A detachment of the retina ( retinal detachment, retinal detachment ) refers to the separation of the inner portions of the retina ( neurosensory retina ) of the eye from its supply layer, the retinal pigment epithelium ( pars pigmentosa, RPE ). It represents an ophthalmological emergency. In most cases there is a progression in the direction of the visual center ( macula ), which increases the extent of the necessary intervention and radically worsens the prognosis of the final visual acuity that can be obtained when the visual center is reached.
Myopic people are especially predisposed to retinal detachment . The probability of occurrence ( incidence ) of retinal detachment in non-operated myopic eyes in the general population is given in large studies as 0.71% to 3.2% and increases to over 100-fold in eyes with extremely high myopia over −15 diopters (Dpt) especially in the age group between 20 and 40 years of age. For a long time, the LASIK operation was also assumed to have an increased risk of retinal detachment due to mechanistic considerations because of the application of the suction ring to guide the keratoma. A study of over 12,000 eyes that had been operated on for myopia of up to −10 Dpt, however, showed an astonishingly low rate of retinal detachment. The incidence was 0.05% (11 / 22.296) in the first year, 0.15% (18 / 11.371) after five years, and 0.19% (22 / 11.594) ten years after LASIK surgery. Possibly the fact that LASIK candidates are more closely examined and educated for the risk of retinal detachment than the general population is the explanation for this phenomenon.
Origin and forms
The neuroretina normally rests directly on the pigment epithelium, but is only firmly connected to the optic nerve head ( papilla nervi optici, papilla ) and its outermost periphery behind the iris. In addition, the close contact is maintained through active pumping of the pigment epithelium and the interlocking of the rods and cones with the pigment epithelial cells. The intact neuroretina is sucked in by the pigment epithelium.
Retinal detachment caused by cracks ( Rhegmatogene amotio retinae )
Tensile forces from attachment points of the vitreous body to the neuroretina can lead to cracks. These cracks allow fluid to penetrate between the neuroretina and pigment epithelium and thus lead to a local breakdown of the suction between the two layers. A local detachment of the retina occurs, which can expand over the entire retinal surface within hours due to further inflow of fluid.
Retinal detachment caused by tension ( tractive amotio retinae )
Various diseases such as: B. the diabetic retinopathy develop connective tissue membranes. These membranes are firmly attached to the retina at some points. They tend to shrink and pull the retina from its base like a tent.
Retinal detachment caused by the accumulation of fluid ( serous amotio retinae )
With damage to the retinal vessels z. B. in the context of an inflammation and a restriction of the pumping function of the pigment epithelium, fluid can accumulate under the neuroretina, which causes the retina to lift off ( serous amotio retinae or retinopathia centralis serosa ). Such an accumulation of fluid, which leads to the detachment of the retina, can also be congenital (for example Coats disease ).
Retinal detachment caused by tumors
A tumor under the retina can also cause retinal detachment due to its mass and an accompanying serous amotio.
Retinal detachment caused by pressure waves
Frequent use of firearms with ammunition of larger caliber (e.g. .50 BMG ) and with muzzle brakes can lead to gradual, selective retinal detachment. The combustion gases of the propellant charge, which are deflected backwards towards the shooter, generate pressure waves in the eyeball, which accordingly pre-damage the retina.
Symptoms of rhegmatogenic amotio, in particular, are the seeing of flashes ( photopsia ) as a result of the vitreous tract, the sudden appearance of dense black or red spots in the visual field ( soot rain ) as a result of bleeding associated with the retinal tear, and curtain-like and bar-like visual field restrictions if the retinal detachment has reached greater proportions. Retinal detachment is one of the most important emergency situations in ophthalmology, as it usually leads to blindness if left untreated. Detected early and treated quickly with argon laser therapy, cryocoagulation or indenting sealing operations, the eyesight can usually always be saved. The first self-help measure is to avoid head movements and rest until fundoscopy or ultrasound of the eye has allowed a clear diagnosis.
However, the detachment can also take place completely without symptoms and only become visible when the macula is reached, for example through a distorted display ( metamorphopsia ), comparable to a defect in a glass.
If the retina with its nerve cells and photoreceptors is no longer supplied through contact with the pigment epithelium, depending on the duration, an irreparable loss of function (blindness) of the affected retinal areas can occur. After reinvestment, improvement can occur over weeks or months.
If a complete retinal detachment persists, there is a long-term risk of painful shrinkage of the eyeball ( phthisis bulbi ) and thus loss of the eye.
Retinal detachment is usually treated surgically. The procedure depends on its cause, location and extent. In particular, causes (holes, tractions, etc.) in the lower hemisphere of the eye often require surgical treatment with silicone oil tamponades, because due to the floating properties of the gases, but also of individual silicone oils, it is often not possible to achieve adequate retinal contact and hole sealing in the lower parts.
By introducing a gas mixture with components such as perfluoroethane , perfluorpropane , octafluoropropane , sulfur hexafluoride or nitrogen into the inside of the eyeball (globe) and holding the head accordingly, the detached retina can be reattached to the pigment epithelium. The gas is absorbed after a few weeks. Pneumatic retinopexy is always combined with cryopexy and / or laser treatment.
In the case of a localized, not too large detachment, a laser can be used, which can stop the progression. The assumption that the retina can be welded onto the supply layer with the laser is widespread, but incorrect insofar as the therapeutic effect does not occur immediately. The laser effect creates scars in the area that has not yet been lifted off, and after about five days they firmly connect the neuroretina and pigment epithelium. The Swiss ophthalmologist Jules Gonin used a similar principle as early as 1927 when he applied cautery to treat retinal detachment.
Surgical treatment using a seal, cerclage and vitrectomy (removal of vitreous humor)
Surgical measures to reattach the retina aim to close the retinal detachment and relax the vitreous body. This can be achieved, for example, by sewing on specially shaped plastic cushions ( seals ) or by looping around the globe with flexible silicone bands or tubes ( hump surgery ) on the outside of the eyeball, which press it in so that contact between the pigment epithelium and the neuroretina is restored and the vitreous humor is counteracted ("indenting operation"). With the improvement in the surgical technique of vitrectomy , however, (supplementary) interventions are increasingly being carried out from the inside of the eyeball. The glass body and tractive (see above) membranes are removed as completely as possible and the hole is closed by tamponing gases or liquids. However, especially in young patients with a (still) clear eye lens, attempts are often made to achieve success without vitreous body surgery, since all tamponades lead to significantly accelerated lens opacity (cataract).
If the tear is too large or too far in the periphery of the eye, it can be treated with cryosurgical intervention. In this procedure, a cold stick is placed on the outside of the eye while the effect on the retina is observed through the pupil. The procedure takes about 20 minutes.
Further treatment approaches
In the case of serous amotio, the underlying inflammation is treated, if possible. In the case of tumor-related amotio, treatment is usually initially directed at the tumor.
In particular, people with risk factors for retinal detachment, e.g. B. with high myopia, poorly controlled diabetes, retinal detachment in the other eye or with familial occurrence of the disease, your retina should be examined regularly by the ophthalmologist for weak points. The routine examination of the retina of premature infants in the first weeks of life is intended to reveal early stages of premature retinopathy , which, if left untreated, leads to retinal detachment. The cryopexy is to reduce a measure of cold application in connection with surgical procedures other retinal damage, reduce the risk of accidental detachment of the retina.
- JF Arevalo, AF Lasave, F. Torres, E. Suarez: Rhegmatogenous retinal detachment after LASIK for myopia of up to -10 diopters: 10 years of follow-up . In: Graefes Arch Clin Exp Ophthalmol . tape 250 , no. 7 , 2012, p. 963-970 .
- Franz Grehn: Ophthalmology . 30th, revised and updated edition. Springer, Heidelberg 2008, ISBN 978-3-540-75264-6 , pp. 210-211 .
- Franz Grehn: Ophthalmology . 30th, revised and updated edition. Springer, Heidelberg 2008, ISBN 978-3-540-75264-6 , pp. 212-213 .
- Franz Grehn: Ophthalmology . 30th, revised and updated edition. Springer, Heidelberg 2008, ISBN 978-3-540-75264-6 , pp. 215-216 .
- Nicolas Feltgen, Peter Walter: Retinal detachment caused by cracks - an ophthalmological emergency , Deutsches Ärzteblatt Int 2014; 111 (1-2): 12-22; doi: 10.3238 / arztebl.2014.0012 .
- Retina / Vitreous - Surgical Treatment Methods ( Memento of the original from July 25, 2010 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. . Website of the Teufen Eye Clinic. Retrieved July 24, 2010.
- Barbara I. Tshisuaka: Gonin, Jules. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , p. 502.