Retinal detachment causes separation of the retina from the choroid. Between the layers, liquid accumulates. The retina arches like a blister into the eyeball. In the area of withdrawal, the retina is no longer supplied with oxygen and nutrients from the choroid.
Retinal detachment is a rare disease. Every year about one in 10,000 people are affected. Acute courses take place especially between the ages of 45 and 65 years. In addition, the retinal detachment occurs familial. The disease has a special significance in ophthalmology because untreated retinal detachment can lead to blindness on the affected eye.
Retinal detachment usually progresses rapidly. Due to the fact that the detachment, as a rule, begins from the periphery of the visual field, you may not immediately notice the changes. If you do not start treatment in time, the detachment can spread to the center of the retina (macula) and disrupt the central vision.
Retinal detachment requires emergency medical care. Without treatment, visual impairment caused by retinal detachment progresses from minor impairments to severe changes or even blindness for a few days to several hours.
However, tears or holes in the retina may not require any treatment. Sometimes with age, small, round-shaped holes form in the retina. Many of them never lead to retinal detachment. Retinal tears due to pressure on the vitreous body (vitreous traction) often cause retinal detachment.
Gaps in the retina caused by the traction of the vitreous body can cause outbreaks and floating opacities before the eyes. Gaps that have not arisen from the traction of the vitreous body, as a rule, do not cause any symptoms and very rarely lead to retinal detachment compared to gaps accompanied by clinical symptoms.
With retinal detachment, you need surgery to attach the retina and restore vision. If you already had retinal detachment in one eye, the risk of developing this disease in the second one increases significantly.
Retinal detachment threatens to fall out of the area from the field of view, or, more simply, a „veil“ forms in front of the eye. This indicates that the sensory layer of the retina has moved away from the choroid, as a result of which the process of visual perception has been disturbed. Such a "veil" can be formed in any area of the eye, while localization occurs in the area opposite the defective area. For example: if the “veil” is observed from above, then retinal detachment occurred in the lower part.
All the above symptoms are accompanied by a decrease in visual acuity, curvature of the outlines of objects and a "floating" image. In the morning, patients notice some improvement in vision. This is due to the partial absorption of fluid accumulated under the retina during sleep. This is a temporary phenomenon, and the morning improvements are no longer observed after a few days. They are replaced by "veil", which is becoming more every day.
Defects in the visual field may increase gradually or may not progress over a month or even several years. A noticeable reduction in vision begins only when the macula is involved in the pathological process.
In a neglected form, retinal detachment threatens complete loss of vision. Therefore, when detecting the described symptoms, you should immediately contact a specialist to select the appropriate treatment method.
Detachment may be a consequence of vitreochorioretinal dystrophic processes on the retina, which lead to its rupture. Fluid from the vitreous, which exfoliates the reticular membrane in its path, enters the space formed. Such a mechanism for the formation of detachment is characteristic of high myopia.
And so let's see why there is retinal detachment? Retinal detachment can occur due to an eye injury - a contusion or a penetrating injury. When this occurs, not only the reticular, but also the other shells of the eye break.
Various diseases of the organ of vision can lead to retinal detachment — vascular tumors, uveitis and retinitis, retinal vascular disorders, diabetic retinoptia, age-related macular degeneration, and others.
The most dangerous are peripheral vitreochorioretinal dystrophies, which do not lead to deterioration of vision, are in absolutely healthy people and therefore are very rarely detected. This requires a thorough examination of the peripheral zone of the retina through a wide pupil using a Goldman three-mirror lens.
Thus, the risk factors that can lead to detachment are:
- Peripheral vitreochorioretinal retinal dystrophy;
- retinal detachment in the paired eye;
- high myopia with changes in the fundus;
- other pathology of the retina;
- eye injuries;
- work related to weight lifting and physical stress;
- the presence of retinal detachment in close relatives.
Patients at risk should be at a dispensary account with an ophthalmologist and be sure to look around with a wide pupil once a year.
The reticular and the choroid of the eyes function only together, therefore, if any of these diseases occur, the pathological processes may become irreversible. Patients may experience different symptoms, but the diagnosis will be disappointing in each of the cases. Pathogenesis is quite fast, which requires urgent intervention. There is one common symptom - the sharpness of perception of visual information decreases.
Symptoms for which treatment may already be required can be divided into several main stages:
- Initial stage. Its main features are photopsies, that is, the appearance in the eyes of flashes, lightning and sparks. They occur quite often, so the patient can easily identify them. At the same time, coordination of movement fails, a sharp decrease in the perception of the clarity of objects is observed. Photopsies can appear in two cases: under mechanical action and in bright sunlight. There is a contraction that stretches the retina of the eye, thus irritating the cells with photosensitivity, and creating these phenomena.
- Floating stage. This stage gets its name due to the appearance of characteristic symptoms. The patient can see floating threads, dots or flies against the background of the image. These symptoms are not always indicative of incipient retinal detachment. Sometimes this confirms the development of destruction of the vitreous body. But in any case, when these symptoms appear, it is imperative that a specialist should appear for a competent consultation and a full examination. You should not engage in self-treatment using folk remedies and methods.
- The final stage, which is characterized by the appearance of turbidity. Experts call this effect "Weiss ring". This symptom is a good reason to start a more detailed study. At the final stage, not only detachment of the eye retina, but also hyaloid posterior membrane detachment can occur. In this case, surgical treatment is mandatory and necessary. The general state of this process is characterized by the sudden appearance of several different symptoms at once: photopsies, haze and loss of clarity of vision. If the necessary medical measures are not taken, the stratification can continue until the vitreous hemorrhage occurs, and then the process will be irreversible. The final stage, in which the final detachment of the eye retina occurs, can threaten a person with complete loss of vision without the possibility of restoring it. During a hemorrhage into the vitreous, rupture of the blood vessels occurs, therefore, even at the first signs of deterioration of vision, diagnosis and appropriate treatment are required. The disease progresses very quickly.
In most cases, the detachment of the retina is preceded by the appearance before the eyes of special light phenomena:
- Photopsies (bright flashes of light);
- metamorphosis (zigzag lines);
- black dots.
With further progression of the disease, a veil appears in front of the patient’s eyes, which increases in size over time. In addition, patients quickly deteriorate vision. Due to the fact that during sleep the retina can independently fit into place, in the morning visual functions can be restored, but during the day the symptoms of the disease return again.
When the retina is broken in the lower parts of the eye, the detachment progresses slowly over several months without causing significant visual defects. And, on the contrary, with the localization of a gap in the upper parts of the eye, the disease develops very quickly, sometimes within a few days.
In the absence of timely and competent treatment, all quadrants of the retina are disconnected from the choroid. This process is accompanied by oscillation and curvature of visible objects, a sharp drop in vision, diplopia, the development of latent strabismus, sluggish hemophthalmia and iridocyclitis.
Retinal detachment during pregnancy is the main threat to the female visual system. That is why the consultation of an ophthalmologist is necessary for all expectant mothers, regardless of whether they have vision problems. In this way it is possible to prevent the development of this terrible complication.
During pregnancy, toxicity, elevated blood pressure and other complications that accompany the carrying of the fetus can affect the state of vision. Hormonal changes that occur in a woman’s body during this period affect everyone in different ways, and the eyes are one of the organs that experience its effects.
The first consultation of the oculist should take place at the beginning of pregnancy (at 10-14 weeks). The doctor does not only conduct a general examination of the visual system, but also assesses the state of the fundus with an expanded pupil. In the absence of any abnormalities, re-consultation is appointed by the end of pregnancy (at 32-36 weeks). In identifying pathologies of the fundus of the eye, the frequency of observations by an ophthalmologist is determined individually.
Monthly follow-up is recommended for women with myopia during pregnancy. In this pathology, the eyeball increases, and because of this, the retina stretches and becomes thinner. It may form micro-gaps, causing its detachment. Particularly likely is the development of retinal detachment during natural childbirth, when a woman’s body is under tremendous pressure.
The state of the retina is not always associated with the severity of myopia. Even with its high degree, a satisfactory state of the retina can be observed, and with minor disturbances (no more than 1-3 diopters), serious dystrophic changes can be detected in the fundus. That is why the decision about the need for treatment or prescription of cesarean section is made strictly individually, according to the survey.
In some cases, women with the threat of retinal detachment may be recommended prophylactic laser coagulation, which can be performed up to 35 weeks of pregnancy. The procedure can be performed on an outpatient basis by performing several rows of coagulates along the entire periphery of the retina. In this way, the laser beam strengthens the retina and protects it from further stretching and peeling.
When a serious degree of stretching or dystrophy of the pregnant woman’s retina is detected, obstetric aid is recommended through cesarean section, as the eyes experience a heavy load during natural childbirth, and this may contribute to tearing and detachment of the retina.
Risk factors in such situations are:
- Hypertonic disease;
- medium or high myopia;
Depending on the reasons that cause retinal detachment, ophthalmologists distinguish several types of detachments. Accurate determination of the causes of this disease allows you to choose the right tactics for treating a patient. There are 5 types of retinal detachment:
- Regmatogenic (from the Greek. Rhegma - break) retinal detachment, also called primary, idiopathic, is associated with the presence of a retinal break, through which fluid from the vitreous penetrates under it. The main mechanism of formation of the gap is associated with thinning of the retina in the zone of so-called dystrophies. In this case, the detachment is called dystrophic. There are a large number of varieties of retinal dystrophies: ethmoid, racemoid, retinosis, etc. In a degeneratively modified retina, a rupture can occur during sudden movements, physical exertion or even spontaneously.
- Traction retinal detachment occurs during tension (traction), which the retina is experiencing from the vitreous body due to the formation of fibrinous cords or newly formed vessels that grow into the vitreous body (for example, in diabetic retinopathy).
- Traumatic retinal detachment is associated with an eye injury. Detachment can occur either directly at the moment of injury or immediately after it, or within a few years. Retinal detachment, which arose as a complication as a result of surgical intervention, also belongs to the category of traumatic.
- Secondary detachment is a consequence of various diseases and pathological conditions of the eye: neoplasms, inflammatory diseases of the choroid and retina, hemorrhages and thrombosis, diabetic retinopathy, retinopathy of prematurity, sickle cell anemia, etc.
- Exudative detachment, or serous, occurs when, as a result of any pathological process, fluid begins to accumulate under the retina, and no rupture forms in the retina itself.
Treatment of retinal detachment is carried out after a comprehensive examination of patients. From the timeliness of diagnosis depends on the prognosis for health. The following studies are conducted:
- Assessment of visual acuity;
- the study of the structures of the eye in transmitted light;
- coherent tomography;
- general blood analysis;
- biochemical research;
- general urine analysis;
- electrophysiological study.
Unlike many other diseases of the eye, detachment occurs on the background of low or normal vision. In this regard, the assessment of the sharpness of the vision of objects is not of great value.
With this pathology is perimetry. It allows you to assess the field of view. Computer perimetry is most often performed. With retinal detachment, visual fields on the opposite side fall out.
Biomicroscopy is of great value. In this study, all eye structures are evaluated in detail under high magnification. When biomicroscopy applied slit lamp.
Additional diagnostic methods include tonometry. The pressure in both eyeballs is measured. With detachment, it may be slightly reduced.
The simplest method of diagnosis is ophthalmoscopy. It is direct and indirect. The study revealed a plethora of blood vessels, a site of detachment and a decrease in the fundus reflex.
In the traction form of detachment, cords and neovascular membranes are visible. If necessary, the presence of entopic phenomena is determined. The functional state of the retina is assessed by electrophysiological examination.
Retinal detachment requires immediate treatment. A long pathological process provokes persistent hypotension, cataracts, iridocyclitis, subatrophy of the eye and blindness. The main task of therapy is to bring together the layers of the retina and block the gaps. In the treatment of detachment, it is important to achieve a convergence of the photoreceptor layer with the pigment epithelium and limit the rupture by the foci of chorioretinal inflammation. This is a local sterile inflammation that glues the retina to the choroid and stops the progression of the disease.
- High degree of myopia and astigmatism, which provoke thinning and tearing of the retina;
- age from 45 years;
- heavy loads and high risk of injury in athletes;
- diabetes mellitus causing diabetic retinopathy and hemorrhage;
Surgical intervention for detachment can be extrascleral (on the surface of the sclera) and endovitreal (from the inside of the eye). The advanced treatment method is vitrectomy. This is a procedure to remove the vitreous body and replace it with a little silicone or gas to ensure a tight fit of the detachment to the adjacent layers.
Possible surgery for detachment:
- Extrascleral filling. The operation is carried out in the presence of gaps that do not require exposure from the inside of the eye. The seal is installed outside.
- Vitreoretinal surgery. It is used in old detachments, when careful cleaning and smoothing of the retina is required. A special silicone is introduced through dot punctures with long tools.
- Cryocoagulation gaps, as well as subclinical detachment.
The goal of treatment is to block the retinal tear. The sooner the operation is performed, the more reliable the result will be and the better the vision will be restored. Doctors give the most favorable prognoses for detachments that did not affect the central zone.
If the pathology has managed to close the center of the retina, even after a successful operation, it is not possible to restore the vision completely.
Since retinal detachment is the result of a rupture, it is necessary to regularly undergo preventive examinations and identify them in time. For the treatment of tears, laser coagulation techniques are used.
Detachments that were treated incorrectly or unsuccessfully should be operated on for a year while the eye still perceives light. Surgical treatment of retinal detachment is painless, safe and quick. The operation is carried out with the help of the latest equipment and only by highly qualified specialists. Outpatient procedures take from 40 minutes to 1.5 hours, given the complexity of the operation and complications.
Retinal detachment can be eliminated by surgical intervention, but it is not in each case that the integrity of the retina and full vision can be restored. Even after successful treatment of severe detachment, vision is rarely returned. Only in some cases, it is restored to its original level.
After surgical treatment there are no restrictions on visual loads, but for a month the patient is forbidden to visit the bath, sauna and swimming pool. Physical activity should be minimized for a period from a month to a year, depending on the severity of the condition.
After surgery to eliminate detachment, refractive disturbances (myopia, astigmatism) are often amplified. Sometimes relapses occur, repeated surgical intervention is required, which is often ineffective. The success of surgery for detachment is determined by the timeliness of treatment. A long pathological process, as a rule, ends with irreversible changes in the retina and the death of visual neurons.
Endovitreal treatment of retinal detachment
Endovitreal surgery involves intervention from the cavity of the eyeball. The doctor makes three incisions of the sclera (approximately 1 mm each) through which it gains access to the vitreous body and the retina. This procedure is called sclerotomy. Instruments, an illuminator are inserted through the incisions and the solution is allowed to maintain the tone of the eye. The most commonly used vitreot - a cylinder of 1 mm, which hides a knife, dissecting intraocular tissue. If necessary, the doctor may use other tools.
For smoothing and crushing the retina to the membranes use expanding gases, silicone oil or organofluorine compounds. After the introduction of a special substance can be carried out laser coagulation of the retina.
Indications for vitrectomy for detachment:
- Big sizes;
- long tears of the retina along the dentate line;
- proliferative vitreoretinopathy, the presence of folds;
- rear retinal tear;
- combination of a gap with hemophthalmus.
With endovascular intervention, the vitreous body is removed (transciliary vitrectomy). Sometimes it takes a long tamponade cavity silicone oil or gas. The bubble from the gas will dissolve within 2-4 weeks, decreasing and replacing with intraocular fluid. Silicone oil is removed a little longer (2-3 months).
In case of rheumatogenous detachment, the doctor removes the vitreous body and the posterior hyaloid membrane. To remove traction remove the strands and membranes. During the operation on the fundus create a bubble of "heavy water", which presses down the retina. Excess fluid is removed through the gap, laser coagulation of the affected zones is performed. After that, the “heavy water” is replaced with a physiological solution, and the incisions are sutured. When the proliferative vitreoretinopathy of the tissues arises during the old detachment and cannot be smoothed out, peripheral cuts are required (retinotomy).
Extrascleral treatment of retinal detachment
With endovitreal access, the operation is performed from the inside of the eye, and with extraxleral intervention, the retina and pigment epithelium are brought closer together by indentation of the sclera (filling). During the operation, the doctor creates an indentation shaft that blocks the gap, and the accumulated fluid is gradually absorbed into the epithelium and choroid.
Before such an operation, bed rest is required so that the detachment bubbles decrease as the subretinal fluid is resorbed. This facilitates the detection of rupture. After surgery, bed rest is also prescribed, at least for a day.
When filling the sclera, the retina layers are brought closer by pressing the sclera from the outside. In the projection of the gap, a silicone strip or seal of the required size is attached to the sclera. The strip is literally sewn on. Under her pressure, the sclera is pressed inward, pressing the vascular membrane against the retina. In this position, the accumulated liquid begins to dissolve.
Stages of sealing:
- Determination of break points, marking of this zone on the sclera. For these purposes, they use a diathermotor, the tip of which the doctor pushes, creates a shaft and marks the place of the projection of the gap on the sclera.
- Vykraivanie seals and filing it to the sclera in the projection area. The position of the filling will depend on the type of pathology, location and number of breaks. It happens radial, sectoral and circular filling.
- If there is a large amount of fluid, it is necessary to remove it through the opening to the sclera (drainage).
- In addition, air or gas can be introduced into the vitreous. As long as the bubble resolves (a few days), the vision will remain low.
- Stitching the conjunctiva.
With a large accumulation of subretinal fluid, it is drained through a puncture in the sclera. When filling using soft silicone sponge. From silicone it is easy to cut out the seal for the desired parameters.
The type of filling is determined by the doctor, taking into account the type and location of the gap. It happens radial, sectoral and circular filling. In some cases, they resort to a circlapse (circular indentation with a silicone thread or braid). Circling create in the equatorial region of the eye.
Possible complications after sealing:
- Early: infection of the eyeball and orbit, vascular detachment, glaucoma, dysfunction of the eye muscles, ptosis, strabismus.
- Late: exposure of the seal, changes in the central region, refractive disorders, cataracts.
- Consequences: lack of adhesion of the detachment, relapse.
Sight restoration after filling occurs gradually. This process usually takes several months.
The operation involves the temporary leading to the sclera of the catheter with a balloon (in the area of the projection of the gap). Liquid is injected into the balloon, its volume is increased, creating the effect of scleral pressing in, similar to a sealing operation.
Ballooning creates the conditions for resorption of subretinal fluid and the successful conduct of otgranitelny laser coagulation of the retina. The balloon is removed after the formation of adhesions between the retina and adjacent tissues. Ballooning is less traumatic and is used in various pathologies of the visual system.
Laser coagulation with detachment
After extrascleral operations, it is possible to perform diathermal, laser or photographic coagulation. The effect can be fixed by cryopexy at the borders of the detachment from the side of the cavity through the pupil (transpupillary) or sclera (trans scleral). An additional effect provokes the formation of adhesions around the gap and reliable fixation of the retina.
Laser treatment for detachment allows to create adhesions between the retina and the vessel lining. The doctor uses laser coagulators to create microburns. Such an operation is effective for the prevention of detachment, limiting existing lesions (flat detachments) and additional coagulation after surgery.
Laser coagulation of the retina is performed under local anesthesia. Goldman's lens is installed on the eye, which focuses the laser radiation on a certain part of the fundus. Adhesions are formed in two weeks.
Possible complications of laser coagulation:
- Exudative detachment;
- detachment of blood vessels;
- degenerative changes in the central region.
After treatment of retinal detachment, patients need care. The bandage is applied. This helps prevent the entry of germs and secondary infection. The dressing should be changed regularly. It must be sterile. The eyelids are treated with an antiseptic solution. Soon the dressing can be replaced with sterile gauze.
After surgery, temporary pain is possible. Analgesics are used to eliminate it. After the operation, you need to comply with bed rest. All patients need to abandon weight lifting.
Allowed to lift items weighing no more than 5 kg. It is necessary to prevent stressful situations and mental overload. After the operation on the eye, it is necessary to temporarily exclude the ingress of water, soap and gels on the damaged area. Eye drops are used to prevent postoperative complications. The doctor prescribes a remedy from the group of glucocorticoids or antibiotics.
If a person has a history of diabetes, then corticosteroid-based drops are used. After discharge it is necessary to visit an ophthalmologist to assess the condition of the visual analyzer.
In the first weeks after surgery, a person must wear glasses or contact lenses. Most often, vision is normalized within a few months. At the weakened people this period increases.
To avoid accidents after the operation is not recommended to drive a car. It is necessary to limit fluid intake. It is recommended to follow a salt-free diet and completely abandon alcoholic beverages.
During the month after surgery, the patient is not recommended to go to the sauna, and you also need to avoid rooms with high levels of humidity and high temperatures. It is necessary during this period to ensure that water does not fall into the eye, and to avoid heavy physical exertion. All recommendations of the attending physician should be strictly followed and re-examined to avoid complications and speed up the process of restoring impaired visual functions. Depending on the doctor’s instructions and compliance with all recommendations, it will be possible to return to work within 1-2 weeks after the operation.
Possible complications after surgery
In rare cases, complications may occur after surgery. They are usually associated with cataracts, glaucoma, and the general poor health of the patient.
The most common complications include:
- Repeated detachment of the retina, which will require a new surgical intervention;
- Enhanced scar formation on the retina (that is, proliferative vitreoretinopathy). In this case, repeated operational activities are also held;
- The development of endophthalmitis as a result of infection in the eye.
It is necessary to immediately consult a doctor if there is discharge from the eyes, fever, chills, if there are swelling and redness, shortness of breath, cough, pain in the chest.
Prevention of retinal detachment is reduced to the early diagnosis of peripheral vitreochorioretinal dystrophies of the retina and other factors predisposing to the appearance of retinal detachment, timely implementation of preventive measures, rational employment of patients and dynamic monitoring.
The most dangerous types of vitreochorioretinal dystrophies in terms of retinal detachment include isolated retinal breaks, “lattice” dystrophy, dystrophy “cochlear track”, degenerative peripheral retinochism.
Predisposing factors include retinal detachment in the double eye, aphakia or artifacia, especially if laser capsulotomy is planned, high myopia accompanied by “lattice” vitreochorioretinal dystrophy, systemic diseases - Marfan syndrome, Stickler syndrome.
Prophylactic methods of treatment include transpupillary argon or diode laser coagulation around zones of vitreochorioretinal dystrophies or ruptures (fig. 31-54) or transscleral cryopexy or diode laser coagulation of these zones, carried out under the control of indirect ophthalmoscopy with sclerocompression.
To prevent the retina from peeling off, the following recommendations should be followed:
- Visit an ophthalmologist regularly and check your eyesight;
- treat myopia;
- exclude any injuries to the eye and ingestion of foreign objects into it;
- stop smoking and alcohol;
- abandon heavy and traumatic sports;
- treat diabetes mellitus and hypertension in the early stages;
- lead a correct lifestyle during pregnancy.
People at risk need to go to an ophthalmologist at least once a year. If detachment is already detected, laser coagulation can be performed. It allows you to prevent complications. If this pathology is diagnosed in a pregnant woman, then a cesarean section may be required.
An important aspect of prevention is the prevention of inflammatory diseases and the elimination of head injuries. Thus, detachment of the retina is a dangerous pathology. Self-medication can cause blindness. Emergency surgical care required.