Distacco retinico Flashcards
General findings
Retinal detachment refers to the detachment of the inner layer of the retina (neurosensory retina) from the retinal pigment epithelium. The most frequent causes of retinal detachment are tears or holes in the retina (rhegmatogenous retinal detachment), risk factors for which include myopia, previous intraocular surgery, trauma, and/or posterior vitreous detachment. Less commonly, retinal detachment occurs without any retinal tears (non-rhegmatogenous retinal detachment). Non-rhegmatogenous retinal detachment is most often the result of vitreoretinal bands (e.g., proliferative diabetic retinopathy), subretinal/intraretinal tumors (e.g., choroidal melanoma), or a number of systemic and ocular causes that result in subretinal fluid accumulation. Small detachments typically present with photopsia, floaters, and/or visual field defects. Loss of vision may be severe if the retinal detachment is extensive and/or the macula is affected. The diagnosis is confirmed by ophthalmoscopy. To prevent retinal detachment, laser photocoagulation in the direct vicinity of the retinal defect should be performed after diagnosis of retinal tears or holes. Extensive retinal detachment is an ophthalmic emergency and usually requires prompt surgery to prevent further detachment and restore sensory function. Visual prognosis depends particularly on the extent of retinal detachment (poor with macular involvement) and how much time passes before the retina is reattached.
Regmatogeno
🧨Most common type
Retinal tears → retinal fluid, which is formed by vitreous degeneration, seeps into the subretinal space → retinal detachment (Rhegmatogenous retinal detachment primarily starts peripherally in areas of degenerative change or retinal holes and disseminates centrally.)
Fattori di rischio
- Previous intraocular surgery (e.g., cataract surgery)
- Posterior vitreous detachment
- Retinal detachment of the other eye (incrementa il rischio del 10 % sull’occhio controlaterale)
- Peripheral retinal breaks, commonly due to:
- Pathological myopia (cioè maggiore di 6 diottrie)
- Trauma
- Family history of retinal detachment
- CMV retinitis
- Lattice degeneration: refers to focal thinning of the peripheral retina. It is seen in 8% of the general population and 20–30% of patients with non-traumatic rhegmatogenous retinal detachment.
Trazionale (non regmatogeno)
Formation of vitreoretinal bands → traction on the vitreoretinal band during eye movements or as a result of sudden decrease in intraocular pressure → retinal detachment. The most common cause of vitreoretinal band formation is neovascularization of the retina.
Fattori di rischio
- Proliferative diabetic retinopathy
- Retinopathy of prematurity
- Sickle cell retinopathy
- Inflammatory effusions
Essudativo (non regmatogeno)
TRAUMI!!
Subretinal fluid accumulation without retinal tears!!
Fattori di rischio
- Systemic diseases
- Pre-eclampsia
- Hypertension
- Bleeding disorders
- Polyarteritis nodosa - Ocular diseases
- Sudden decrease in intra-ocular pressure due to
- perforating injuries or intraocular surgery - Tumori
- Retinoblastoma
- Malignant melanoma of the choroid
CLINICA
💥Non c’è dolore!
💥NB. Le miodesopsie e la fotopsia sono tipici di spot della retina e rotture ma non indicano un distacco retinico. Il distacco retinico vero e proprio si manifesta con i sintomi di cui sopra e con una alterazione del campo visivo, cioè una perdita del visus opposta alla lesione. Questa differenza è importante perchè cambia la tipologia del trattamento
1.Prodromal symptoms: result from posterior vitreous detachment (il distacco posteriore del vitreo non significa distacco retinico!!)
-Floaters (miodesopsie, mosche volanti)
-Flashes of light (photopsia)
▪Caused by traction on the retina (e.g., in posterior
vitreous detachment via adhesion between the
retina and vitreous body). Photopsia is usually
absent in the case of exudative retinal detachments.
2.Localized retinal detachment: scotoma (visual field defect)
Patients may describe the impression of a curtain or shadow either descending or ascending on the field of vision depending on the location of detachment.
The visual field defects may begin in either the nasal or temporal visual field.
Typically unilateral
3.Extensive retinal detachment and/or macular involvement
Sudden, painless loss of vision in the affected eye (often described by patients as a curtain descending over their field of vision)
Relative afferent pupillary defect
Diagnosi (The unaffected eye should always be examined, as in ∼ 15% of cases of rhegmatogenous retinal detachment, there is a bilateral tear. Preliminary stages of retinal detachment should be diagnosed early and, if necessary, promptly treated (e.g., via laser)!)
Opthalmoscopic findings: A freshly detached retina has a grey color instead of the normal pink color and may appear crinkled. (Both direct and indirect ophthalmoscopy should be performed after dilating the pupil. Indirect retinoscopy is useful to visualize the peripheral retina.) La fluorangioscopia è indicata in caso di patologia proliferativa!
L’oftalmoscopia viene praticata ogni anno per lo screening della retinopatia diabetica nei soggetti affetti da diabete mellito
1.Rhegmatogenous retinal detachment
A RETINAL TEAR may potentially be visible (e.g., horseshoe, linear, or round retinal tears).
The detached retina floats freely in the vitreous body, and moves with eye movements.👀
Blood-vessel orientation in the detached portion of the retina differs from that in the normal retina.
2.Non-rhegmatogenous retinal detachment: No retinal tear is observed.
Differential diagnoses
Retinoschisis: Retinoschisis refers to splits within the neurosensory retina. A sua volta è un fattore di rischio per il distacco retinico regmatogeno
Choroidal detachment : detachment of the choroid from the sclera as a result of accumulation of fluid in the suprachoroidal space.
Trattamento
✔Regmatogeno (c’è una rottura!)
For retinal holes/retinal tears with little or no retinal detachment (prophylaxis against retinal detachment): laser photocoagulation or cryoretinopexy in the direct vicinity of the retinal defect!
In the case of extensive retinal detachment: prompt surgical treatment
First-line:
-CERCHIAGGIO (external tamponade), da preferirsi in soggetti giovani per il minor rischio associato di cataratta.
Second-line: vitrectomy followed by subretinal fluid drainage, internal tamponade (aria o olio di silicone a seconda della localizzaizione della lesione), and laser photocoagulation/cryoretinopexy (per il trattamento delle rotture retiniche)
nb. la retinopessi pneumatica solo per distacchi superiori
✔Trazionale
Vitrectomy followed by internal tamponade and laser photocoagulation/cryoretinopexy. (come possiamo notare c’è la ablazione laser perchè qui c’è proliferazione vasale)
✔Exudative (serous) retinal detachment:
- Due to sub-retinal fluid accumulation: spontaneous reabsorption of fluid; no treatment is required. Prognosi ottima
- Due to tumors: enucleation. La prognosi dipende dalla storia del tumore
Complicanze
- Without treatment, progressive retinal detachment causes blindness, especially if the macula is involved.
- Proliferative vitreoretinopathy
- Toxic uveitis (due to endocular toxins) in the case of long-standing retinal detachment
- Retinal detachment in the other eye
- aumenta l’incidenza di CATARATTA (soprattutto il trattamento mediante fotoblazione)
