Retinopathy is a lesion of retinal vessels that leads to impaired blood supply to the retina, its dystrophy, optic nerve atrophy and blindness. Disease proceeds painlessly: at the same time, there is the appearance of floating spots (cattle) and shrouds in front of the eyes, a progressive decrease in vision. Diagnosis requires consultations of specialists (ophthalmologist, neurologist, cardiologist, endocrinologist), studies of visual acuity and fields of vision, ophthalmoscopy, biomicroscopy, fluorescence angiography of the fundus, electrophysiological studies, ultrasound of the eye. With retinopathy, it is necessary to achieve compensation for concomitant diseases, the appointment of vasodilators, vitamins, anticoagulants, hyperbaric oxygenation, retinal laser coagulation.
H35.0 Background retinopathy and retinal vascular changes
The concept of “retinopathy” in ophthalmology refers to various pathological changes of the retina that are not associated with inflammation (primary), as well as retinal lesions that develop as a result of other diseases (secondary). Among the primary, central serous, acute posterior multifocal and external exudative are distinguished. Secondary includes diabetic, hypertensive, traumatic, as well as retinopathy in blood diseases. This disease of prematurity is distinguished in a separate form, which is studied not only by ophthalmology, but also by pediatrics.
Central serous retinopathy
The etiology of primary retinopathy remains unknown, so they are classified as idiopathic. Central serous retinopathy (central serous retinitis, idiopathic macular detachment) is more often detected in men 20-40 years old who do not have somatic diseases. In the anamnesis, patients indicate emotional stress, frequent migraine headaches. In central serous retinopathy, retinal lesion is usually unilateral.
Symptoms of central serous form include micropsia (reduction in the size of visible objects), the appearance of cattle, decreased acuity and narrowing of the visual fields. An important differential diagnostic feature is the improvement of vision when using weakly positive lenses.
The pathomorphological picture in central serous retinopathy is characterized by a serous detachment of the pigment epithelium in the macular region, which is determined during ophthalmoscopy as a limited oval or round bulge of a darker color than the surrounding retinal tissues. Typically, the absence of a foveal reflex (a light strip around the central fossa of the retina), the presence of yellowish or grayish precipitates.
Laser retinal coagulation is used in the treatment of central serous retinopathy. Therapy is carried out aimed at strengthening the vascular wall, improving microcirculation, reducing retinal edema; oxygenobarotherapy is prescribed. In 80% of cases, with timely active therapy of serous retinopathy, it is possible to stop retinal detachment and restore vision to its original level.
Acute posterior multifocal pigmented epitheliopathy
This form can be one- or two-sided. With acute posterior multifocal pigmented epitheliopathy, multiple flat subretinal foci of grayish-white color are formed, with the reverse development of which depigmentation areas are formed. Examination of the fundus determines perivascular edema of peripheral retinal vessels, tortuosity and dilation of veins, edema OND.
In a significant part of patients, vitreous turbidity occurs, episcleritis and iridocyclitis develop. Central vision is disrupted early, central or paracentral scotomas appear in the field of vision.
Treatment of posterior multifocal pigmented epitheliopathy is carried out conservatively; it includes the appointment of vitamin therapy, vasodilators (vinpocetine, pentoxifylline, etc.), angioprotectors (solcoseryl), retrobulbar injections of corticosteroids, hyperbaric oxygenation. The prognosis for this form of primary retinopathy is usually favorable.
External exudative retinopathy
The development of external exudative retinopathy (Coats’ disease, external exudative retinitis) is mainly observed in young men. Retinal damage is more often unilateral. With this form of disease, exudate, hemorrhages, cholesterol crystals accumulate under the retinal vessels. Changes, as a rule, are localized on the periphery of the fundus; damage to the macular zone is rare. Often, retinal angiography reveals multiple microaneurysms, arteriovenous shunts.
The course of external exudative retinopathy is slow, progressive. Treatment is carried out by retinal laser coagulation and hyperbaric oxygenation. The prognosis is burdened by retinal detachment requiring urgent intervention, the development of iridocyclitis and glaucoma.
Pathogenetically, hypertensive form disease is associated with arterial hypertension, renal insufficiency, toxicosis of pregnant women. In this form of retinopathy, there is a spasm of the arterioles of the fundus, followed by elastofibrosis or hyalinosis of their walls. The severity of the lesion is determined by the degree of hypertension and the duration of the course of hypertension.
There are 4 stages in the development of hypertensive retinopathy. The stage of hypertensive retinal angiopathy is characterized by reversible functional changes affecting the arterioles and venules of the retina.
In the stage of hypertensive angiosclerosis, the lesion of retinal vessels is organic in nature and is associated with sclerotic compaction of vascular walls, a decrease in their transparency.
The stage of hypertensive form is characterized by the presence of focal changes in the retinal tissue (hemorrhages, plasmorrhagia, lipid deposits, protein exudate, ischemic infarction zones), partial hemophthalmos. In patients with hypertensive retinopathy, there is a decrease in visual acuity, scotomas (floating spots) appear in front of the eyes. Usually, against the background of antihypertensive therapy, these changes regress, and the symptoms disappear.
At the stage of hypertensive neuroretinopathy, angiopathy, angiosclerosis and retinopathy proper are joined by the phenomena of OND edema, exudation, foci of retinal detachment. These changes are more typical for malignant hypertension and hypertension of renal genesis. The stage of hypertensive neuroretinopathy may result in atrophy of the optic nerve and irreversible loss of vision.
Diagnosis of hypertensive form includes consultation with an ophthalmologist and cardiologist, ophthalmoscopy and fluorescence angiography. The ophthalmoscopic picture is characterized by a change in the caliber of retinal vessels, their partial or total obliteration, Salus—Gunn’s symptom (displacement of the vein into the deep retinal layers due to pressure on it by a strained and compacted artery in the area of their intersection), subretinal exudation, etc.
With hypertensive disease, arterial hypertension is corrected, anticoagulants, vitamins are prescribed, oxygenobarotherapy and laser retinal coagulation are performed. Complications of hypertensive retinopathy are recurrent hemophthalmos and retinal vein thrombosis. The prognosis of hypertensive retinopathy is serious: a significant decrease in vision and even the development of blindness is not excluded. This disease aggravates the course of the underlying pathology and pregnancy, therefore it can become a medical basis for artificial termination of pregnancy.
The cause of the development of atherosclerotic retinopathy is systemic atherosclerosis. The changes occurring in the retina in the stages of angiopathy and angiosclerosis are similar to those in hypertensive retinopathy; in the stage of neuroretinopathy, small capillary hemorrhages appear, deposits of crystalline exudate along the veins, pallor OND.
The main methods of ophthalmological diagnosis of atherosclerotic retinopathy are direct and indirect ophthalmoscopy, angiography of retinal vessels. Special treatment of atherosclerotic retinopathy is not carried out. The therapy of the underlying disease is of the greatest importance – the appointment of disaggregants, antisclerotic, vasodilating drugs, angioprotectors, diuretics. With the development of neuroretinopathy, courses of electrophoresis with proteolytic enzymes are indicated. Complications of atherosclerotic retinopathy are often occlusion of the retinal arteries, optic nerve atrophy.
The pathogenesis is due to the presence of type 1 or type 2 diabetes mellitus. The main risk factors for the development of retinopathy are the duration of diabetes, severe hyperglycemia, nephropathy, hypertension, obesity, hyperlipidemia, anemia. Diabetic retinopathy is the most frequent and serious complication of diabetes and is the main cause of visual impairment and blindness.
In the development of this form of the disease, the stages of diabetic angiopathy, diabetic retinopathy and proliferating diabetic retinopathy are distinguished. The first two stages (angiopathy and simple retinopathy) proceed with the same changes as similar stages of hypertensive and atherosclerotic retinopathy. In the early stage of proliferating diabetic retinopathy, neovascularization of the retina develops, in the late stage there is an ingrowth of newly formed vessels and recurrent hemorrhages into the vitreous body, an overgrowth of glial tissue. The tension of the fibers and the deformation of the vitreous body cause the development of traction retinal detachment, which is the cause of incurable blindness in diabetic retinopathy.
In the initial stages, diabetic retinopathy is manifested by a steady decrease in visual acuity, the appearance of a veil and floating spots in front of the eyes, which periodically disappear. It is difficult to read and perform minor work. In the late proliferating stage, complete loss of vision occurs.
Conducting ophthalmoscopy under mydriasis allows you to examine the fundus in detail and identify the changes characteristic of diabetic retinopathy. The functional state of the retina of the peripheral zones is examined using perimetry. With the help of ultrasound of the eye, areas of seals, hemorrhages, scars in the thickness of the eyeball are determined. Electroretinography is performed to determine the electrical potential and assess the viability of the retina. Laser scanning tomography and retinal angiography are used to clarify the condition of the retina.
Additional information in the complex of ophthalmological examination of patients with diabetic retinopathy is obtained by determining visual acuity, biomicroscopy, diaphanoscopy of the eye, determining the critical frequency of flickering fusion (CCSM), etc.
Diabetic retinopathy should be treated under the supervision of an ophthalmologist and an endocrinologist (diabetologist). It is necessary to carefully monitor blood glucose levels, timely intake of antidiabetic drugs, vitamins, antiplatelet agents, angioprotectors, antioxidants, and means that improve microcirculation. When the retina is detached, laser coagulation is used. In the case of pronounced changes in the vitreous body and the formation of scars, vitrectomy, vitreoretinal surgery is indicated.
Complications of diabetic retinopathy are cataracts, hemophthalmos, opacity and scarring of the vitreous body, retinal detachment, blindness.
Retinopathy in blood diseases
Retinopathy can develop with various pathologies of the blood system – anemia, polycythemia, leukemia, myeloma, Waldenstrom’s macroglobulinemia, etc.
Each of the forms is characterized by a specific ophthalmoscopic picture. So, with retinopathy caused by polycythemia, the veins of the retina acquire a dark red color, and the fundus – a cyanotic shade. Retinal vein thrombosis and OND edema often develop.
In anemia, the fundus, on the contrary, is pale, the retinal vessels are dilated, the color and caliber of the arteries and veins are the same. Retinopathy in anemia may be accompanied by subretinal and extraretinal hemorrhages (hemophthalmos), exudative retinal detachment.
With leukemia from the fundus, there is tortuosity of the veins, diffuse edema of the retina and OND, hemorrhages, accumulation of exudate zones.
With myeloma and Waldenstrom’s macroglobulinemia, as a result of dysproteinemia, paraproteinemia, blood thickening, retinal veins and arteries expand, microaneurysms develop, thrombotic vein occlusions, retinal hemorrhages.
Treatment of retinopathy associated with the pathology of the blood system requires therapy of the underlying disease, retinal laser coagulation. Regarding visual function, the prognosis is serious.
The development of traumatic retinopathy is associated with sudden and sharp compression of the chest, in which arteriole spasm occurs, retinal hypoxia occurs with the release of transudate into it. In the immediate period after injury, hemorrhages and organic changes in the retina develop. Traumatic retinopathy can lead to optic nerve atrophy.
The consequences of contusion of the eyeball are changes called Berlinovskoe retinal opacity. This form of traumatic retinopathy is associated with subchorioidal hemorrhage and edema of the deep retinal layers, the exit of the transudate into the space between the retina and the vascular membrane.
For the treatment of traumatic retinopathy, vitamin therapy is prescribed, the fight against tissue hypoxia, hyperbaric oxygenation is carried out.
Retinopathy of prematurity
The forms of retinopathy listed above are mainly found in adults. A special form of the disease is retinopathy of prematurity, associated with retinal underdevelopment in children born from premature birth. To complete the formation and maturation of all eye structures, premature infants need visual rest and oxygen-free local tissue respiration (glycolysis). On the other hand, additional oxygenation is required for the nursing of premature babies and stimulation of metabolic processes in vital organs, which leads to inhibition of glycolysis in the retina and vascular membranes of the eye.
The greatest risk of developing retinopathy of prematurity are children born at less than 31 weeks gestation, with a birth weight of less than 1500 g, unstable general condition, receiving long-term oxygen therapy, having undergone blood transfusion.
Newborns at risk of developing retinopathy are examined by an ophthalmologist 3-4 weeks after birth. Ophthalmological examination is repeated every 2 weeks until the completion of retinal formation. Late complications of prematurity include myopia, strabismus, amblyopia, glaucoma, retinal detachment, low vision.
In the initial stages of prematurity, spontaneous healing may occur, therefore, observational tactics are used. In other cases, laser coagulation or cryoretinopexy is indicated, and if ineffective, scleroplombing, vitrectomy.
In order to prevent the development of retinopathy, dispensary observation by an ophthalmologist of patients with hypertension, diabetes mellitus, atherosclerosis, kidney disease, blood diseases, injuries, pregnant women with nephropathy, etc. is necessary.
Prevention of prematurity requires careful management of pregnancy in women at risk for premature birth, improving the conditions for nursing premature babies. Children who have had retinopathy during the newborn period should be examined by a pediatric ophthalmologist annually until the age of 18.
An important role in the prevention is played by the consistency of the actions of specialists of various profiles: ophthalmologists, endocrinologists, cardiologists, neurologists, obstetricians, gynecologists, pediatricians, traumatologists, etc.