Retinal detachment: diagnosis

Detection of primary retinal rupture

Primary ruptures are considered the main cause of retinal detachment, although there may be secondary ruptures. The identification of primary changes is extremely important. They have the following characteristics.

Quadrant distribution

• About 60% - in the upper quadrant.
• About 15% - in the upper quadrant.
• About 15% - in the lower-central quadrant.
• About 10% - in the low-grade quadrant.

Thus, the upper quadrant is the most frequent localization of the retinal ruptures and, if not, first, it must be examined in detail later.

Approximately in 50% of cases of retinal detachment, several discontinuities can be detected, which in the majority lie within 90 °.

[1], [2], [3], [4], [5]

Configuration of retinal detachment

The subretinal fluid normally extends according to the direction of gravity. The configuration of the retinal detachment is limited anatomically (ora serrata and the optic nerve disk, as well as the area of the primary retinal rupture.If the primary rupture is on top, the subretinal fluid first flows downwards to the side of the rupture, and then rises back.Thus, by analyzing the configuration of retinal detachment, probable place of primary rupture.

The flat lower detachment of the retina, at which the subretinal fluid rises somewhat from the temporal side, indicates a primary rupture in the same half.

The primary rupture, localized at 6 hours, will lead to detachment of the retina from below with an appropriate level of fluid.

With bullous lower retinal detachment, the primary rupture is usually localized in the horizontal meridian.

If the primary rupture is located in the upper quadrant, the subretinal fluid will move to the optic nerve disk, then upward to the temporal side to the level of rupture.

Subtotal detachment of the retina with a vertex from above indicates a primary rupture localized at the periphery closer to the upper boundary of the detachment. If the subretinal fluid crosses the vertical median line from above, the primary rupture will be located in the 12-hour region, the lower edge of the retinal detachment corresponds to the side of the rupture.

When diagnosing a primary rupture, secondary ruptures can be avoided, following the principles of preventive treatment. Confirmation of the primary discontinuity is facilitated by the configuration of retinal detachment.

The sectoral appearance of photopsy has no diagnostic value in determining the localization of the rupture. However, that quadrant, in which the first changes in the field of vision, deserve special attention, because it corresponds to the region of origin of the retina detachment. So, if visual field defects are noted in the upper-quadrant, the primary rupture can be localized in the lower-quadrant quadrant.

[6], [7], [8], [9], [10], [11], [12]

Ultrasound diagnostics

B-scan ultrasound is indicated for opacification of media with suspicion of a latent rupture or retinal detachment. This is especially true for recent vitreous hemorrhage, which prevents the examination of the fundus. In such cases, ultrasound helps differentiate the posterior detachment of the vitreous body from detachment of the retina. It can also detect the presence of ruptures with a flat detachment of the retina. Dynamic ultrasound, in which the study of structures carried out with movements of the eyeball, is useful for assessing the motility of the vitreous and retina in the eyes with vitreorhinopathy.

Indirect ophthalmoscopy

With indirect ophthalmoscopy, condenser lenses of different strengths are used. The higher the force, the smaller the increase; the shorter the working distance, the larger the area for inspection. The survey technique is as follows:

1. The pupils of both eyes should be maximally expanded.
2. The patient should be absolutely calm.
3. The lens is kept flat all the time in the direction of the patient parallel to its iris.
4. Display a pink reflex, then the fundus.
5. If the visualization of the fundus is difficult, avoid moving the lens relative to the patient's eye.
6. The patient is asked to move his eyes and head to select the optimal position for examination.

Sclerocompression

Goal

Sclerocompression improves the visualization of the periphery of the retina anterior to the equator and makes it possible to carry out dynamic observation.

Equipment

1. To inspect the area of ora serrata, respectively, 12 o'clock the patient is asked to look down. The scleral compressor is placed on the outer surface of the upper eyelid along the edge of the tarsal plate.
2. After this, the patient is asked to look up; At the same time, the compressor is moved to the front part of the orbit parallel to the eyeball.
3. The doctor must combine the look with the lens and compressor, which he will produce gentle pressure. The indentation is defined as a shaft on the fundus. The compressor should be directed along a tangent line relative to the eyeball, because perpendicular indentation is inconvenient.
4. The compressor is moved to inspect adjacent areas of the fundus, while the doctor's eye, lens and compressor should always be on the same straight line.

Retinal card

Equipment. With indirect ophthalmoscopy, the image is upside-down and lateral, so the upper half of the map will show the picture of the lower parts of the retina. In this case, the inverted position of the card relative to the patient's eye corresponds to the inverted image of the fundus. For example, a U-shaped break at 11 o'clock in the eye will correspond to 11 hours on the map. The same applies to the area of "latticular" dystrophy between 1 and 2 hours.

Color Codes

• The boundaries of detachment of the retina are separated, starting from the optic nerve disk towards the periphery.
• The detached retina is depicted in blue, the flat one in red.
• Retinal veins are depicted in blue, while arteries are not depicted at all.
• The retinal ruptures are painted red with a blue outline; the retinal rupture valve is painted blue.
• Thinning of the retina is marked with a red stroke with a blue contour, "lattice" degeneration - blue hatching with a blue contour, pigment in the retina - black, exudate in the retina - yellow, opacity of the vitreous (including blood) - green.

Viewing a three-mirror Goldmann lens

The three-mirror Goldmann lens consists of several parts:

1. The central part, allowing to see the back pole within 30 °.
2. Equatorial mirror (the largest, in the form of a rectangle), allowing to visualize the area from 30 to the equator.
3. Peripheral mirror (average in size, in the form of a square), which allows to visualize the region from the equator to oa serrata.
4. A gonioscopic mirror (the smallest, in the shape of a dome) can be used to visualize the extreme periphery of the retina and the pars plana, so it is fairly believed that the smaller the mirror, the more peripheral the retinal area it produces.

The central part of the mirror displays the actual vertical image of the rear segment. With respect to the three mirrors:

• Mirror should be located opposite the monitored area of the retina.
• When viewing a vertical meridian, the image is upside down.
• When examining the horizontal meridian, the image is rotated in the lateral direction.

Equipment

1. Contact lens is imposed, as in gonioscopy.
2. The light beam should always be inclined, except for the cases of viewing the vertical meridian.
3. When examining the sectors of the peripheral retina, the axis of the light beam rotates so that it always hits the right corner of each mirror.
4. To visualize the entire fundus, the lens is rotated 360, the equatorial mirror is first used, then the peripheral mirror is used.
5. To ensure a more peripheral visualization of the given sector, the lens is tilted in the opposite direction, and the patient is asked to look in the same direction. For example, to inspect the most peripheral zone, respectively, the 12-hour meridian (a mirror corresponding to 6 hours), the lens is tilted downward, and the patient is asked to look up.
6. The vitreous cavity is examined through a central lens using both horizontal and vertical light beams, then the rear pole is inspected.

Indirect Biomicroscopy with Slit Lamp

This is a method of using lenses with a large optical power (usually +90 D and +78 D), providing a significant area for inspection. Lenses are used by analogy with usual indirect ophthalmoscopy; the image is turned upside down in the vertical and lateral directions.

Equipment

1. The width of the slit beam should be 1/4 of its full diameter.
2. The illumination angle is adjusted according to the axis of the visualizing system of the slit lamp.
3. The lens is immediately placed in the slit ray area just before the eye of the patient.
4. Determine the red reflex, then move the microscope back to a clear visualization of the fundus.
5. The eye bottom is inspected with a constant adjustment of the slit lamp in the horizontal and vertical directions and the fixed lens.
6. The width of the beam can be increased for a wider view.
7. Increasing the strength of the lens is used for a more detailed examination.
8. During the examination of the periphery, the patient's vision should be directed accordingly to the visualization area, as with indirect ophthalmoscopy.

Interpretation of results

• The vitreous humor in young people has a uniform consistency and the same density.
• The central part of the cavity of the vitreous can contain optically empty areas (lacunae). Sealing of the contents of the cavity can be mistaken for the posterior detachment of the hyaloid membrane (pseudo-stratum of the vitreous).
• In the eyes with detached vitreous body detached hyaloid membrane is determined.
• The Weiss ring is a rounded cloudiness, which is a glial fabric. Detached from the edge of the optic disc. This pathognomonic sign of vitreous detachment.
• Pigmentary inclusions (in the form of "tobacco dust") in the anterior part of the vitreous in a patient with complaints of sudden appearance of sparkling lights and vagueness in the eye can cause retinal rupture. In this case, a careful examination of the periphery of the retina (especially the upper half) is necessary. The inclusions are represented by macrophages containing destroyed PES cells.
• Multiple small opacities in the front of the vitreous or retrogialoid space are a sign of the presence of blood.
• In a wide view, it is possible to examine the equatorial ruptures of the retina.

Differential diagnosis of retinal detachment

Degenerative retinosis

Symptoms. Photopsies and floating opacities are not noted, since there is no vitreoretinal traction. The process usually does not extend to the back pole, so there are practically no changes in the field of vision, and if they are, they are characterized by absolute scotomas.

Symptoms

• The retina is elevated, convex, smooth, thin and immobile.
• A thin inner sheet of "schizis" can be mistaken for old atrophic rheumatogenic retinal detachment. However, with retinoschisis, there are no demarcation lines and secondary cysts in the inner leaf.
• In the eyes with reticular retinoschisis, breaks can be in one or two layers.

Choroid detachment

Symptoms. Photopsies and floating opacities are not noted, since there is no vitreoretinal traction. Changes in the field of vision occur with extensive choroid detachment.

Symptoms

• Intraocular pressure may be very low due to the concomitant detachment of the ciliary body.
• The stratification of the choroid appears as a brown, convex, smooth, bullous relatively relatively fixed elevating formation.
• The periphery of the retina and the "dentate" line can be seen without the use of sclerocompression.
• Elevation does not extend to the rear pole, because it is limited by strong fusion between the suprachoroidal membrane and the sclera at the entry point of the vortex veins into the scleral canals.

Syndrome of uveal effusion

The syndrome of uveal effusion is a rare, idiopathic condition characterized by detachment of the choroid in combination with exudative detachment of the retina. After resolution of the PES process, characteristic residual mottle is often observed.

Uveal effusion may be mistaken for either a retinal detachment with a complicated choroid detachment or an annular melanoma of the anterior choroid.

[13], [14], [15], [16]