LECTURE No. 20. Pathologies of the fundus (part I)

1. General diagnostic questions

If patients complain of deterioration in visual acuity, changes in peripheral vision, loss in visual fields (scotomas), blurred vision at dusk (hemeralopia, or night blindness), impaired color perception, then pathology of the retina can be assumed.

When clarifying the data on the picture of the fundus in children and adults, it should be borne in mind that in newborns the fundus is light, the optic nerve head is grayish-pink, its boundaries are not entirely clear, there may be pigment deposits at the optic nerve head, the macular reflex is absent, the ratio the caliber of arteries and veins is 1:2.

In pathological conditions of the retina, due to various reasons, a variety of changes can be observed in the fundus:

1) edema and retinal detachment;

2) clouding and ischemia;

3) atrophic foci;

4) tumor formations;

5) change in the caliber of vessels;

6) preretinal, retinal and subretinal hemorrhages.

To judge the location in the retina of foci of hemorrhages, one should be guided by their shape, size, color, location in relation to the vessels of the retina.

The lesions located in the layer of nerve fibers have the appearance of streaks or an oblong (linear) shape. In the area of ​​the macula, in the layer of Henle, the lesions are located radially, form a “star” pattern, and have a yellowish-white color. In the middle layers of the retina, lesions are round or irregular in shape and have a yellowish or bluish tint. If the lesion is located in such a way that it covers the retinal vessels, then it is located in the inner layer of the retina. In cases where the lesion is located behind the retinal vessels, it is located in the middle or outer layers of it.

The presence of pigment in the focus speaks in favor of damage to the neuroepithelial layer and choroid. The defeat of the inner layers of the retina is accompanied by swelling of the optic disc, its hyperemia. At the same time, the disk tissue is opaque, its borders are blurred, the retina in the peripapillary zone is opaque.

Retinal hemorrhages have the form of lines, strokes located radially around the optic nerve head. Larger hemorrhages are triangular in shape with the apex facing the optic nerve head.

Point hemorrhages of a rounded and oval shape are located in the middle and outer layers of the retina. Hemorrhages in the region of the optic disc or in the area of ​​the macula, which are ovoid, dark in color, or bowl-shaped with a dark lower half and a lighter upper layer, are characteristic of preretinal localization. Subretinal hemorrhages have the appearance of a blurry red spot behind the retinal vessels.

The ischemic retina is dull white, without a sharp border. The edematous retina looks dull, cloudy, the retinal vessels are not clearly visible. For a detailed examination of the fundus, patients should dilate the pupils with mydriatics.

2. Pigmentary degeneration (degeneration) of the retina (retinitis pigmentosa)

From the anamnesis of patients with retinitis pigmentosa, characteristic complaints of poor vision at dusk are revealed. Objectively determined concentric narrowing of the field of view, impaired dark adaptation. The optic disc is waxy, the retinal vessels, especially the arteries, are constricted. On the periphery of the fundus, there is an accumulation of pigment in the form of "bone bodies". The field of view gradually narrows to a tubular one, the process always ends in blindness due to the death of photoreceptors and atrophy of the optic nerve. The disease is often bilateral and may present in early childhood; in half of the cases is hereditary. The presence of non-pigmented foci in the fundus is characteristic of non-pigmented retinal degeneration. Functional disorders in patients are the same as in retinitis pigmentosa.

3. Macular degeneration of the retina (degeneratio maculae luteae)

Patients complain of a decrease in visual acuity, they note that they are better oriented in the evening than in the afternoon. With ophthalmoscopy in the area of ​​the macula, pigmented and yellowish dotted foci, blanching of the optic nerve head from the temporal side are determined. When examining the visual field, a relative central scotoma is determined, as well as a violation of color perception for red and green colors.

The disease is bilateral and often has a family-hereditary nature.

4. Macular Degeneration in Tay Sachs Disease

This systemic disease, which is detected in children four to six months old, is manifested by mental retardation, seizures, muscle weakness due to fatty degeneration of ganglion cells of the retina and brain. In the area of ​​the macula in such children, a degenerative white lesion with a bright red round spot in the center is detected. The child, as a rule, goes blind and dies before reaching the age of two.

Treatment. Due to the fact that the etiological factors in the development of retinal dystrophies are not yet known, treatment is aimed at improving retinal trophism. It consists mainly in the appointment of vasodilators, vitamins of groups B, A, E, C, PP, intermidin, pilocarpine, cysteine, heparin, glucose, etc.

5. Retrolental fibroplasia

Every premature newborn, especially if he was in an oxygen tent, should be examined by an optometrist. These children may develop retrolental fibroplasia of retinopathy of prematurity.

It occurs in both eyes of children in incubators already in the second to fifth week after birth.

There are three periods of the course of the disease. The first period (the acute phase lasting from three to five months) is characterized by the presence of retinal edema, vasodilation, and gentle diffuse opacification of the vitreous body on the periphery of the fundus.

The second period (regression period) is characterized by the spread of newly formed vessels with their supporting tissue from the area of ​​retinal changes into the vitreous body, the appearance of hemorrhages, and retinal detachment.

In the third period (scar phase), a significant mass of opaque tissue and foci of proliferation are detected in the vitreous body, covering most of the retina. Fibrous masses gradually fill the entire vitreous body up to the lens. The anterior chamber becomes shallow, posterior synechiae appear due to developing iridocyclitis, then complicated cataracts, secondary glaucoma, and microphthalmos occur.

Often eye changes are accompanied by microcephaly, hydrocephalus, tissue hypoplasia of the hemispheres, cerebellum, leading to mental retardation.

Symptomatic treatment: absorbable therapy, corticosteroids.

6. External exudative hemorrhagic retinitis, or Coates' disease (retinitis exsudativa haemorrhagica externa)

The disease is characterized by varicose veins in the central zone of the fundus. Exudative and hemorrhagic foci of white, gray or yellowish (golden) color with fuzzy contours, bumpy or smooth surface are found near the optic nerve head. The retina prominates in these places.

The vessels “climb” onto the lesions, make bends, form loops, aneurysms, resembling the picture of angiomatosis. Exudation can be so pronounced that it appears as if there is a retinal detachment, as in retinoblastoma. Exudate accumulates between the choroid and the retina and penetrates the vitreous body. The fundus becomes poorly visible due to exudate and repeated hemorrhages. Gradually, the vitreous body takes on the appearance of a homogeneous grayish mass with hemorrhagic inclusions. Over time, the exudate is replaced by connective tissue, powerful moorings are formed that extend from the retina into the vitreous body and lead to retinal detachment. Gradually, starting from the posterior sections, the lens becomes cloudy. Visual functions decrease depending on the severity of the process. In the later stages, when there is retinal detachment, diaphanoscopy, radioisotope studies and echography help to exclude retinoblastoma.

Treatment. The etiology of the disease is not yet known, so treatment is usually ineffective. Given the similarity of the process with retinal tuberculosis, specific anti-tuberculosis therapy is often used in combination with non-specific anti-inflammatory and resolving agents (corticosteroids and enzymes).

7. Acute obstruction of the central retinal artery (embolia s. thrombosis arteriae centralis retinae)

Patients complain of a sudden sharp deterioration in vision, a typical picture is determined in the fundus: against the background of an ischemic milky-white retina, the central fovea stands out in the form of a cherry-red spot (the “cherry pit” symptom), the arteries are sharply narrowed, intermittency of blood flow is determined in narrow retinal arteries. Gradually, the optic disc becomes pale and atrophies, and the patient becomes blind.

In children, embolism is rare, but sometimes spasm or embolism occurs in the presence of autonomic vascular disorders or rheumatic endocarditis. In adults, the causes of embolism are hypertension, rheumatism, endarteritis.

8. Thrombosis of the central retinal vein (thrombosis venae centralis retinae)

The disease develops more often in older people on the basis of sclerotic changes, vascular changes in hypertension, in children with blood diseases.

Patients complain of a rapid decrease in vision in one eye, the appearance of fiery flashes, fog before the eyes. The picture of the fundus: the optic disc and retina are edematous, the size of the disc is enlarged, it is red, protrudes into the vitreous body, the vessels are lost in the edematous tissue, the veins are dilated, tortuous, reminiscent of leeches. Throughout the fundus of the eye, especially in the area of ​​the disk, there are various sizes and forms of hemorrhage.

Treatment of acute obstruction of the central retinal artery, as well as thrombosis of the central retinal vein: therapy of the main suffering, the appointment of heparin, fibrinolysin, antispasmodics and vasodilators, and later absorbable drugs, physiotherapy. For the prevention of secondary glaucoma with thrombosis of the central retinal vein, instillations of pilocarpine are indicated.

Author: Shilnikov L.V.

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