Retinal Detachment.docx

Retinal Detachment视网膜脱离Caryn Plummer, DVM, DACVO, University of FloridaJANUARY 2016 OPHTHALMOLOGY PEER REVIEWED Retinal detachments (RDs) may develop secondary to a variety of systemic and/or local (ocular) conditions.视网膜脱落(RDs)可能继发于多种系统性和/或局部性(眼部)疾病。Two Types of Retinal DetachmentsComplete: The entire retina becomes detachedPartial: A portion of the retina remains attached in its normal anatomic location while another section has detached视网膜脱落的两种类型完全型：整个视网膜完全脱落部分型：部分视网膜还在正常位置，其他部分脱落In the normal state, the retina sits directly adjacent to the concave contour of the posterior globe to receive oxygen and nutrients from the choroid, with which it is intimately associated. When the retina detaches, it floats anteriorly within the vitreal chamber and is evident as a thin grey veil with visible vasculature (Figures 1 and 2).正常情况下，视网膜位置是在眼球后方的凹痕里，同时从脉络膜那里获得氧气和养分。当视网膜分离时,它漂浮在玻璃体腔的前面，外观为表面可见血管的灰色薄纱（图1和图2）。Figure 1. External photograph of a terrier dog with RD. The retinal vessels are visible even from a distance, indicating that the retina has detached and come anteriorly within the vitreal chamber.图1.视网膜脱落患犬的照片。从远处也能看到视网膜血管,这表明视网膜已经脱落并位于玻璃体腔的前部。Retinal detachment may be unilateral or bilateral. If the cause is related to a systemic condition or a congenital or inherited ocular condition, both eyes are likely to be affected to some degree, although perhaps asymmetrically or sequentially. Local disease, such as unilateral trauma, cataract, or intraocular neoplasia, will typically only result in detachment in the affected eye.视网膜脱落可能是单侧或双侧。如果病因与全身情况或先天性或遗传性的眼部疾病有关,两只眼睛可能在某种程度上都受到影响,尽管可能不对称或先后性的。局部疾病,如单侧外伤、白内障或眼内肿瘤,通常只会导致病眼的视网膜脱落。Figure 2. Bullous RD in cats secondary to systemic hypertension. Note the vessels are in different planes of focus. A focal intraretinal hemorrhage is present (A). Images were obtained without use of an ophthalmoscopy lens.图2.继发于系统性高血压的猫大泡性视网膜脱落。注意不同焦距下平面中的血管。图2A展示了局部性视网膜内出血。以上图像是在未使用检眼镜检查情况下拍摄。Clinical Signs临床症状RD is usually associated with mydriasis and incomplete or absent pupillary light reflexes. If a detachment is complete, the affected eye will be blind. Some sight may be retained with partial detachment. Accompanying uveitis or intraocular hemorrhage may also be present, particularly if the underlying cause is vascular (eg, systemic hypertension) or traumatic.视网膜脱落通常与瞳孔放大和瞳孔对光反射不完整或缺失有关。如果是视网膜完全脱落，病眼将失明。部分脱落可能保留部分视力。伴发的葡萄膜炎或眼内出血也可能存在,特别是根本病因是血管性(如系统性高血压)或创伤性。Diagnosis诊断Diagnosis of RD is made during a thorough ophthalmic examination that includes either direct or indirect ophthalmoscopy. RD will appear either as a thin grey veil of tissue with visible blood vessels or as a hyporeflective section of the fundus with indistinct or fuzzy margins on ophthalmoscopy. Retinal blood vessels may be observed in different planes of focus depending on how far forward they have been displaced (Figure 3). 视网膜脱落诊断由全面的眼科检查确定,包括直接或间接的检眼镜检查。视网膜脱落要么是呈现为可见血管的灰色薄纱状组织，或是检眼镜检查时边界模糊、反射性低的一段眼底。根据其脱落后前进的位置，视网膜血管可以在不同平面观察到(图3)。Figure 3. Photograph of the fundus of a dog utilizing a condensing lens for indirect ophthalmoscopy. RD and intra- and subretinal hemorrhage are demonstrated. Note the different planes of focus, the indistinct margins of blood vessels, and the prominent dorsal and ventral partial detachments. These conditions were secondary to acute kidney disease and systemic hypertension in this patient.图3.聚光透镜间接检眼镜检查时的犬眼底图片。图像表明有视网膜脱落和视网膜内及视网膜下出血。注意不同焦距下,血管的模糊边缘,以及背侧和腹侧显著的部分脱落。以上症状是继发于急性肾病和系统性高血压。Ocular ultrasonography is necessary if the posterior segment of the eye cannot be visualized because of corneal opacity, debris in the anterior chamber associated with uveitis, or cataract; ultrasonography may show a thin, linear hyperechoic structure protruding into the vitreal chamber. Most commonly, the retina will remain attached at the optic nerve and ora ciliaris retinae, which is where the ciliary body transitions into choroid and the peripheral retina begins (Figure 4). This will cause a gullwing appearance, or “seagull” sign, on ultrasonography, but partial detachments or disinsertions (tearing of the retina in addition to detachment) will not show the classic seagull sign.如果有角膜混浊，眼前房充满与葡萄膜炎或白内障有关的碎片，导致无法看到眼后段，那么超声则是有必要的。超声可能显示出一个薄的、线状的高回声结构突入玻璃体腔。最常见,视网膜仍然附着于视神经和网膜睫缘，这是睫状体转换到脉络膜和周边视网膜开始的位置(图4)。超声图像上为海鸥翼的外观（即海鸥征），但视网膜部分脱落或锯齿缘离断(视网膜除了脱落还有撕裂)不会显示典型的海鸥征。Figure 4. Ultrasonographic image of an eye, with the cornea oriented to the top of the image. The anterior chamber is filled with hyperechoic material, consistent with hemorrhage and fibrin (white arrow) that were evident on examination. The retina is detached (arrowheads) and is forming the classic seagull sign; 2 hyperechoic linear structures representing the retina (arrowheads) within the vitreal chamber, attached at the ora ciliaris retinae (blue arrow) and the optic nerve (red arrow).图4.眼超声图像,角膜面向图像顶部。前房充满了强回声物质,符合出血，纤维蛋白(白色箭头)很明显。视网膜脱落(三角形箭头)并形成典型的海鸥征;强回声的线性结构代表视网膜（三角箭头）位于玻璃体腔内,附着于视网膜睫状体缘(蓝色箭头)和视神经(红色箭头)。When a patient has acute vision loss and RD, investigation of the underlying cause should include measurement of systolic blood pressure, a complete physical examination, and a minimum database consisting of a CBC, serum chemistry panel, and urinalysis. RD may result from panuveitis secondary to infectious diseases (including fungal, bacterial or rickettsial causes), trauma, neoplasia (ocular or systemic), congenital ocular diseases (eg, Collie eye anomaly), or cataracts. 遇到急性视力损失和视网膜脱落的病例,根本病因的调查应该包括测量收缩压,完整体格检查,和含有血常规、血生化、尿检的实验室检查。视网膜脱落可能源于继发于传染病(包括真菌、细菌、立克次体)的全葡萄膜炎、创伤、肿瘤(眼部或全身性)、先天性眼疾病(例如柯利犬眼部异常)或白内障。Treatment治疗Treatment depends on the cause of RD. If the RD is a result of systemic hypertension, prompt therapy with systemic antihypertensive agents (eg, calcium channel blockers, angiotensinconverting enzyme ACE inhibitors) is indicated. As blood pressure normalizes, the retina will often return to its normal or near-normal anatomic position.治疗取决于视网膜脱落的原因。如果视网膜脱落是系统性高血压的结果,提示及时使用全身性抗高血压药物(如钙通道阻滞剂,心血管紧张素转化酶(ACE)抑制剂)。血压正常化后,视网膜往往返回正常或接近于正常的解剖位置。If detachment is secondary to an inflammatory or autoimmune condition, treatment of the primary problem and the associated inflammation (typically systemic corticosteroids) may affect improvement. RD associated with primary ocular disease (congenital anomalies such as retinal dysplasia or lenticular disease such as cataract) may be difficult to treat; referral to a veterinary ophthalmologist for evaluation for reattachment surgery may be indicated.如果脱落继发于炎症或自身免疫状况,治疗原发病和相关炎症(通常是全身用皮质类固醇)可能有疗效。原发性眼病(先天性畸形如视网膜发育异常或晶状体病如白内障)相关的视网膜脱落可能很难治疗,建议转诊给兽医眼科医生进行视网膜复位术。Prognosis预后The prognosis for regaining vision following retinal detachment is usually guarded- to-poor. If the RD is caused by systemic hypertension that is corrected promptly, reattachment may occur and vision may be restored. However, if the detachment is chronic or has been associated with extensive retinal or intraocular inflammation, return of sight is unlikely. Retinal degeneration is a common sequela to RD even if physical reattachment occurs (Figure 5). 视网膜脱落后的视力恢复预后通常谨慎或不良。如果脱落由系统性高血压引起,及时纠正后,视网膜可能复位和视力也可以恢复。然而,如果脱落是慢性或与广泛视网膜或眼内炎症有关,恢复视力是不太可能的。视网膜变性是一种常见的视网膜脱落后遗症，即使视网膜已经复位(图5)