Chorioretinitis is an inflammation of the posterior choroid and retina. The main symptoms of the disease are the appearance of “flies” and “floating opacities” in front of the eyes, a violation of dark adaptation, decreased vision, photopsia, macro- and micropsia. Diagnostics is based on bacteriological seeding, ELISA, determination of C-reactive protein, gonioscopy, angiography, perimetry, ophthalmoscopy. Conservative therapy includes the appointment of antibacterial agents, nonsteroidal anti-inflammatory drugs, mydriatics, glucocorticosteroids, biogenic stimulants and reparants.
ICD 10
H30 Chorioretinal inflammation
General information
Chorioretinitis is a common pathology among people of the Caucasian race. Inflammation of the anatomical structures of the uveal tract is possible at any age, but it is most common in people after 40 years. The prevalence ratio of the disease among women and men is 2.3:1. 22% of patients have a latent lesion of the vascular membrane (absence of depigmented foci at the first examination of the fundus). According to statistics, the average duration of the disease before diagnosis is 3 years. Chorioretinitis by the type of “shot shot” is more often diagnosed in residents of Northern Europe.
Causes of chorioretinitis
Inflammation of the choroid and the retina is promoted by many factors. The viral, bacterial and parasitic nature of the pathology is described. It has been proven that persons suffering from high-grade myopia are more at risk of developing the disease. The role of other anomalies of clinical refraction in the etiology of lesions of the uveal tract has not been studied. The main causes of chorioretinitis:
- Infectious diseases. The disease often occurs against the background of tuberculosis, syphilis. With the tuberculous nature of pathology, ophthalmoscopically revealed lesions of different prescription, which differ in color. In syphilis, changes from the posterior part of the eyes are less pronounced.
- Traumatic injuries. In post-traumatic genesis, the inflammatory process is preceded by ruptures of the vascular membrane and hemorrhages into the suprachoroidal space. In most cases, it is possible to identify the entrance gate of infection. Chorioretinitis is combined with damage to the anterior segment of the eyes.
- Focal infections. Pathological agents can spread hematogenically in the presence of a focus of acute or chronic infection in the oral cavity, eye socket or lesion of ENT organs. The causative agent, as a rule, are pyogenic strains of bacteria.
- Toxoplasmosis. The pathogen is able to penetrate into the posterior segment of the eyeball hematogenically. The most common cases of intrauterine infection. Pathology is often combined with other eye malformations (anophthalmos, microphthalmos).
Pathogenesis
In the mechanism of disease development, the leading importance is given to the effects of bacterial toxins that trigger allergic reactions, less often an autoimmune process. Bacteria or viruses can enter the structures of the uveal tract endogenously or exogenously. Predisposing factors to the development of pathology are anatomical (wide vascular bed) and hemodynamic (slowing of blood flow) structural features. The retina is affected first. The spread of pathological agents into the vascular membrane occurs a second time. Atrophy of anatomical formations of the uveal tract occurs due to a violation of blood supply, which normally occurs due to choriocapillary vessels. There are non-granulomatous and granulomatous types of the inflammatory process.
Classification
According to the nature of the course in ophthalmology, acute and chronic forms of inflammation are distinguished. Depending on the localization of the affected area, panuveitis, peripheral and posterior uveitis are distinguished, which is divided into focal, multifocal, disseminated, neuro-chorioretinitis and endophthalmitis. According to the activity of chorioretinitis , it is classified into the following stages:
- Active. It is characterized by a progressive decrease in visual acuity. Patients note increased fatigue when performing visual work, which is combined with a deterioration in well-being.
- Subactive. It occupies an intermediate position between the active and inactive stages. It is detected during the infectious process of another localization. Clinical symptoms are poorly expressed. In the absence of timely treatment, it turns into a chronic form.
- Inactive. There are no signs of inflammation. Ophthalmoscopy reveals chronic foci of infection of dense consistency. Patients report persistent visual dysfunction that does not progress. The inactive stage is a random find.
In the classification according to the localization of the inflammatory process, central and peripheral forms are distinguished. Diffuse and focal lesion of the uveal tract is possible. Pathological foci can be single and multiple.
Symptoms of chorioretinitis
Patients complain of progressive vision loss. The severity of visual dysfunction varies significantly. Patients note the appearance of floating dots, “fog” or “shroud” in front of their eyes. With the location of individual foci on the periphery of the vascular membrane, visual acuity in the daytime is not reduced, but at dusk visual dysfunction increases. With the opacity of the optical media of the eyeball, patients experience a myopic type of clinical refraction. A common symptom is the appearance of “opacities” or “flies” in front of the eyes.
In the case of severe flow, there is a loss of individual sections of the visual field, photopsia. The development of micro- and macropsia leads to distortion of objects in front of the eyes. Many patients indicate that the appearance of clinical symptoms is preceded by infectious, systemic and autoimmune diseases. Less often, chorioretinitis occurs after surgery on the eyeball or eye socket. Visually pathological changes are not detected. Due to the fact that visual acuity can remain normal for a long time, diagnosis is often difficult.
Complications
Increased exudation leads to the development of ophthalmic hypertension, secondary glaucoma occurs less often. Purulent chorioretinitis is complicated by optic neuritis. The accumulation of exudate and the organization of purulent masses lead to the development of pan- and endophthalmitis. Retinal atrophy is often preceded by its rupture or detachment. Massive hemorrhages cause hyphema and hemophthalmos. When the photoreceptors of the inner shell of the eye are affected, color vision is impaired. Hemeralopia is detected in most patients. In prognostic terms, the most unfavorable complication is complete blindness.
Diagnostics
The diagnosis is based on anamnestic data, the results of instrumental and laboratory research methods. During an objective examination, pathological changes are not detected. This is an important criterion that allows differentiating chorioretinitis with pathology of the anterior pole of the eyeball. Laboratory diagnostics is reduced to carrying out:
- Bacteriological seeding. The material for the study is a biopsy of the orbital conjunctiva or conjunctival fluid. The purpose of the method is to identify the pathogen and determine sensitivity to antibacterial therapy.
- Enzyme immunoassay (ELISA). The study of the titer of antibodies (Ig M, Ig G) is used to detect pathogens of chlamydia, herpes simplex, toxoplasmosis, cytomegalovirus. ELISA allows you to assess the stage of activity of the inflammatory process.
- Test for the determination of C-reactive protein. The detection of protein in the blood makes it possible to exclude or confirm the autoimmune nature of the disease. With a positive test for C-protein, rheumatological tests are carried out.
In order to diagnose and assess the extent of the lesion, the ophthalmologist uses instrumental methods. With the help of visometry, a decrease in visual acuity of varying degrees of severity with a tendency to myopic refraction is determined. An increase in intraocular pressure (IOP) is observed only with moderate severity and severe course. Specific diagnostics include:
- Gonioscopy. An accumulation of pus is detected in the anterior chamber of the eyeball, which indicates hypopion or exudate. Hemorrhage in the anterior chamber of the eye leads to hyphema.
- Ophthalmoscopy. During ophthalmoscopic examination, lesions of a grayish-yellow hue with indistinct contours, spot hemorrhages are visualized. The detection of a limited area of white color indicates atrophy. The area of the macula is pigmented.
- Fluorescent retinal angiography (FRA). It is possible to visualize the signs of retinal vasculitis. When performing FRA with contrast, dark spots are detected in the place of accumulation of indocyanine green.
- Perimetry. In the peripheral form of the disease, there is a concentric narrowing of the visual field. Focal lesion leads to the loss of small areas from the field of view.
Differential diagnosis
Differential diagnosis is carried out with macular degeneration and malignant neoplasms of the vascular membrane. Unlike a tumor with chorioretinitis, a perifocal focus of inflammation with blurred cones is detected. With dystrophic changes of the macula, there are no signs of inflammation and opacity of the vitreous body. With the traumatic origin of the disease, an X-ray of the eye socket is performed, which makes it possible to identify pathological changes in the postadibular fiber and the bone walls of the orbit (fracture, displacement of fragments).
Treatment of chorioretinitis
Etiotropic therapy is based on the treatment of the underlying disease. In case of traumatic etiology, surgical intervention is required, which is aimed at plasty of the bone wall of the eye socket, comparison of displaced fragments. A short course of antibiotics is indicated before surgery and in the early postoperative period. Conservative therapy is reduced to the appointment:
- Nonsteroidal anti-inflammatory drugs. They are used for the purpose of relieving the inflammatory process. Patients are given daily instillations 5-6 times a day. With a complicated course, retrobulbar administration is indicated.
- Mydriatics. M-holinoblockers and sympathomimetics are used to prevent the formation of synechiae and to improve the outflow of watery moisture. Timely administration of mydriatics reduces the risk of glaucoma.
- Hormonal drugs. The indication for the appointment is acute chorioretinitis. Patients are given installations or subconjunctival injections of hydrocortisone. Additionally, you can put hydrocortisone ointment 3-4 times a day under the eyelid.
- Antibiotics. Antibacterial therapy is carried out with the toxoplasmotic nature of chorioretinitis, as well as in the case of bacterial complications. If the effect is insufficient, sulfonamides are additionally indicated.
- Reparants and biogenic stimulants. Preparations of this group contribute to the regeneration of the retina. The expediency of using taurine, sulfated glycosaminoglycans has been proved.
To increase the effect of conservative treatment in the subacute period or in the chronic course of the disease, physiotherapy procedures are prescribed. With the help of electrophoresis, calcium chloride, antibacterial agents, proteolytic enzymes of plant origin are introduced. At the stage of pathology resolution, ultrasound therapy is used on the side of the lesion. Regardless of the form of inflammation, the use of vitamins B, C and PP is indicated. With an increase in IOP, it is advisable to prescribe antihypertensive agents.
Prognosis and prevention
The prognosis depends on the etiology, the immune status of the patient, the localization and prevalence of the pathological process. In the absence of timely diagnosis and treatment, the outcome of the disease is atrophy of the vascular membrane, as well as the retina, which leads to complete blindness. There is no specific prevention. Non-specific preventive measures are aimed at sanitizing foci of focal infection, preventing the development of infectious and parasitic diseases. If there is a high risk of eye injury, personal protective equipment (glasses, mask) should be used.
