What exactly happens inside the eye
The retina is a thin nervous tissue that lines the inside of the eye, like a film on the inner wall of a ball. It is not attached to the wall along its entire length, but is pressed against it by the pressure of the intraocular fluid and the vitreous body, tightly fixed along only a few lines. Under the retina lies the pigment epithelium, and below it is the choroid, from which the outer layers of the retina receive oxygen and nutrition. When fluid gets between the retina and the pigment epithelium, the membrane moves away from the wall, loses access to nutrition and stops working. What a person sees in this place is not darkness, but rather the absence of an image—as if part of the picture had been erased.
The mechanism in the vast majority of cases is as follows: first, a gap appears in the retina, often in the periphery. Through it, the intraocular fluid flows under the membrane and begins to peel it off, like water peeling wallpaper off a wall. While the gap is small and fluid has not yet gone under the retina, the problem is solved in one laser session in the clinic. As soon as the fluid has flowed in, we are talking about a surgical operation. The difference between the two situations can be several days, which is why outbreaks and sudden showers of flies are a reason to inspect today rather than on a convenient day.
- Rhegmatogenous detachment is the most common and begins with a retinal tear
- Traction - the vitreous body or scar cords pull on the retina and tear it off; typical for advanced diabetic retinopathy
- Exudative - fluid accumulates under the retina due to inflammation, tumor or vascular pathology, but there is no rupture
- Local detachment - a limited area of the periphery is affected, vision may remain high
- Total - the entire retina is detached, vision drops to the perception of light
Why it doesn't hurt - and why people lose an eye because of it
There are no pain receptors in the retina. At all. Therefore, detachment develops absolutely painlessly: the eye looks calm, the white does not turn red, there is no lacrimation, no photophobia, no sensation of a foreign body. A person is accustomed to the fact that a serious problem announces itself through pain, and the absence of pain is perceived as proof that nothing terrible is happening. Often the symptom is explained by fatigue, blood pressure, cervical osteochondrosis or overwork at work and they decide to observe.
- Flashes, lightning, sparks in the dark - the vitreous body pulls on the retina, and it responds to mechanical irritation with a light signal
- A sudden shower of black dots, “soot”, “cobwebs”, “swarm of midges” - often means blood or pigment entering the vitreous during a rupture
- A dark shadow or curtain on one side, which increases over hours and days, is already a detachment
- Loss of a sector of the visual field, most often noticed when closing the second eye
- Curvature of straight lines and loss of central vision - fluid has reached the macula
- The feeling that the “field of vision has narrowed”, the orientation from the side has worsened
A separate trap is the second, healthy eye. It compensates for the lost area so successfully that a person may not notice a serious detachment in one eye for a week and discover it by accident by rubbing the other eye or closing it in the shower. That's why the simple habit of once a month taking turns closing your eyes and looking at straight lines - a window frame, a doorway, a tile grout - is worth more than it seems. This check takes ten seconds, but it discovers something that is basically invisible with both eyes.
Who's at risk
Retinal detachment rarely occurs in a completely healthy eye without any prerequisites. There is almost always a background that a person either knows about or could have known about during a normal examination with a dilated pupil. The largest risk group is myopic people, and the connection here is mechanical: with myopia, the eyeball is elongated, and the retina is stretched over a larger surface and therefore thinned, especially in the periphery. The higher the degree of myopia, the greater the risk.
- Myopia, especially medium and high myopia, is a major factor; the risk increases several times compared to a normal eye
- Peripheral retinal dystrophies, primarily latticework, are areas of thinning where a tear easily occurs
- Previous cataract surgery, especially complicated
- Eye trauma, including blunt trauma without visible damage, and head contusion
- Retinal detachment in the second eye or in blood relatives
- Age over 50 years - due to age-related vitreous detachment
- Diabetic retinopathy in an advanced stage - traction mechanism
- Heavy physical activity with straining, jumping, diving, boxing and other contact sports with existing dystrophies
Examination: what to do if there is suspicion
- Проверка остроты зрения и полей зрения — определяют, есть ли выпадение и затронут ли центр.
- Осмотр глазного дна с расширенным зрачком — main метод. Периферию, где обычно и находится разрыв, невозможно увидеть без расширения зрачка, поэтому отказ от капель делает осмотр бессмысленным.
- Осмотр с линзой Гольдмана или налобным офтальмоскопом со склерокомпрессией — позволяет заглянуть на крайнюю периферию сетчатки.
- Ультразвуковое исследование глаза — незаменимо, когда кровоизлияние в стекловидное тело не даёт рассмотреть сетчатку.
- Оптическая когерентная томография — уточняет, вовлечена ли макула, и в каком она состоянии.
- Измерение внутриглазного давления: при отслойке оно нередко снижено по сравнению со вторым глазом.
- Фотографирование глазного дна для документирования площади отслойки и последующего контроля.
- Обязательный осмотр второго глаза — примерно у каждого десятого пациента там находят разрывы или опасные дистрофии без всяких жалоб.
Treatment: from laser to vitrectomy
The tactics depend on what stage the process is at, and the difference between the options is huge - from an outpatient procedure to abdominal surgery with a long recovery.
- Laser coagulation is used when there is a rupture or dangerous dystrophy, but there is no detachment yet. The laser creates a chain of micro-cauterizations around the defect, which in 10-14 days turn into strong adhesions and prevent fluid from going under the retina. The procedure is outpatient, takes minutes, and hospitalization is not required.
- Pneumoretinopexy - a gas bubble is injected into the eye, which presses the retina from the inside; Suitable for small detachments of a certain location and requires strict head position.
- Episcleral filling - a silicone filling is sutured to the outside of the sclera, which slightly presses the wall of the eye and brings it closer to the detached retina; often chosen in younger patients.
- Vitrectomy - the vitreous body is removed through micropunctures, the retina is straightened, the tears are treated with a laser and the cavity is filled with gas or silicone oil.
- Gas tamponade resolves on its own within a few weeks; Silicone oil is removed in a separate operation after several months.
- After an operation with gas tamponade, a forced position of the head is required, sometimes face down, for several hours a day - the result directly depends on this.
It’s worth talking about the timing directly, without softening it up. As long as the center of the retina is not involved, the operation is considered urgent and is performed within the next few hours or days - the goal is to prevent the fluid from reaching the macula. If the center has already peeled off, the urgency is formally reduced, but delaying still worsens the outcome: the longer the photoreceptors of the center are deprived of power, the fewer of them will be restored. Retinal reattachment after the first operation can be achieved in most cases, but some patients require repeated intervention due to scarring. It is important to understand the other side: anatomical success, that is, a reattached retina, does not equal complete return of vision - it depends on how many cells survived the period of detachment.
What to do right now if symptoms appear
- Закройте по очереди один и другой глаз и посмотрите, нет ли выпадения участка поля зрения. Двумя глазами дефект не виден.
- Не ждите утра, выходных и «пока само пройдёт»: при тени в поле зрения обращаться нужно в тот же день, в дежурное офтальмологическое отделение.
- Не садитесь за руль сами — и потому, что поле зрения нарушено, и потому, что после осмотра зрачок будет расширен.
- Ограничьте физическую нагрузку, наклоны, подъём тяжестей и резкие движения головой до осмотра.
- Не закапывайте сосудосуживающие капли и не грейте глаз — это не поможет, а время будет потеряно.
- Возьмите с собой очки, старые рецепты и выписки о перенесённых операциях на глазах.
- Если врач нашёл разрыв и предложил лазер — соглашайтесь сразу: это несопоставимо проще операции, к которой приведёт отсрочка.
- После лечения обязательно приходите на контрольные осмотры, включая осмотр второго глаза.
