retinal detachment
Introduction
Introduction to retinal detachment Retinal detachment (retinal detachment) is the separation between the retinal neuroepithelial layer and the pigment epithelial layer. Primary retinal detachment is a common clinical disease. The number of male patients is more than 3:2 for males, most adults over 30 years old, 10 years old. The following children are rare, the difference between left and right eyes, the incidence of both eyes is about 15% of the total number of patients. Occurs in myopia, especially high myopia. Retinal detachment from primary retinal detachment is still based on surgery. The principle of surgery is electrocoagulation, condensation or extrabulbar, intracoronary photocoagulation in the corresponding scleral plane with the hiatus to cause local choroidal reactive inflammation, causing choroid and retinal nerves. The cortical layer has an adhesive surface that closes the hole. In order to achieve this goal, it is necessary to try to alleviate or eliminate the vitreous traction on the retina, discharge the subretinal fluid, pressurize the bulb wall, shorten the sclera, scleral cerclage to reduce the lumen of the eyeball, or inject a certain gas into the vitreous cavity. A certain kind of liquid is used to strengthen the contact between the neuroepithelial layer and the pigment epithelial layer. If the vitreous traction is severe, a glass 2-body cutting operation is required. The surgical procedure was chosen based on the condition of retinal detachment and the formation of vitreous membrane. How to choose the appropriate surgical method and accurate positioning of the hole. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: choroidal detachment glaucoma cataract
Cause
Cause of retinal detachment
Pathological changes (25%):
Retinal degeneration and tear formation Due to the complex structure of the retina, unique blood supply, degeneration due to various reasons, peripheral parts and macular part are degeneration sites, retinal degeneration is the basis of retinal tear formation, before the occurrence of the hole, the following changes are common:
(1) Lattice-like degeneration: lattice-like degeneration is most closely related to retinal detachment, and 40% of the pupils account for the rupture of the hole. It is also visible in the normal eyeball, which is about 7%. And gender differences, infringement of both eyes, its formation and location are often symmetrical, more common in the temporal or temporal quadrant between the equatorial and serrated margins, fusiform and strip-shaped, edge-clear island-like lesions, long axis and serrated The edges are parallel, and the lesion area varies greatly. The long right varies from 1DD to 1/2 circumference, and the width varies from 0.5DD to 2DD. The lesion retina is thin, and there are many white lines, which are staggered into a grid facade. The retinal blood vessels outside the lesion are actually occluded or peripheral blood vessels with tubular white sheaths. The distribution of white pigments is sometimes seen in the lesions, called pigmentary lattice-like degeneration, and the pigment is derived from the retinal pigment epithelial layer.
(2) cystic degeneration: occurs in the vicinity of the macular part and the inferior side of the serrated edge, the edge is clear, round or round, dark red, small cavity can be merged into a large cyst, so the size varies greatly, occurs The reticular sac-like degeneration in the peripheral part of the fundus becomes a cluster-like and slightly elevated red dot. The vitreous or granular opacity is nearby, and the cystic degeneration of the macula is a honeycomb-like small cyst. It is particularly obvious when the red light is examined. The small cystic cavity in the peripheral or macular area gradually merges into a large cystic cavity. The front wall is often broken by the vitreous traction, but only when the front and rear walls are broken, it becomes a true hole and causes retinal detachment. .
Cystic degeneration is caused by a variety of reasons (such as senile changes, inflammation, trauma, high myopia, etc.) affecting the metabolism of the retina, causing the breakdown of its neural components, thereby forming a cavity in its inner plexiform layer or inner and outer nuclear layers. A change in the gap is filled with a liquid containing a mucopolysaccharide component.
(3) frosty degeneration: mostly occurs near the equator and the serrated edge. Some areas covered by tiny white or slightly yellow shiny particles can be seen on the surface of the retina, and the thickness is uneven, as if the retina is covered with a frost. Degeneration can occur alone or in combination with lattice-like degeneration and cystic degeneration. The frosty degeneration is close to the equator and merges into a band, also known as snail trace degeneration.
(4) paving stone degeneration: generally seen in myopia patients over 40 years old, more common in both eyes, occurs in the lower part of the fundus, showing a pale yellow round or round shape with pigmented edges, clear boundaries Sexual atrophy lesions, large and small lesions are grouped into a paving stone. The choroidal capillary network in the central part of the lesion is atrophied, exposing the choroidal large blood vessels or even the pale white sclera. If the degeneration area is pulled by the vitreous, the retinal tears are formed.
(5) Retinal pressure whitish and non-pressurized whitish: After the sclera is depressed, the bulge of the fundus becomes opaque grayish white, which is called vaginal whitening. When the lesion is further aggravated, it is grayish even if it is not pressurized. It is called non-pressurized whitish, and its trailing edge sometimes forms a clear sputum, which is more common in the peripheral part of the upper fundus. It is considered to be an indication of vitreous traction. For example, after the vitreous detachment, the trailing edge can be torn apart. Split hole.
(6) Dry retinal longitudinal fold: wrinkles extend from the edge of the serrated edge to the equatorial direction, which is a fold of excessively growing retinal tissue, generally without treatment, but also occurs by objectively pulling the vitreous at the posterior end of the fold. The possibility of a hole.
Vitreous degeneration (25%):
Under normal circumstances, the vitreous is a transparent gel-like structure filled in the cavity of the posterior 4/5 of the eyeball, which supports the retinal neuroepithelial layer in the pigment epithelial layer, except in the ciliary body flat to serrated The margins and adhesions around the optic disc and the retina are only closely attached to the inner limiting membrane of the retina, but there is no adhesion.
Before the occurrence of retinal detachment, common changes in vitreous degeneration include: detachment of vitreous, liquefaction, turbidity, membrane formation, and concentration.
(1) detachment of vitreous body: vitreous detachment refers to the gap between the critical surface of the vitreous and the tissue in close contact with it. It is more common in high myopia and elderly patients, and the outer interface of each part of the vitreous body can be detached. After the vitreous detachment, the upper detachment is common, and the relationship with the retinal detachment is relatively close.
The reason for the vitreous detachment is mainly the depolymerization and dehydration of hyaluronic acid in the vitreous, forming one or more small liquefied cavities in the vitreous body and merging with each other to form a large cavity, such as the liquid in the cavity breaks through the external interface of the glass and enters the retina. Separation occurs between the vitreous and the inner limiting membrane of the retina. If there is some pathological adhesion to the retina at the detachment, retinal tears may occur due to traction.
(2) Fluidity of vitreous body: Vitreous liquid is a vitreous state that changes from a gel state to a dissolved state. It is a colloidal balance damage caused by a new metabolic disorder of the vitreous. It is also common in high myopia and elderly patients, and liquefaction is generally At the beginning of the vitreous, an optical space appears, which gradually enlarges. It is also possible to fuse a plurality of smaller liquefied cavities into a larger liquefied cavity. The liquefied cavity has a translucent gray-white tow or a floc floating.
(3) Vitreous opacities and concentration: There are many reasons for vitreous opacity, but those associated with primary retinal detachment are caused by the destruction of vitreous scaffold structure, so they are often separated from the vitreous, liquefied at the same time, turbid Fiber strands have the potential to cause retinal tears.
The so-called vitreous concentrating is also a vitreous turbidity. It is an opaque body formed by dehydration and denaturation of the scaffold structure when the vitreous is highly liquid. Therefore, it can be called atrophic concentration, and the membrane turbidity of the outer interface when it is detached from the front vitreous body. Compared with the tow-like or flocculent turbidity in the vitreous liquefaction chamber, there is not much difference in the nature, only the degree of severity is more serious, and the risk of causing retinal detachment is also more intense.
(4) Vitreous membrane formation: also known as the peri-proliferative membrane (massive perietinal proliferative membrane) co-formation mechanism is very complex, is not fully understood, there may be glial cells, free pigment epithelial cells and their transformed macrophages Cells, fibroblasts, etc. are involved, and the proliferating membrane grows along the anterior, posterior or posterior interface of the retina. After contraction, the retina can be collapsed to form some fixed adhesion folds or star folds, or even the entire posterior retina. Shrink together to form a closed funnel shape.
Such a proliferative membrane is seen in patients with detachment before retinal detachment, and in detachment and old detachment, which occurs as an important cause of retinal detachment.
In summary, the so-called primary detachment is only a idiom, in fact, secondary to retinal and vitreous degeneration, retinal tears and vitreous liquefaction, detachment and pathological adhesion to the retina, is the primary retina The two necessary conditions for detachment are indispensable. For example, some cases have been found to have clear retinal tears in the clinic. As long as the vitreous is healthy, retinal detachment will not occur. Similarly, only the vitreous degeneration changes and the retina has no holes. Retinal detachment does not occur. For example, it is observed that 65% of people aged 45 to 60 have posterior vitreous detachment, and only a few of them have retinal detachment. This also indicates that retinal detachment is the result of mutual interaction between retinal degeneration and vitreous degeneration. Retinal tears are often formed by the pathological adhesion of the vitreous on the basis of various manifestations of degeneration. The vitreous liquefaction, on the one hand, weakens the support of the retinal neuroepithelial layer attached to the pigment epithelial layer, and on the other hand liquefies The vitreous is perfused into the neuroepithelial layer.
In addition, it has been observed that retinal tears occur in the corresponding points of the oblique and oblique points of the fundus, so it is speculated that the holes are related to the traction of these muscles. It has also been found that most patients recall a history of minor trauma at the bottom of the eye and think that the detachment is related to trauma. In fact, in addition to a few special cases such as severe eyeball blunt trauma, oblique muscle traction and trauma can only be considered as the cause of retinal detachment.
Risk factors (20%):
(1) Relationship with myopia: Retinal detachment occurs mostly in patients with myopia. In the case of larger samples of rhegmatogenous retinal detachment, there are many patients with myopic diopter above -6.00D, and the incidence of rhegmatogenous retinal detachment in myopia. The age is lighter than that of the right eye. The lesion of myopia is mainly in the posterior segment of the eyeball. Starting from the equator, the posterior segment of the eyeball gradually expands. The capillary layer of the choroid shrinks and even disappears. The retina also undergoes degeneration, atrophy, and vitreous. Liquefaction also occurs, and retinal detachment is prone to occur with these pathogenic factors.
(2) The effect of extraocular muscle movement: the end of the four rectus muscles is located in front of the serrated edge, and its movement has little effect on the retina, while the oblique muscle stops at the back of the eyeball, and the superior oblique muscle pulls the eyeball down. Adding the gravity effect of the vitreous body may have a certain relationship with the easy recurrence of the retina in the supracondylar quadrant. The macular part is prone to cystic degeneration, which may be secondary to a hiatus. Some people think that it is also related to the traction of the inferior oblique muscle. The distribution of the holes in 286 cases of retinal detachment surgery showed that 68.4% of the holes were in the temporal side of the retina, of which 47.49% corresponded to the position of the upper and lower oblique muscles, that is, the hole was in the upper quadrant, and the right eye was concentrated in the right eye. 10 to 11 o'clock, 1 to 2 o'clock position of the left eye, 13 to 15 mm behind the limbus, in addition to the 11 to 1 o'clock position, large horseshoe-shaped holes 16 to 22 mm behind the limbus, the lower quadrant The holes are concentrated at 8 to 9 o'clock in the right eye and 3 to 4 o'clock in the left eye, and 16.46 to 26 mm behind the limbus.
(3) Relationship with ocular trauma: the occlusion of the eyeball after blunt trauma can develop retinal detachment, and the prevalence of ocular trauma in the retina is higher, accounting for 18.71% to 20%. At the moment of eyeball contusion, the deformation of the eyeball can cause tearing in the distal part of the retina. In addition, severe trauma can directly produce retinal tears in the equator, and the posterior pole capillary circulation stagnant caused by trauma, retinal oscillation and vitreous traction. In the case of macular hole or cystic degeneration, it develops into a hole. In addition to these retinal detachment, which has a clear relationship with trauma, most other cases, the retina and vitreous have been degenerated or adhered, and have the intrinsic factors of retinal detachment. Trauma only induces retinal detachment as a cause.
(4) Relationship with heredity: Some cases of retinal detachment occur in the same family, indicating that the disease may have genetic factors, may have recessive or irregular dominant inheritance, and most pathological myopia has a more positive hereditary There are many cases of retinal detachment. In addition, patients with bilateral retinal detachment have bilateral symmetry on the fundus, which indicates that some retinal detachment may be closely related to congenital growth and development factors.
Prevention
Retinal detachment prevention
The incidence of rhegmatogenous retinal detachment is about 15%, so when the detachment has occurred at a glance, the other eye must be fully dilated and carefully examined for fundus. If retinal degeneration is found, especially the existing fissure and shallow detachment, vitreous degeneration (liquefaction) And membrane formation), it is necessary to take appropriate surgery in time to prevent further expansion.
Found in the peripheral hole, the condensation on the corresponding scleral surface, if there is no retinal detachment in the vicinity of the hole (so-called dry hole), laser photocoagulation, macular hole, as long as the vitreous has no obvious abnormality, or after the vitreous detachment However, there is no adhesion at the edge of the hole, and still maintain a good visual acuity, whether surgical treatment or laser photocoagulation should be cautious.
prevention
1. It is not advisable to use excessive fatigue.
2. Lift heavy objects.
3. Prevent the occurrence of myopia.
4. Do less intense activities.
5. Patients with myopia should go to the hospital regularly, especially those with poor fundus.
6. Prevent eye injuries.
Complication
Retinal detachment complications Complications choroidal detachment glaucoma cataract
There are usually complications during retinal detachment surgery. Common complications are:
1 ball wall perforation, can occur in the broken sputum, when the water is released, such as the perforation occurs in the detachment area of the omentum, can be treated as a drainage hole; if it occurs in the non-retinal detachment area, it should be suture repair, local condensation and external pressure;
2 water release complications, in addition to the perforation of the ball wall, such as the incision is too large, the liquid outflows too fast, the sudden drop in intraocular pressure, can cause choroidal exudation, hemorrhage, once found, immediately cut the sclera, release the liquid in the suprachoroidal cavity or Blood, rapid ligation of the scleral suture and cerclage band, excessive compression of the eyeball when releasing water can invade the retina, vitreous wall, and form a fibrous vascular membrane after surgery, causing repeated bleeding and traction;
3 elevated intraocular pressure: occurs in the choroidal detachment, mannitol should be given intravenously, if necessary, for anterior chamber puncture, after surgery or surgery failure cases progress to full retinal detachment, successive uveitis, glaucoma, complicated cataract Etc., can also cause low intraocular pressure, and even the eyeball shrinks.
Symptom
Symptoms of retinal detachment Common symptoms Anterior dark shadow uveitis pigmentation plaque visual field vision visual impairment visual object deformation
Symptom
Most cases have sudden onset, with decreased vision or black shadows in front of the eyes. Many cases have prodromal symptoms such as flying mosquitoes and flashing sensations.
The detachment of the retina is characterized by early symptoms, and only early detection can be treated early. The early symptoms of retinal detachment are as follows.
(1) Flying mosquitoes and flashes: the earliest. It is actually a symptom of detachment of the vitreous. Middle-aged and elderly people, especially those with high myopia, and then a large number of flying mosquitoes, when a certain direction continues to flash, should be alert to the possibility of retinal detachment.
(2) Decrease in central vision: retinal detachment in the posterior pole, and visual acuity drops sharply. When the peripheral part is first detached, there is no influence or little influence on the central vision. The fundus should also be examined in detail when high-risk patients have decreased vision.
(3) Visual distortion: When the peripheral retinal detachment affects the shallow or detachment of the posterior or posterior pole, in addition to the decrease in central vision, there is still visual distortion.
(4) Visual field defect: When the retinal detachment occurs, some sensitive patients may notice visual field defects. However, only the visual field defect below has early diagnostic value.
Retinal detachment is the detachment of the neuroepithelial layer. Due to the nutritional supply problem, the cells are first damaged, and the visual cell damage first affects the blue sensation. The blue field of the normal eye is larger than the red field of view. The retinal detachment eye is white, blue and red. The target field is inspected, and the corresponding field is not only the visible visual field defect, but also the blue color and the red field of view intersect.
(5) Central visual impairment: Due to the location and extent of retinal detachment, the visual acuity suddenly drops significantly when the posterior pole is detached, and the peripheral detachment has no effect or little influence on the central visual acuity. Only when the disengagement range extends to the posterior pole Central visual impairment occurs.
(6) Allergies: When the detachment occurs in the peripheral part and the posterior part of the sensation occurs, in addition to the decrease in central vision, there are symptoms such as deformation and smallness of the object.
2. Signs
Rhegmatogenous retinal detachment, anterior segment examination is generally normal, a few patients with choroidal detachment or detachment, the aqueous humor may have flash or post-iris adhesion, vitreous liquefaction or degeneration, visible posterior detachment and/or upper of vitreous The detachment, the coarse pigment particles in the vitreous is characterized by rhegmatogenous retinal detachment.
(1) Fundus performance:
A small number of retinal detachments can not be ascertained by the presence of vitreous hemorrhage or opacity. However, most of them can see the fundus, and the detachment is shallow and the subretinal fluid is clear. The choroid is yellow or reddish through the retina. The normal structure of the choroid cannot be seen, the newly occurring spherical detachment, the retina is grayish white or dark gray; after a long time, there is undulating undulation, and it can flicker with the rotation of the eyeball, and the center of the vascular wall of the retina is reflected. The detachment area disappears, and the blood column is dark red and undulating and crawling on the detached retina. The retinal round holes or tear holes are often found in the detached area, and most of them are 1 hole (51.9%-80.2%). If there are many holes, Can be concentrated in one quadrant can also be distributed, the peripheral small holes are not easy to find in the examination, small holes or irregularly shaped holes are often located near the retinal blood vessels, must be distinguished from bleeding.
The retinal degeneration and retinal proliferation occur further in the retinal detachment, the retinal transparency is significantly reduced, gray, and often wrinkled or stacked appearance, the retinal septum can be covered, and the early detachment of the subretinal fluid From the vitreous, it is very clear. After a long time of separation, the choroid develops exudative reaction. The subretinal fluid contains more fibrin, the color turns yellow and is more viscous. In some cases, there are scattered white or yellow-white dots behind the retina. Sudden deposits, with retinal reattachment after surgery can completely disappear.
The proliferation of vitreous and the degree of proliferation of the retina surface may be inconsistent. Some long-term detachment of the retina, the retina has been extremely thin and atrophic, but the proliferation of the retina is not significant and only the subretinal proliferation of the cord, the proliferation of the vitreous, vitreous and The retina is firmly adhered to form a fixed wrinkle, often in the shape of a starburst, and is more common in the posterior pole. Severe proliferation can cause the retina to detach completely. It is attached only to the optic disc and the serrated edge. It is funnel-shaped, and even the optic disc is also The retina and proliferative tissue are covered and become a closed funnel.
There are very few self-resets of retinal detachment. Most of them need to be treated by surgery. After self-reset, irregular white lines can be seen under the retina and its margins. The blood vessels of the retina straddle it. Pigmentation or pigmentation, the color tone is different from the undetached zone.
(2) Retinal tears:
Sealing the retinal tears is the key to the treatment of rhegmatogenous retinal detachment. Therefore, it is very important to check the holes, but the holes are affected by the shape, size, position, shape of the refractive interstitial and the shape of the retinal detachment. Difficult to find, in the past 20 years, using binocular indirect ophthalmoscope combined with scleral compression and slit lamp three-sided examination, the discovery rate of retinal tears can reach more than 90%, the number, size, shape and distribution of retinal tears in each case Inconsistent, the hole can be less than 0.1mm, can also be greater than 10PD, or the whole circumference of the serrated edge to break away, to find the retinal tears in addition to the necessary equipment, but also to understand and master the rules of retinal breakage.
Finding the retinal tear is not only the basis for the diagnosis of primary detachment, but also the key to the success of the operation. Therefore, it is very important to find all the holes accurately and accurately. About 80% of the holes occur in the peripheral part of the fundus. The side is the most, the lower side of the underarm is second, the upper side of the nose is second, and the lower side of the nose is the least.
In the main complaint, the patient can also provide some clues to find the hole, the dark spot and the first position of the flash illusion in the field of view, and the corresponding location is often the location of the hole.
The small hole in the detachment area should be distinguished from the bleeding point of the retinal detachment surface. In the range obtained by the slit lamp inspection, the two are easy to separate, and the peripheral part is difficult or even difficult. It must be observed repeatedly for a period of time to identify. .
1 The shape of retinal tears is roughly divided into three types:
A. Round hole: the atrophic hole, the round or oval hole formed by the regressive degeneration of the retina is the most, like the hole made by the puncher, the edge is clear and sharp, one or more piles, more Found in the retinal lattice-like degeneration area, high myopia, traumatic macular hole or pore formed by macular degeneration, mostly single circular hole, sharp edge, choroidal red background at the bottom, sometimes the edge of the hole is connected to the vitreous The hole cover, or the entire hole cover is pulled and torn by the vitreous body. The size and shape of the hole cover are the same as those of the hole. The macular hole should also be distinguished as a lamellar hole or a full-layer hole, which can be diagnosed by OCT examination.
B. Horseshoe-shaped split hole: This hole is shaped like a horseshoe, or has a half-moon shape and an arrow shape. The flange of the hole often points to the posterior pole of the fundus. The concave edge faces the periphery of the fundus, that is, the base of the vitreous body. The mechanism is the vitreous and retina. There is local adhesion, such as the back of the serrated edge of the normal eye or the edge of the lattice-like degeneration. When the vitreous is detached, the retina at the adhesion is torn into a hole, and the cap is often adhered to the vitreous body, most of which are single-hole. , generally larger, mostly located in the upper part of the retina, a small number of tears and retinal blood vessels, combined with vitreous hemorrhage.
C. Sawtooth edge separation: often occurs after the serious blunt trauma of the emmetropic eye, the eyeball deformation at the moment of heavy blow, causing the retina to avoid at the attachment of the serrated edge, more common above the nose, often accompanied by other traumatic damage of the eyeball In a few cases, the ciliary body can be combined with pigmented epithelial detachment. The dark red serrated edge is seen off the nose, and the avulsed vitreous base is suspended in the vitreous like a streamer. The detachment is also good for young males. The underarm quadrant is more common. It often involves both eyes and is symmetrical. The number varies from one to many, and the size varies from 1 serrated to full-circle, and the retina can be seen in both eyes. Disengage, or at a glance, the retina is detached, and the other eye has only a serrated edge.
2 Distribution of retinal tears: Most of the holes are distributed around the retina, near the equator, near the serrated edge, or between the two, with more than 70% of the temporal sulcus, especially in the upper quadrant, followed by the armpit. There are fewer nasal sides and the lowest under the nose. The macular hole accounts for 5.4% to 8.4% of China, which is higher than that reported in foreign literature.
For example, in the upper quadrant of the upper quadrant, there is a spherical retinal detachment, and the hole is often on the sac. Later, due to the influence of gravity, the retinal detachment rapidly spreads to the macula and develops to the underarm. The retinal detachment of the nasal upper quadrant caused by the upper nasal hole also gradually expands downward, but Less affecting the macular area, the small hole above the fundus often produces a shallow retinal detachment. After a period of time, the upper part is free to lie flat, and the subretinal fluid remains underneath. Therefore, the eye of the lower retinal detachment should also be carefully examined. The retina above, the retinal detachment in the inferior quadrant or the lower nasal quadrant, the reef is often at the highest point of detachment, and the retinal detachment caused by the temporal resection is generally more extensive than the nasal side, as well as the nasal septum. Retinal detachment is also wider on the nasal side than on the temporal side.
The posterior pole retinal detachment and/or the lower retinal detachment should be observed to see if there are any macular holes or small holes in the lower peripheral part. Pay attention to the careful finding of the holes in the vitreous and retinal adhesions and in the degeneration area of the retina.
(3) Intraocular pressure:
In the early stage of retinal detachment, the intraocular pressure can be normal, and then gradually decline. The size and number of retinal tears are not related to the degree of intraocular pressure drop. However, the larger the dissociation range, the higher the incidence of low intraocular pressure, and the intraocular pressure of the retina completely detached is significantly lower. Partial detachment, uveal inflammatory response is strong, lower intraocular pressure, acute angle-closure glaucoma can occur in external compression or combined with scleral cerclage, may be silicone block oppression of vortex vein, intraocular fluid reflux blocked Causes choroidal detachment and ciliary body edema, causing the angle of the anterior chamber to close. In addition, attention should be paid to a small number of open-angle glaucoma that may be associated with retinal detachment, and retinal detachment caused by intense decompression agents in patients with occasional glaucoma. There are also a few cases of retinal detachment that have not been treated or failed. The long-term uveitis causes pupillary atresia, and the angle of the anterior chamber is increased and the intraocular pressure is increased.
If the early detachment area is not large, the intraocular pressure is normal or low, and it decreases with the expansion of the detachment range. If the ocular pressure is more than one quadrant, the intraocular pressure is significantly reduced, and even the tonometry cannot be measured. The reason why the intraocular pressure drops may be separated from the retina. The fluid dynamics of the eye is related to the posterior part of the eyeball through the posterior chamber, the vitreous, the retinal fissure and the subepithelial space, transported through the pigment epithelium, and then the choroidal vasculature discharges the misdirected flow of aqueous humor outside the eye.
Several special types of retinal detachment
1. Congenital choroidal defect combined with retinal detachment: Congenital choroidal defect is caused by fetal regurgitation during embryonic development. The retinal neuroepithelial layer in the defect area is also easy to detach. The defect is transparent under the retina and is the white sclera. Most patients cannot. When retinal tears are found, such as hemorrhagic plaques at the choroidal defect, the holes are mostly in the vicinity of the choroidal defect, and the posterior margin of the choroidal defect should be closed during surgery. However, due to the large range of defects, the effect is poor.
2, retinal detachment of aphakic eyes: detachment occurred 1 to several years after cataract surgery, because the iris crystal barrier moved forward, especially in the operation of the vitreous detachment, most of the postoperative vitreous detachment, retinal tear hole, 1 ~ A few, can also be scattered in each quadrant, mostly located in the periphery of the fundus, sometimes visible adhesion to the vitreous.
According to the above clinical findings, the diagnosis is not very difficult, but the shallow detachment with a small peripheral area is often easy to miss the diagnosis, especially the detachment of the extreme peripheral part. The direct ophthalmoscope cannot be found, and the indirect ophthalmoscope or the three-sided mirror must be used. Scleral compression can be determined after repeated and careful examination.
Examine
Examination of retinal detachment
Slit lamp microscope and ophthalmoscope inspection
The anterior segment of the eyeball is generally normal, the anterior chamber can be slightly deeper, and the person who has been out of the long-term will cause a slight inflammatory reaction of the uveal tract. The Tyndall phenomenon of the aqueous humor is weakly positive, and there is a brown point-like deposit after the cornea.
Vitreous opacity and liquefaction, inevitably exist in the primary detachment eye, this change is more clear under the slit-like microscope light section, the liquefaction cavity is an unstructured optical space, between the liquid cavity and the cavity, there is a glass body scaffold tissue dehydration atrophy The formation of silky turbidity, sometimes in the liquid cavity and silky turbidity, there are brown or grayish white turbid spots, the liquefaction cavity gradually expands and fuses with each other, and the liquefied vitreous passes through the external interface into the front of the retina and the external interface of the glass. It becomes a vitreous detachment. There are several types of anterior, upper, lateral and posterior detachment due to different positions. The upper detachment and the posterior detachment are most closely related to retinal detachment. When the vitreous is detached, there is often a degree of pathological adhesion between the vitreous and the retina. It is called incomplete detachment. The adhesion is often caused by traction, causing retinal tears. The slit light is examined by the cut surface. The interface at the detachment of the vitreous is unevenly turbid. When it is detached, a grayish white ring is visible at the rear interface of the detached vitreous. The posterior interface of the vitreous is a hole, which is the tearing of the vitreous and the peripheral edge of the optic disc. , Lasted longer half-moon-shaped or irregular, may also be compressed into a transparent pellet polyethylene.
The various lesions of the above-mentioned vitreous can also be seen under the direct mirror, but it is not as clear as the slit lamp microscope, and the layer is distinct and has a three-dimensional effect.
Under the direct ophthalmoscope, the retina is detached and wavy, bulging, undulating with the rotation of the eyeball, and the fresh detachment of the epithelial layer and its effusion are transparent, which can see the yellow-red or reddish choroidal color under the pigment epithelial layer, but The choroid texture can not be seen clearly, and the retinal blood vessels crawling and undulating on the surface are formed into a light-blocking body, which has a dark red line. It is difficult to distinguish the arteries and veins, and sometimes a vascular projection consistent with the retinal blood vessels can be seen. The detachment time is longer and the neuroepithelial layer is present. Translucent paraffin pattern, detached arteries and veins can be distinguished, longer-term old detachment, effusion under the neuroepithelial layer, due to choroidal exudation, fibrin increased, into a light brown viscous fluid, behind the neuroepithelial layer Yellow-white spotted sediment.
The hole is often seen in the retinal detachment, 1 to several, the upper side of the fundus is the prone site of the hole, but due to the heavy cause, the effusion sinks, but the hole is slightly detached or not detached.
The contact ophthalmoscope can check the fundus within 70o after the pupil is fully scattered and the eye position is rotated. Therefore, the crack in the peripheral part outside the 70o is not easy to find. Indirect ophthalmoscopy should be used for both eyes. If necessary, a scleral compressor should be added. A slit mirror can also be used under a slit lamp microscope to detect and add a scleral compressor to detect some denaturation changes near the serrated edge and the flat portion of the ciliary body or the base of the retina and vitreous.
Fundus examination
Under full dilation, indirect ophthalmoscope combined with scleral depression or slit lamp and contact lens can be used to check the appearance of the surrounding of the omentum. The fundus examination shows that the retina of the dissociated area loses normal red reflection and is gray or blue-gray. Slight tremor, dark red blood vessels crawling on the surface, the ridge of the retina is like a hill undulation, the extent of the bulge can cover the optic disc, and there are wrinkles, flat detachment, if not detailed examination is often missed, when the macular area is detached, The fovea of the macula has a red dot, which is in sharp contrast to the retina that is grayish-white.
Ophthalmoscopy
Ophthalmoscopy is the most important. Finding all retinal tears is not only the basis for diagnosing rhegmatogenous retinal detachment, but also one of the keys to success. Therefore, how to find all the holes accurately and without fail is extremely important. % of the holes occur in the peripheral part of the fundus, especially on the upper side of the iliac crest, the lower side of the iliac crest, the lower side of the lower part of the nose, and the lower part of the lower part of the nose. When the retinal detachment is higher, these peripheral holes are often obscured. Must be carefully searched from all angles, in the case of binocular indirect ophthalmoscope plus scleral compression can not be found, can be pressure bandaged eyes, let the patient stay for a few days, after the retina is slightly flat, then check, retinal detachment range Large, high degree of bulge, there are often several holes, can not be satisfied with a hole, especially a small hole, in addition to looking for holes in the detachment area, should also pay attention to not detached or detached from the invisible area, especially the upper fundus A hole, due to the sinking of the liquid, the retinal detachment may not be visible in the hole and its vicinity, the position and shape of the retinal detachment, and sometimes the hole is sought The top of the fundus is detached, the hole is always out of the zone; the lower part is detached. If the detachment is a hemispherical bulge, the hole may be directly above it; if it is a general detachment below, the hole may be above the higher side of the detachment zone. If the height of the two sides is basically the same, the hole is often at the lower periphery of the patient. The patient's complaint sometimes provides some clues to find the hole. The dark area and the position where the flash is first appeared in the field of view, and the corresponding position is often the hole. In the site, retinal detachment can often be found in the hole, the search for holes and surgical closure of the hole is the key to the treatment of this disease, the hole is red, the surrounding retina is grayish white, more common in the sputum, followed by the armpit, the nose is the least seen, the serrated edge The holes are mostly under the armpits or below. The holes can also occur in the macular area or the retina that has not yet detached. The size and number of the holes can vary from round to round or horseshoe-shaped, but also striped, serrated and broken. Irregular, detached retina sometimes has a high degree of bulging to obscure the hole, allowing the patient to change the position of the head during the examination, or to bandage the double Eyes, stay in bed for 1 to 2 days, and check again when the degree of elevation is reduced.
Diagnosis
Diagnosis of retinal detachment
