Retinopathy

Retinopathy is a group of non-inflammatory diseases that lead to retinal damage.

The main reasons for the development of retinopathy are vascular disorders, leading to a violation of blood circulation in the vessels of the retina. Retinopathy is manifested as a complication of arterial hypertension, diabetes mellitus, hematological diseases of other systemic diseases

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Retinopathy in hypertension

Arterial hypertension can lead to various changes on the fundus, the pathophysiology and degree of expression of which depend on the stage of the disease.

Clinically, with arterial hypertension, there are two types of disorders on the fundus:

• vascular, represented by focal intraletinal, periarteriolar transudates, cotton-like foci, changes in arterioles and veins of the retina, intra-retinal microvascular disorders;
• extravascular - retinal edema and macula, hemorrhages, hard exudate, loss of nerve fibers.

Retinopathy with arterial hypertension may be acute or remain in remission depending on the nature of the course of the underlying disease. Focal necrosis of the walls of the vessels is the cause of hemorrhages in the layer of nerve fibers, the occlusion of surface capillaries, the formation of cotton spots that are localized in the layer of nerve fibers, the development of deep retinal edema and exudation in the outer plexiform layers. In the acute stage, the arterioles significantly narrow, and there may be edema of the optic disc. With fluorescent angiography, circulatory disorders in the choroid that precede changes in the retina are revealed.

There are three qualitatively different stages in the course of arterial hypertension. Corresponding to these phases, it is often possible to trace rather characteristic changes in the retinal vessels.

The first stage of arterial hypertension is the initial stage, when there is no noticeable symptoms and impairments of functions on the part of systems and organs with already high blood pressure. With arterial hypertension, the function of terminal capillaries is primarily disturbed (their permeability increases, resulting in numerous capillary hemorrhages and plasmorrhages). If these hemorrhages occur in the retina, then with the timely technique of ophthalmoscopy, you can see the smallest hemorrhages and plasmorrhagia in the form of white, different size spots with sharp boundaries and in different amounts. Thus, changes in the retina in the first stage of hypertension may be absent or expressed in single small hemorrhages, mostly round in shape, located randomly. Venous thin branches around the yellow spot, usually invisible, become convoluted and easily noticeable (Haista symptom). With careful observation, periodic spastic narrowing of the arteries can be observed. In the first stage of arterial hypertension has a reversible character, and with appropriate treatment and treatment, hemorrhages disappear, and the eye function remains unchanged, as hemorrhages do not spread to the central fossa.

The second stage of arterial hypertension is transitional. In this phase, more profound and irreversible changes occur in the terminal capillaries. Already, large vessels of the retina are changing: the amount of hemorrhage in the retina becomes larger; except for round hemorrhages, there are hemorrhages in the form of strokes along the vessels of the retina. Along with hemorrhages, large, but isolated white specks of plasmorrhages appear in the retina. In severe cases, the second phase of hypertensive disease goes to the third phase.

The third stage of arterial hypertension is a stage, as a rule, irreversible. It is characterized by organic disorders of the entire vascular system and, especially, of the terminal capillaries: in the brain, in the eye, in the parenchymal organs. The retina is typical: white spots of large sizes predominate, sometimes the entire retina is white. Hemorrhages recede into the background. In the region of the central fossa, a white star-shaped figure is often seen. The disc of the optic nerve is poorly contoured, its borders are sharply stymied. Strongly expressed atherosclerotic changes in the vessels of the retina: the walls of the artery thicken and lose their transparency. The blood current at first seems yellowish, the artery looks like a copper wire, and then the blood flow in the artery does not shine, the artery looks like a silver wire. A dense, sclerosed artery wall in places of its cross with a vein pushes a vein into the thickness of the retina and disrupts the flow of blood in it.

Due to the thickening of the wall and narrowing of the lumen, attention is drawn to the crimp of the vessels and the unevenness of their caliber. Sometimes plasmorrhage breaks through the retina and causes it to detach. This picture indicates deep lesions of the end capillaries. In these cases, the prognosis is poor not only in regard to the function of vision, but also the life of the patient.

In diagnostics, in addition to ophthalmoscopy, which must be performed at least once a year, electro-retinography is used to detect abnormalities in the bioelectrical activity of the retina, the degree of variation of which is judged on the degree of ischemia of the retina; perimetry, in which limited defects in the fields of vision can be detected.

Treatment of retinopathy in hypertension

Energetic treatment by therapists in a hospital in the first two stages of hypertension gives quite satisfactory results.

Treatment should include antihypertensive therapy aimed at stabilizing blood pressure, which is carried out under the control of biochemical and rheological properties of blood, as well as coagulogram analysis.

Prevention is an active and wide-ranging detection of arterial hypertension with obligatory ophthalmoscopy.

Hypertensive retinopathy

Diabetic retinopathy

Diabetic retinopathy is the main cause of blindness in diabetes mellitus. In carrying out ophthalmoscopy, single, different amounts of hemorrhage to the retina are noted, often they are located in the region of the central fossa. Sometimes otatmoskopicheskaya picture is similar to the picture observed with hypertension. With successful treatment of diabetes mellitus, changes in the retina may disappear, while the visual function is restored.

Diabetic retinopathy

[11], [12], [13], [14]

Retinopathy in diseases of the hematopoietic system

With myeloma leukopenia, a fairly characteristic change is observed in the mesh shell and in all the vessels. The entire retina slightly opalesces, in places in its layers there are multiple yellowish-white rounded formations, which somewhat rise above the retina, surrounded by a hemorrhage ring. The size of such foci is 1 / 5-1 / 3 of the diameter of the optic disc. These elements are scattered mainly around the periphery, but often they are also observed in the central fossa, where their size reaches the diameter of the optic disc.

As the hemoglobin level falls, the retinal vessels lose their tone, then the arteries become indistinguishable from the veins. The retina around the optic nerve thickens, and the boundaries of the disc are fading. The background of the reflex is not red, but yellowish, anemic. The number of hemorrhages with white formations in severe myeloma leukopenia increases day by day, and the focus in the yellow spot grows.

A rapid increase in myeloma occurs not only in the retina, but also in the solid cerebral rim - bones and other organs. Modern methods of treatment, which are used in hematology and oncology, have a positive effect and allow prolonging the life of the patient in some cases.

Changes in the retina in pernicious anemia Pale yellow color of the reflex from the fundus is observed due to a general decrease in the hemoglobin level (sometimes up to 10%), atony and vasodilation. As a result of porosity of the walls of small vessels, hemorrhages appear in the retina, which are scattered throughout its length, sometimes preretinal hemorrhages in the zone of the yellow spot (in the form of a circle with a sharply cut line along the chord). Such hemorrhages are located in front of the retina and under the membrane of the vitreous. Despite significant measures, preretinal hemorrhages can be resorbed, in this case the visual function is restored.

Treatment of the disease and blood transfusion give quite good results.

Retinopathy in blood diseases

Sickle-cell retinopathy

Radiation retinopathy

Radiation retinopathy can develop after treatment of intraocular tumors with brachytherapy or external irradiation of malignant tumors in the sinus, orbital or nasopharynx.

The time interval from the beginning of irradiation to the disease is unpredictable and can vary from an average of 6 months to 3 years.

Signs of radiation retinopathy (in order of manifestation)

• Limited capillary occlusion with the development of collaterals and microaneurysms; better determined by foveal angiography.
• Edema of the macula, deposits of solid exudate and hemorrhage of the retina in the form of "tongues of flame".
• Papillopathy, widespread occlusion of arterioles and cotton-like foci.
• Proliferative retionopathy and traction detachment of the retina.

Treatment of radiation retinopathy

Laser coagulation, which is effective in swelling of the macula and proliferative retinopathy. Papillopathy is treated with systemic steroids.

The prognosis depends on the severity. A poor prognostic sign is papillopathy and proliferative retinopathy, which can lead to hemorrhages and traction retinal detachment.