RETINOPATHIES (late lat. retina a mesh cover + Greek pathos suffering, a disease) — the collective concept combining various diseases of a retina of an eye of circulator and exchange character and damage of a retina at nek-ry diseases of other bodies and systems.
Carry idiopathic central serous R., an acute back multifocal pigmental epite-liopatiya, outside exudative River to the first group P. (primary R.). Damages of a retina at other diseases (secondary R.) include hypertensive and diabetic R., retinopathies at diseases of blood, a traumatic retinopathy of Purcher, berlinovsky opacification (contusional hypostasis of a retina), etc.
Patol. process in to a retina (see) it is connected with disturbance microcirculation (see) in vessels of an eyeground, a cut can develop at a number of diseases and patol. states — an idiopathic hypertensia, toxicosis of pregnant women, a diabetes mellitus, diseases of blood, etc. Thereof there are changes of permeability of a vascular wall with an exit in tissue of a retina of elements of blood, formation of subretinal hypostases and hemorrhages, microaneurysms and development of processes of neovascularization. Primary defeat of capillary system of an eye causes a hypoxia of a retina that leads to its further disturbances.
Morfol. changes in capillaries are expressed in reduction or full loss of pericytes and endothelial cells, a thickening of a basal membrane. The thickening of walls of arterioles with the subsequent their obliteration is noted. In nek-ry cases the necrosis of arterioles develops. Hemorrhages and formation of exudate are characteristic. At R. find a varicose hypertrophy of nerve fibrils, fatty dystrophy of ganglionic cells, adjournment of cholesterol in a retina.
Subjective and objective symptoms at R. are connected with dysfunction of a retina.
At oftalmoskopiya (see) a picture P. (see tsvetn. the tab. to St. Eyeground , fig. 28 — 34, 38—48) consists of change of vessels of a retina in the form of narrowing of arteries and a phlebectasia, a partial or full obliteration of vessels, emergence of arteriovenous decussations («a symptom of decussation», or Salyusa — the Hun), at to-rykh a vein is narrowed before and after decussation, microaneurysms, hemorrhages, solid and soft exudate. Microaneurysms have size from 20 to 90 microns, are localized in an inner nuclear layer of a retina, usually meshotchaty form, develop within from 12 to 24 months. Further they are exposed to a hyalinosis or thrombosis. Hemorrhages in a retina can be striate or roundish. Striate are located in a nerve fiber layer and follow on their course, roundish hemorrhages are in deep layers of a retina. Solid exudate represents the white or grayish focuses which are located more often in the central area of a retina and not contrasted at fluorescent angiography (see). Their origin is connected with an exit of lipids of blood through a vascular wall in connection with the broken permeability. Soft exudate at an oftalmoskopiya has an appearance of white roundish, friable, hlopkoobrazny focuses. Researches by means of a fluorescent angiography showed that formation of soft exudate is connected with occlusion of arterioles y that gave the grounds to consider it a heart attack of a retina.
For R.'s diagnosis use all methods of a research of an eyeground — oftalmoskopiya (see) in a direct and return look, fluorescent angiography (see). Also detailed inspection of the patient is necessary for diagnosis of the basic disease which caused River.
The differential diagnosis is difficult because of similarity of an oftalmoskopichesky picture at R. of various genesis.
Idiopathic central serous retinopathy (synonym: idiopathic amotio of a makula, preretinalny hypostasis, the central angiospastic retinopathy, the central serous horiopatiya, the central serous retinitis) in a separate nosological form was allocated by Gus (J. D. M of Gass). The etiology of a disease is not found out.
Usually arises at somatic healthy faces aged from 20 up to 40 years, in the anamnesis at to-rykh emotional stresses and pristupoobrazny headaches of type are often noted migraines (see). Men are ill more often than women. As a rule, process happens unilateral and develops only in 5 — 10% of cases on both eyes. The symptomatology develops from metamorphopsias (see) in the form of a micropsia, positive scotomas (see) and decrease visual acuities (see). Improvement of visual acuity at correction by weak positive glasses is characteristic that matters for early diagnosis of a disease. The leading sign is serous amotio of a pigmental epithelium in a macular zone, edges of an oftalmoskopicheska the surrounding retina is defined in the form of the protrusion of more dark shade limited a round or oval form, than (tsvetn. fig. 4). The Fovealny reflex (a light strip around the central pole of a retina), as a rule, is absent. In nek-ry cases on a back surface of a retina grayish or yellowish precipitated calcium superphosphates can be visible.
For treatment use antiprostaglandinovy drugs (indometacin, Brufenum) and a lazerkoagulyation (see. Laser ).
The forecast favorable at timely treatment. At 80% of patients in 1 — 4 month from the beginning of a disease serous amotio of a retina can spontaneously disappear with recovery of visual acuity to initial level, however a small metamorphopsia, and sometimes and easing of color perception remains within several months.
Acute back multifocal pigmental epiteliopatiya it is for the first time described in 1968 by Gus. The etiology is not established. The disease is characterized by bystry development of disturbance of the central sight owing to emergence of the multiple outlined flat subretinal centers of grayish or white color. Extent of changes varies, defeat can be one - or bilateral. In field of vision (see) appear central or paracentral scotomas (see). During the period from several days to several weeks after the beginning of a disease involution of the centers is noted, at the same time multiple sites of a depigmentation and accumulation of a pigment come to light.
In half of cases opacification is noted vitreous (see), perivascular couplings in peripheral vessels of a retina, small expansion and crimpiness of her veins, hypostasis of a disk appear optic nerve (see); episclerites are sometimes observed (see. Sclerite ), iridocyclites (see).
Treatment includes use of vitamins, hormonal and the vasodilators, drugs increasing fabric oxygenation. Also apply hyperbaric oxygenation (see).
The forecast at development of complications adverse.
Outside exudative retinopathy (synonym: G. Coats's syndrome, G. Coats's disease, an outside exudative retinitis) it is described in 1908 by G. Coats. The etiology is not found out. Defeat is usually unilateral, appears at young age preferential at males.
The wedge, a picture is characterized by emergence of the white or yellowish exudate with indistinct edges which is localized under vessels of a retina and combined with adjournment of crystals of cholesterol and hemorrhages. Changes occupy the periphery of an eyeground and reach a paracentral zone. The macular zone (area of a macula lutea) is surprised seldom. In many cases reveal multiple anomalies of vessels in the form of micro and a macroaneurysm, arteriovenous shunts that is well visible at a fluorescent angiography of an eyeground. Wedge, current slow, chronic.
For treatment use the laser coagulation and hyperbaric oxygenation; in case of amotio of a retina — operation of circular impression — tsirklyazh (see. Amotio of a retina ).
Azotemic retinites meet at a hypertension, diseases of kidneys, toxicosis of pregnant women. M. L. Krasnov's classification, according to a cut of change only of vessels, having generally functional character gained distribution in assessment of the changes of an eyeground caused by hypertensia, qualify as a hypertensive angiopatiya of a retina; changes in vessels of organic character — as a hypertensive angiosclerosis of a retina; if tissue of a retina, an optic disk is involved in process, then it is hypertensive R., or a neuroretinopathy. In clinical practice data of an oftalmoskopichesky research use for diagnosis of stages idiopathic hypertensia (see).
Retinopathy at an idiopathic hypertensia. Three basic groups of an idiopathic hypertensia are allocated, at to-rykh corresponding changes on an eyeground develop: the idiopathic hypertensia with low figures of the ABP matching involutional arteriosclerosis; the idiopathic hypertensia which is beginning at early age and followed by a reactive sclerosis and a malignant form of an idiopathic hypertensia.
At an idiopathic hypertensia with an involutional sclerosis straightening and narrowing of arterioles of a retina (retinal arterioles) is observed. Perifovealnye of arterioles y (arterioles around the central pole) thin, at the same time the venules of an izvita corresponding to them are also expanded. It is considered that narrowing of arterioles happens in connection with increase in diastolic pressure. There is Salyus's symptom — the Hun (tsvetn. fig. 5). At further increase in the ABP there can be hemorrhages in a retina and a papilledema that indicates development of a phase of circulator insufficiency.
The idiopathic hypertensia at youthful age is shown by the generalized narrowing of arterioles of a retina and their local blanching connected with reduction of transparency of a vascular wall owing to what the vascular reflex gets a yellowish shade (a symptom of «a copper wire»). At considerable consolidation of walls the gleam of small vessels is narrowed, and the vessel takes a form of white silvery thread (a symptom of «a silver wire»).
In nek-ry cases, as well as at an idiopathic hypertensia with an involutional sclerosis, there can be hemorrhages, a papilledema, the centers of soft exudate.
The malignant form of an idiopathic hypertensia is characterized by widespread defeat of arterioles, in to-rykh hyperplastic and necrotic processes develop.
Vascular changes in a retina are shown in the form of extensive transudation, exudation and hemorrhages. Trombotichesky occlusion of small vessels causes development of the soft exudate forming a figure of «star» in a macular zone (tsvetn. fig. 6), edges not a patognomonichna for R. at an idiopathic hypertensia. It meets also at various infections and intoxications — measles, flu, an ugly face, helminthoses, etc. For similar cases Leber (Th. Leber, 1909) offered the term «pseudonephritic retinitis stellata» (a synonym a pseudoalbuminuric retinitis).
Treatment first of all is directed to a basic disease (see. Idiopathic hypertensia ). Apply also vasodilators, vitamins, anticoagulants, etc.; use a lazerkoagulyation and hyperbaric oxygenation.
Forecast serious. Sight can decrease, and sometimes comes blindness (see).
Prevention includes timely and adequate treatment of a basic disease.
Retinopathy at a disease of kidneys it is connected by hl. obr. with an albuminuria it is also described under the name «albuminuretic retinitis».
The acute glomerulonephritis can be followed by vasoconstriction of a retina. The small papilledema, the single centers of soft exudate and striate hemorrhages developing along with them are often noted. These symptoms can disappear at successful treatment of a basic disease.
Hron. the glomerulonephritis proceeding with increase in the ABP leads to changes in vascular system of a retina, similar changes at a malignant form of an idiopathic hypertensia.
Treatment is directed to a basic disease (see. Glomerulonephritis ). At increase in the ABP treatment same, as at R. caused by an idiopathic hypertensia (see above).
Forecast serious. The river at diseases of kidneys can lead to decrease in sight, sometimes — to a blindness. R.'s development is a bad predictive sign and for a basic disease.
Prevention consists in timely and successful treatment of a glomerulonephritis.
Retinopathy at toxicosis of pregnant women (synonym toksogravidarny retinopathy). At toxicoses of the pregnant women who are not followed by increase in the ABP, vascular changes on an eyeground most often are not found. At eclampsias (see) narrowing of arteries of a retina is noted, a cut can be either eurysynusic, or localized, in nek-ry cases with the developing obliteration. Sometimes there are an easy papilledema and hypostasis of a retina in the central area, and also the single centers of soft exudate and hemorrhage. Emergence of a symptom of Salyus — the Hun indicates development of organic changes in vessels. At toxicosis of pregnant women in a retina the same heavy changes can sometimes develop, as well as at a malignant form of an idiopathic hypertensia. In nek-ry cases subretinal exudate so big that leads to amotio of a retina (see), usually bilateral.
R.'s emergence in pregnant women is a bad predictive sign both for a fruit, and for mother and is the indication to immediate abortion. After abortion of change on an eyeground can disappear, narrowing of arterioles, zones of a depigmentation of a retina, sites of an atrophy of an idiovascular cover and accumulation of a pigment in a macular zone can be their outcome.
Diabetic retinopathy on average in 46 — 48% of cases is a complication of a diabetes mellitus and most often develops at its long current. In diabetic R.'s development allocate three stages. In the first stage note a phlebectasia of the first — the third order, emergence of microaneurysms. Possible expansion of the area of an avascular zone demonstrates already begun process of an obliteration of perifovealny capillaries. In the second stage there are centers of solid and soft (vatopodobny) exudate with rather small gekhmorragichesky activity (tsvetn. fig. 7). Similar changes meet most often. Existence of hypostasis of a macular zone, sometimes considerable is characteristic of the second (exudative) stage of a diabetic retinopathy. Thickness of a retina in a zone of hypostasis can increase by 4 — 5 times. Long existence of hypostasis leads to education micro or poppy-rokistoznoy of the dystrophy which is followed by permanent decrease in visual acuity. In some cases there are single or multiple hemorrhages in a retina. Vascular changes become more widespread. The caliber of veins uneven, occurs their segmented expansion, there are shunted vessels, couplings, reduplications, and also zones of focal ischemia.
The third (proliferative) stage of diabetic R. is characterized generally by neovascularization and formation of so-called glial fabric.
Proliferation of glial fabric, as a rule, proceeds odnovrekhmenno with neovascularization. More often the gliosis is defined in a zone of an optic disk or the main vascular trunks. Sometimes glial fabric in a macular zone forms a peculiar canopy on a back surface of a vitreous, causing considerable decrease in visual acuity at relative safety of a retina. In diabetic R.'s outcome there is a scarring and shift of a vitreous that with its simultaneous consolidation can cause a tension and amotio of a retina (see).
Treatment is coordinated with the endocrinologist. First of all apply a complex of the actions directed to treatment of a diabetes mellitus (see. diabetes mellitus ). The main method of treatment is the laser coagulation. Besides, sosudozashchitny drugs (Doxium, Dicynonum) are shown.
Diabetic R.'s forecast heavy. The disease in 16 — 18% of cases comes to an end blindness (see). Diabetic R. is in the developed countries of one of the main reasons for a blindness. E.g., in the third (proliferative) stage of diabetic R. the blindness comes in 50% of cases. There is an opinion that R.'s development defines the forecast for life at patients with a diabetes mellitus.
Prevention consists in timely and adequate treatment of a diabetes mellitus.
Retinopathies at diseases of blood develop at an Osler's disease, anemia, a leukosis, Valdenstrem's disease.
At true polycythemias (see) veins of a retina can be gyrose and have unusual dark red color that gives to an eyeground a cyanochroic look. Sometimes there are a vein thrombosis and a papilledema connected with a circulatory unefficiency in internal sleepy, vertebral or the main arteries. At a cerebral vasomotor spasm come to light hemianopsias (see).
At anemias (see) a reflex of an eyeground owing to decrease in a hemoglobin content becomes more pale, arteries and veins of a retina extend and sometimes the caliber and their coloring become identical. At considerable reduction in the amount of erythrocytes there are pale hemorrhages which are located in a nerve fiber layer, their extent depends on expressiveness of anemia. At defeat of deep capillaries of a retina there are deep hemorrhages of various form and the sizes, with white sites in the center — Roth's spots (tsvetn. fig. 8).
Ekstraretinalny hemorrhages can be or in own to a choroid of an eye (see), in the form of the brownish disk which is slightly raising a retina (hemorrhagic amotio of a pigmental epithelium) or in the form of the preretinalny hemorrhages which are localized between a retina and a vitreous, Such massive hemorrhages can bring to partial or full to a hemophthalmia (see). Retinal exudate can be firm or soft. Solid exudate in the field of a makula can lead to development of «a macular star». A rare complication is exudative amotio of a retina.
At leukosis (see) veins of a retina become gyrose, there can be generalized hypostasis сет^ chatka and a papilledema. Arise various type of hemorrhage, including and subretinal. Exudate can be various type, but is more often in the form of the small white points disseminated in the central area of an eyeground.
At Valdenstrem's disease (cm, Valdenstrema disease ), when quantitative relationship of blood proteins is broken and there is their qualitative change, disproteinemichesky and pas-raproteinempchesky Rubles develop. Expansion ретиналь^ ny veins, increase in their crimpiness is characteristic of them. Arteries also extend, but to a lesser extent. There are «a symptom of decussation», microaneurysms, occlusions of small veins, кровоиз^ a liyaniya in a retina. In nek-ry cases in a nerve fiber layer of a retina there are velvet-like centers, in the field of an optic disk — hypostasis. Believe that the specified changes of a retina are connected not roofing felt g to with a hyper paraproteinemia, but also high viscosity of blood. In nitrogen -» a michesky stage of a disease R. characteristic for hron, diseases of kidneys develops.
Treatment shall be having coordinated but with doctors of other specialties, is directed first of all to a basic disease. Also the vitamins, drugs increasing fabric oxygenation, la-zerkoagulyation at a polycythemia are shown — anticoagulants.
Traumatic retinopathy Purchera is described in 1912 by Purcherom (O. Purtscher). It develops at a sudden prelum of a thorax, at the moment to-rogo an arteriolospazm the hypoxia of a retina and an exit in it of transudate and blood is caused. In 1 — 2 day after an injury in a retina around an optic disk there are hemorrhages and milky-white, sometimes silver-white big spots. From complications cases of an atrophy are described optic nerve (see).
Treatment is carried out by the vitamins, vasodilators, drugs increasing fabric oxygenation, apply hyperbaric oxygenation.
The forecast serious — organic changes in a retina can lead to decrease in sight.
Berlinovsky opacification of a retina — the peculiar changes of a retina developing at a contusion of an eyeglobe. Berlin (R. Berlin) which described this R. considered that subchoroidal hemorrhage and hypostasis of deep layers of a retina is the cornerstone of opacification of a retina. According to Beck (S. Vayesk) and other researchers, opacification is connected by hl. obr. with the transudate appearing between a choroid and a retina. At an oftalmoskopiya emergence of whitish opacification on the periphery of a retina on the party of a contusion is characteristic, sometimes the same opacification appears on the opposite side of a retina, and less expressed — in a macular zone.
Treatment includes use of vitamins, the drugs increasing fabric oxygenation, hyperbaric oxygenation.
Bibliography: See bibliogr. to St. Retinitis .
L. A. Katsnelson.