function is also restored. The course is recurrent, exudative retinal detachment often occurs.

The prognosis for vision is unfavorable. Sometimes after the flu, a picture of pigmentary dystrophy of the retina can develop.

Tuberculous retinitis

Tuberculous retinitis - when a specific infection is introduced, the vascular membrane suffers. Isolated retinitis is rare.

Forms of tuberculous retinitis:

1. miliary tuberculous retinitis;
2. solitary tuberculosis of the retina;
3. exudative retinitis without specific picture;
4. tuberculous periphlebitis of the retina;
5. tuberculous periarthritis of the retina.
6. ) miliary tuberculous retinitis (not currently encountered). In this pathology, numerous whitish-yellowish foci appear mainly along the periphery of the retina;
7. solitary tuberculosis of the retina is usually observed in young people, in children. One eye is affected. This is a fusion of several granulomas, which are localized in the center of the optic nerve head, on the periphery (where the blood supply is affected). A specific granuloma has a rounded shape, is located near the optic nerve head, and is often accompanied by hemorrhages. The outcome may be caseous necrosis of the tubercle with transition to atrophy. Tuberculosis may be accompanied by retinal edema in the macular area in the form of a star, while central vision is affected;
8. exudative retinitis without a specific picture - often of allergic origin. This is a small lesion in the macular area or several foci near the optic disc. In the end, the lesion resolves, there are no scars;
9. tuberculous periphlebitis of the retina is the most common and can have central and peripheral localization. With central localization - endo- and periphlebitis. Two branches of the second to fourth order are affected, the caliber of the veins changes, along their course a loose grayish exudate appears, which forms cuffs along the vessels of insignificant length. As the process resolves - a picture of proliferative retinitis.

In the peripheral localization in the early stages, corkscrew-shaped tortuosity of vessels, newly formed vessels (resembling a fan of palm leaves) appear on the extreme periphery of the retina, fibrin accumulates along the venous wall in the form of a cuff. Granulomas are visible along the veins, which close the lumen and can lead to the destruction of vessels. Granulomas look like white foci along the vessels, with unclear boundaries, elongated. It all ends in hemophthalmitis. Blood in the vitreous body can organize and lead to tractional retinal detachment and secondary uveitis.

Thus, we can distinguish the following stages:

1. dilation and tortuosity of veins;
2. periphlebitis and reticulitis;
3. recurrent hemophthalmitis;
4. traction retinal detachment.

The duration of the active process is up to three years. The disease was described by G. Iles under the name "juvenile recurrent vitreous hemorrhage". At the beginning of the 20th century, it was believed that its etiology was strictly tuberculous. At present, it is considered to be a polyetiological syndrome associated with specific and non-specific sensitization of the body in various diseases, such as endocrine diseases, blood diseases, hemorrhagic diathesis, focal infection, toxoplasmosis, viral diseases, etc.

The prognosis regarding vision is poor. Tuberculous arteritis is much less common. Characteristically, large arterial trunks are affected with the formation of a cuff; ischemic foci are possible along with exudative ones. The outcome is a tendency to proliferative processes.

Syphilitic retinitis

Syphilitic retinitis can occur with congenital and acquired syphilis, but more often with congenital syphilis it is not retinitis, but chorioretinitis. With congenital syphilis:

1. "salt and pepper" changes: on the periphery of the fundus there are many white spots (these are inflamed areas of the vascular membranes), which are combined with dark spots. They arise in early childhood and persist throughout life. Central vision is not affected;
2. "shotgun blast" - larger pigment clusters on the periphery (round, in the form of pathological bodies), which can be combined with whitish foci. Accompanied by atrophy of the optic nerve disc;
3. on the extreme periphery - extensive, sharply limited light foci, often merging as they resolve. Atrophic foci with a scarlet rim around them remain, which persist for years;
4. very severe damage - the retina, choroid, and optic nerve are affected. The retina is lead-gray. Throughout the fundus, especially along the vessels, there are large (pigment) foci that sclerose the choroid;
5. congenital syphilitic periphlebitis of the retina - all characteristic features of periphlebitis plus anterior and posterior uveitis.

The following forms of changes in acquired syphilis are distinguished:

1. retinitis without a specific picture - can be central and peripheral localization. For central localization, damage to the vitreous body is characteristic. Against the background of opacification of the vitreous body in the macula - a milky lesion that spreads from the macula to the disk. Against its background, there may be small yellowish foci and small hemorrhages. With disseminated retinitis - multiple foci and opacities in the vitreous body in the form of a dusty suspension;
2. retinitis with predominant damage to the vitreous body - in the central parts of the vitreous body - opacities localized above the macula and the optic nerve head. The opacification of the vitreous body is very intense, so that the fundus is not visible, the vitreous body is transparent at the periphery. Central vision is affected;
3. Retinal gumma - rarely found isolated in the retina. Usually it passes from the optic nerve head and choroid. Gumma has the appearance of a yellowish and yellow-red lesion, rarely protrudes into the vitreous body. There may be small opacities. Vision is rarely reduced. Differential diagnosis is carried out with a tumor;
4. Syphilitic periarteritis of the retina can be in the form of peri- and panarteritis. The arteries look like white stripes, often the changes are not in the retina, but in the area of the optic nerve disc. Sometimes the hemorrhagic component predominates. The outcome is proliferative retinitis.

Rheumatic retinitis

The following are determined on the fundus:

1. short grayish-white cuffs along the course of the vessels, like a circular cuff, with notches;
2. periovascular streak retinal edema;
3. petechiae or hemorrhages are noted;
4. tendency to intravascular thrombosis - a picture of obstruction of the arteries and veins of the retina.

In severe forms, the vessels of the optic nerve head are also affected, then “caps” of exudate appear on the disc, cotton-wool spots, and a “star” figure in the macula.

If left untreated, secondary perivascular fibrosis develops. With treatment, the prognosis is favorable.

Toxoplasmic retinitis

In toxoplasmosis, the vasculitis is exudative, arteries and veins are affected, the lesion begins from the periphery and then spreads to the center. There is abundant accumulation of exudate, which envelops the vessels and spreads to the retina. Exudative retinal detachment often occurs. In acquired toxoplasmosis, there is central exudative retinitis.

Brucellosis retinitis

Brucellosis - changes most often of the type of primary angiitis. The retina is affected (more often in the latent course of brucellosis). Total retinovasculitis from the central to the peripheral sections is characteristic, it can be of the exudative and hemorrhagic type. The couplings can spread in the form of small layers and over a significant area. Small couplings resemble stearin drops located along the course of the vessels. There may be exudative retinal detachment with the formation of adhesions.

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Pseudoalbuminuric retinitis

Pseudoalbuminuric retinitis is a vascular disorder and increased vascular permeability in common infectious diseases (measles, meningitis, erysipelas, syphilis, caries, helminthiasis).

Intoxication with fern preparations, alcohol, anemia, and excessive physical exertion are also important.

Objectively, when examining the fundus, the optic nerve disc is hyperemic, with blurred borders, light foci and hemorrhages in the retina; in the macula - changes in the form of a "star". Differences from renal retinopathy - no retinal edema, the process is reversible.

Other types of retinitis

White spots symptom

Inflammatory multifocal changes in the retina and choroid appear in many infectious diseases.

Multiple transient white spots

The etiologic factor has not been established. In some patients, spots appear after a viral infection, the introduction of the hepatitis B vaccine.

The syndrome is characterized by a typical clinical picture, functional changes and course of the disease. The main difference from the syndromes of multifocal choroiditis and histoplasmosis is that the inflammatory foci appear quickly, disappear within a few weeks and do not progress to the atrophic stage.

Usually young and middle-aged women are affected. The disease begins in one eye with sudden loss of vision, photopsia, changes in the temporal boundaries of the visual field and blind spot. ERG and EOG are pathological.

Ophthalmoscopic picture: many delicate, barely noticeable whitish-yellowish spots of different sizes are found in the posterior pole in the deep layers of the retina, mainly nasally from the optic nerve, the optic disc is edematous, the vessels are surrounded by cuffs. In the early phase of the angiogram, weak hyperfluorescence of white spots, leakage of dye and late staining of the retinal pigment epithelium are noted. Inflammatory cells are found in the vitreous body. With the development of the process in the macular region, weak granular pigmentation is noted.

Treatment of the disease is usually not carried out.

Acute multifocal placoid epitheliopathy

Characteristic signs of the disease are sudden loss of vision, presence of multiple scattered scotomas in the visual field and large cream-colored lesions at the level of the pigment epithelium in the posterior pole of the eye. Acute multifocal placoid pigment epitheliopathy occurs after such prodromal conditions as fever, malaise, muscle pain observed during influenza, respiratory viral or adenoviral infection. A combination of multifocal placoid pigment epitheliopathy with pathology of the central nervous system (meningoencephalitis, cerebral vasculitis and infarctions), thyroiditis, renal vasculitis, erythema nodosum has been noted.

The clinical picture of the disease is represented by multiple whitish-yellow spots at the level of the retinal pigment epithelium. They disappear when the general inflammatory process is stopped.

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Acute focal retinal necrosis

The disease occurs at any age. Characteristic symptoms are pain and decreased vision. The clinical picture includes white necrotic foci in the retina and vasculitis, which are then joined by optic neuritis. Acute retinal damage usually occurs with a systemic viral infection, such as encephalitis, herpes zoster, chickenpox. Necrosis begins at the periphery of the retina, progresses rapidly and spreads to the posterior pole of the eye, accompanied by occlusion and necrosis of the retinal vessels. In most cases, retinal detachment with multiple ruptures occurs. Immunopathological mechanisms play an important role in the development of the disease.

Treatment of this retinitis is systemic and local - antiviral, anti-inflammatory, antithrombotic, surgical treatment.

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