Retinal detachment is a pathology of the retina of the eye, in which it is separated from the underlying choroid (vascular membrane). Retinal detachment is accompanied by a sharp deterioration of vision, the appearance of a veil in front of the eye, progressive narrowing of the field of vision, flickering of “flies”, “sparks”, “flashes”, “lightning”, etc. Diagnostics is carried out using visometry, perimetry, tonometry, biomicroscopy, ophthalmoscopy, ultrasound of the eye, electrophysiological studies. Treatment is performed surgically (sclera filling, sclera balloning, transciliary vitrectomy, vitreoretinal surgery, cryocoagulation, etc.) or by laser methods (laser coagulation of the retina).
Retinal detachment is a dangerous outcome and the most difficult pathological condition in surgical ophthalmology, which is diagnosed annually in 5-20 people for every 100 thousand of the population. To date, retinal detachment is the leading cause of blindness and disability; at the same time, 70% of cases of this pathology develop in people of working age.
With retinal detachment, the layer of photoreceptor cells (rods and cones), for certain reasons, separates from the outer layer of the retina – the pigment epithelium, which leads to a violation of the trophic and functioning of the retina. If specialized care is not provided in time, retinal detachment can lead to vision loss quite quickly.
Causes and classification
According to the mechanism of pathology formation, there are regmatogenic (primary), traumatic and secondary (exudative and traction) retinal detachment.
- The development of regmatogenic retinal detachment is associated with the rupture of the retina and the ingress of fluid from the vitreous body under it. This condition develops with the thinning of the retina in the zones of peripheral dystrophy. With various types of retinal dystrophy (latticed, carpal, retinoschisis, etc.), a rupture in a degeneratively altered area can be triggered by sudden movements, excessive physical exertion, traumatic brain injury, falls, or occur spontaneously. According to the type of defect, the primary retinal detachment may be bubble-shaped or flat; according to the degree of detachment – limited or total.
- Retinal detachment of traumatic genesis is caused by eye injuries (including surgical ones). At the same time, the detachment of the retina can occur at any time: directly at the time of injury, immediately after it, or several years later.
- The occurrence of secondary retinal detachment is observed against the background of various pathological processes of the eye: tumor, inflammatory (with uveitis, retinitis, chorioretinitis), occlusive (occlusion of the central retinal artery), diabetic retinopathy, sickle cell anemia, pregnancy toxicosis, hypertension, etc.
- The accumulation of fluid in the subretinal space (under the retina) leads to secondary exudative (serous) retinal detachment. The traction mechanism of detachment is caused by tension (traction) of the retina by fibrinous cords or newly formed vessels growing into the vitreous body.
Factors that increase the risk of retinal detachment are myopia, astigmatism, degenerative changes in the fundus, eye surgery, diabetes mellitus, vascular pathology, pregnancy, cases of similar pathology in close relatives, etc.
In most cases, retinal detachment develops in one eye, in 15% of patients there is a risk of bilateral pathology. In the presence of bilateral cataracts, the risk of bilateral retinal detachment increases to 25-30%.
At the beginning of the disease there are symptoms-harbingers – the so-called light phenomena. These include flashes of light (photopsies) in front of the eyes and zigzag lines (metamorphopsies). When the retinal vessel ruptures, there is a flicker of “flies” and black dots in front of the eyes, pain in the eye. These phenomena indicate irritation of the photosensitive cells of the retina caused by traction from the vitreous body.
With further progression of retinal detachment, a “veil” appears in front of the eyes (according to patients, a “wide curtain, curtain”), which increases over time and may occupy most or all of the field of vision.
Visual acuity decreases rapidly. Sometimes in the morning, visual acuity improves for a while, and the visual fields expand, which is associated with partial resorption of fluid during sleep and independent retinal fit. However, during the day, the symptoms of retinal detachment return again. Temporary improvement of visual functions occurs only with a recent retinal detachment; with the prolonged existence of the defect, the retina loses elasticity and mobility, which is why it cannot fit into place on its own.
When the retina is torn in the lower parts of the fundus, the detachment progresses relatively slowly, over several weeks or months, without causing defects in the field of vision for a long time. This variant of retinal detachment is very insidious, since it is detected only when the macula is involved in the process, which aggravates the prognosis regarding visual functions. With the localization of retinal rupture in the upper parts of the fundus, on the contrary, the detachment of the retina progresses quite quickly, within a few days. The fluid accumulating in the subretinal space exfoliates the retina over a significant area with its weight.
If help is not provided in time, detachment of all quadrants of the retina, including the macular region, may occur – complete, total detachment. When the macula is detached, curvatures and fluctuations of objects occur, followed by a sharp drop in central vision.
Sometimes, with retinal detachment, diplopia occurs, due to a decrease in visual acuity and the development of latent strabismus. In some cases, retinal detachment is accompanied by the development of sluggish iridocyclitis, hemophthalmos.
If a retinal detachment is suspected, a complete ophthalmological examination is necessary, since early diagnosis avoids irreversible vision loss. If there is a history of TBI, the patient must necessarily be consulted not only by a neurologist, but also by an ophthalmologist to exclude tears and signs of retinal detachment.
The study of visual functions is carried out by checking visual acuity and determining visual fields (static, kinetic or computer perimetry). Visual field loss occurs on the side opposite to retinal detachment.
With the help of biomicroscopy (including using a Goldman lens), the presence of pathological changes in the vitreous body (strands, destruction, hemorrhages) is determined, peripheral areas of the fundus are examined. Tonometry data are characterized by a moderate decrease in IOP compared to a healthy eye.
A key role in the recognition belongs to direct and indirect ophthalmoscopy. The ophthalmoscopic picture allows us to judge the localization of ruptures and their number, the relationship of the detached retina with the vitreous body; it allows us to identify areas of dystrophy that require attention during surgical treatment. If it is impossible to perform ophthalmoscopy (in case of opacities in the lens or vitreous body), an ultrasound of the eye in B-mode is indicated.
The diagnostic complex for retinal detachment includes methods for the study of entopic phenomena (the phenomenon of autophthalmoscopy, mechanophosphene, etc.).
To assess the viability of the retina and the visual, electrophysiological studies are carried out – determination of the threshold of electrical sensitivity and lability of the optic nerve, CFFF (critical frequency of fusion of flickering).
Treatment of retinal detachment
The detection of pathology requires immediate surgical treatment. Delay in the treatment of this pathology is fraught with the development of persistent hypotension and subatrophy of the eyeball, chronic iridocyclitis, secondary cataracts, incurable blindness. The main purpose of the treatment of retinal detachment is to bring the photosensitive receptor layer closer to the pigment epithelium and create adhesions of the retina with the underlying tissues in the rupture zone.
In retinal detachment surgery, extrascleral and endovitreal techniques are used: in the first case, the intervention is performed on the scleral surface, in the second – inside the eyeball. Extrascleral methods include filling and balloning of the sclera.
Extrascleral filling involves sewing a special silicone sponge (seal) to the sclera, which creates a sclera depression area, blocks retinal tears and creates conditions for the gradual absorption of fluid accumulated under the retina by capillaries and pigment epithelium. Variants of extrascleral filling in retinal detachment can be radial, sectoral, circular (circlage) filling of the sclera.
Balloning of the sclera during retinal detachment is achieved by temporarily stitching a special balloon catheter into the projection area of the rupture, when inflated, an effect similar to filling occurs (the shaft of the sclera indentation and resorption of the subretinal fluid).
Endovitreal treatments may include vitreoretinal surgery or vitrectomy. In the process of vitrectomy, the modified vitreous body is removed and special preparations (liquid silicone, saline solution, special gas) are introduced instead, which bring the retina and the vascular membrane closer together.
Sparing methods of treatment include cryocoagulation of ruptures and subclinical retinal detachments and laser coagulation of the retina, which allow to achieve the formation of chorioretinal adhesions. Cryopexy and laser coagulation of the retina can be used both for the prevention and for therapeutic purposes alone or in combination with surgical techniques.
Prognosis and prevention
The prognosis depends on the prescription of the pathology and the timeliness of treatment. Surgery performed early after the development of retinal detachment usually contributes to a favorable outcome.
In most cases, disease can be prevented. To this end, patients with myopia, retinal dystrophy, diabetes mellitus, head and eye injuries need regular preventive examination by an ophthalmologist. An oculist’s examination is included in the standard of pregnancy management and allows you to prevent retinal detachment during childbirth. Patients at risk of retinal detachment are contraindicated from heavy physical exertion, weight lifting, and certain sports.
When detecting areas of this disease, cryopexy or laser coagulation of the retina is performed for preventive purposes.