Retinal tear is an acquired pathology of the visual organ, which is accompanied by a violation of the integrity of the retina with a high risk of its further detachment. Clinical manifestations of the disease are photopsias, “flies” or “veil” in front of the eyes, central or peripheral scotomas. Diagnosis of retinal tear is based on the results of ophthalmoscopy, visiometry, tonometry, biomicroscopy, fluorescent angiography, OCT, ultrasound in In-mode. In case of lamellar tear, laser coagulation is recommended. An extensive lesion or a through macular tear is an indication for performing a vitrectomy.
H33 Retinal detachment and tears
Retinal tear is a linear or rounded defect of the retina that occurs idiopathically or against the background of specific triggers. The first description of a tear in the macula was presented in 1869 by the German ophthalmologist G. Knapp. In 2013, Russian ophthalmologists L. I. Balashevich and Ya. V. Bayborodov described clinical cases of the development of this pathology due to laser radiation. The disease is most common among women. As a rule, it occurs after 60 years. The main cause of development at a young age is traumatic injuries. The peculiarity of retinal tear is that in 45% of patients, clinical symptoms do not correspond to true changes in the inner shell of the eye. This often leads to underdiagnosis and diagnosis at a later date.
The formation of a perforated tear may be due to peripheral retinal dystrophy. At the same time, synechiae form in the thinning zone between the inner shell of the eyeball and the vitreous body. These splices can also provoke valve tears. The pathogenesis is based on the ingress of colloidal masses from the vitreous cavity into the space between it and the retina. At the same time, pronounced synechiae are the trigger of tear and subsequent detachment. Violation of the integrity of the inner shell of the eye in the projection area of the jagged line provokes eye injuries or iatrogenic damage.
Macular retinal tear of traumatic genesis occurs when a shock wave passes through the longitudinal size of the eyeball. The etiological factor of this pathology may be non-compliance with medical recommendations in the postoperative period after treatment of regmatogenic detachment. An important role in the mechanism of retinal tear development is played by atrophic changes in the area of foveolar photoreceptors, increased intraocular pressure, and the formation of an epiretinal membrane. Also, the trigger of this disease is destructive changes in the vitreous area and central chorioretinal dystrophy.
Damage to the inner shell of the eye in the yellow spot appears against the background of early cystic sclerotic dystrophy of the macular zone or retinal ischemia. Retinal tears in the area of the flat part of the ciliary body develop with a closed injury to the eyeball. At the same time, the process is often aggravated by local contusion. Increased physical exertion, head injuries, psychoemotional overstrain, increased intraocular pressure, and a history of myopia contribute to the occurrence of this pathology.
There are complete and lamellar retinal tears. With a complete tear, damage occurs to all layers of the inner shell of the eyeball, with lamellar there is a partial violation of the integrity of the surface sections. The clinical symptoms of the disease are determined by the degree of involvement of retinal layers in the pathological process and the localization of damage. In a number of patients, retinal tear has a latent course for a long time or manifests itself only with increased visual loads. With a unilateral process, symptoms of pathology may occur when a healthy eye is closed.
With a complete tear of the retina, patients complain of the sudden appearance of “flashes of light” in front of their eyes. This symptom develops due to tension of the inner shell of the eyeball or irritation of the optic nerve. Lamellar damage only in rare cases leads to the development of photopsias. At the same time, they often appear in a dark room or against the background of emotional overstrain. In most cases, patients cannot specify the exact time of retinal tear. In rare cases, the disease is prone to independent regression with subsequent restoration of visual functions.
If the retinal tear is accompanied by posterior detachment or hemorrhage into the vitreous, patients note the appearance of “flies” or “shrouds” in front of their eyes. Localization of the pathological process in the peripheral parts leads to the appearance of visual field defects. With macular retinal tear, visual acuity decreases, which is associated with the accumulation of fluid in the subretinal space. Central scotomas occur only when the size of the lesion increases. At the same time, an increase in intraocular pressure provokes atrophy of the optic nerve, which can cause blindness. In the case of an eccentric location of the defect, visual acuity remains within the normal range. Complications of retinal tear: detachment, hyphema, hemophthalmos or optic nerve atrophy.
Diagnosis of retinal tear is based on anamnestic data, results of ophthalmoscopy, visiometry, tonometry, biomicroscopy, optical coherence tomography (OCT), ultrasound examination (ultrasound) of the eyeball in B-mode. With the help of ophthalmoscopy, it is possible to detect a defect of a rounded or longitudinal shape with localization in the area of the flat part of the ciliary body, the foveolar zone or the peripheral parts of the retina. Retinal tear can have different duration and depth. When penetrating through all layers at the bottom of the damage zone, a violation of the integrity of the pigment epithelium and dystrophic foci in the form of yellow dots are visualized. Along the periphery of the tear, the retina has edematous edges.
The visiometry method determines the degree of visual acuity reduction. With an eccentric tear, visual functions are not impaired. Extensive retinal defects lead to blindness. The addition of hyphema or hemophthalmos stimulates an increase in intraocular pressure, which is confirmed by tonometry. Biomicroscopic examination makes it possible to detect a retinal tear zone with clear edges. Fluid accumulation is detected in the subretinal space. Connective tissue is detected above the damage zone, which can eventually form a pseudomembrane. With a prolonged course of the disease, cystic changes occur along the periphery of the rupture, followed by retinal hyperplasia or atrophy.
With the help of OCT, the area of retinal tear and changes in the surrounding tissue are visualized. This method makes it possible to determine the extent and depth of the defect, as well as to assess the condition of the vitreomacular surface. Ultrasound in B-mode allows you to identify a gap, examine the condition of the retina and vitreous body. An auxiliary diagnostic method in ophthalmology is fluorescence angiography, which helps to differentiate retinal tear from choroidal neovascularization.
Treatment tactics depend on the localization, duration and depth of retinal tear. In case of minor damage to the inner shell or lamellar tear, dynamic observation by an ophthalmologist is recommended for patients, since these defects are prone to independent regression. In the absence of signs of regeneration, laser coagulation is performed. During the operation, an argon laser is used, the properties of which lead to a local increase in temperature with further coagulation. Surgical intervention is performed under regional anesthesia. The advantage of this technique is the possibility of exposure in a limited area.
With a complete macular tear of the retina, it is advisable to perform a vitrectomy. During endoscopic surgery, three small incisions are performed. Through the first incision, fluid is supplied to the eye to maintain intraocular pressure. The second access is necessary to provide lighting. The third incision is used to perform surgical manipulations. Under multiple magnification, the vitreous membrane is removed using vacuum tweezers. At the final stage of the operation, the damaged area of the retina is fixed with perfluorodecalin or other artificial polymers. This method allows to avoid iatrogenic traction detachment of the retina and to some extent restore visual acuity.
Prognosis and prevention
No specific prevention of retinal tear has been developed. Non-specific preventive measures are reduced to compliance with safety rules at work when working with materials that require wearing protective glasses or a helmet. The prognosis for life and work capacity in case of retinal tear depends on the extent of the lesion. With minor damage to the inner shell of the eyeball, independent regression is possible. Patients with this type of injury should be monitored by an ophthalmologist. Timely diagnosis and treatment of other forms provide a favorable prognosis. In the absence of adequate therapy, there is a high risk of developing blindness and further disability of the patient.