Myopic staphyloma. Myopic cone and staphyloma - causes and treatment Staphyloma of the optic disc

23-02-2014, 22:44

Description

Clinical classification of myopia

When examining a patient with myopia, the doctor must, first of all, evaluate it for a number of clinical signs that can help to correctly predict the course of the disease and develop adequate treatment tactics. For the convenience of practical ophthalmologists, Professor E.S. Avetisov proposed using a clinical classification of myopia. It includes assessing the condition of the eyes according to a number of parameters:

• By degree of myopia:

1. weak 0,5-3,0 diopter;
2. average 3,25-6,0 diopter;
3. high 6,25 diopters and higher.

• According to the equality of the refraction of the two eyes:

1. isotropic;
2. anisometropic.

• Based on the presence of astigmatism:

1. without astigmatism;
2. with astigmatism.

• By time of occurrence:

1. congenital;
2. early acquired (in preschool age);
3. acquired at school age;
4. late acquired (in adulthood).

• With the flow:

1. stationary;
2. slowly progressive (less 1,0 diopters per year);
3. rapidly progressing ( 1,0 diopters or more per year).

• According to the presence of complications:

1. uncomplicated;
2. complicated.

Complicated myopia is divided according to the form and stage of the process.

• By form:

1. chorioretinal (periodiscal, macular dry and wet, peripheral, widespread)
2. vitreal;
3. hemorrhagic;
4. mixed.

• According to the stage of morphological changes:

1. initial (myopic sickle to 1/3 disk diameter (DD);
2. developed (cone up to 1 DD, macular pigmentation, fundus depigmentation);
3. far advanced (myopic staphyloma around the optic disc or a cone of more than 1 DD, disc pallor, severe depigmentation of the fundus, mottling of the macula, atrophic foci in other parts of the fundus).

• According to the stage of functional changes - visual acuity:

1. 0,8-0,5; -0,4-0,2; -0,1-0,05;
2. 0,04 and below.

The indication for treatment of uncomplicated myopia, as a rule, is its progressive nature. Therefore, in this chapter we will focus mainly on the symptoms that accompany myopic people throughout their lives, and those that appear in them during the period of increased refraction of the eyes.

A study of the medical history of patients with myopia indicates a sharp “rejuvenation” of this process that has occurred in recent years. 5-10 years. If before, myopia in most children (90%) debuted at the age 10 years and older, now more and more often we see children in whom it first appeared in 5-7 - summer age. In these cases, myopia, left without treatment, develops very rapidly, increasing by 1,5-2,0 diopters per year.

It is obvious that such patients are at risk of complicated myopia with an invapidizing course. Therefore, they must receive an adequate therapeutic complex at least twice a year.

The study of clinical symptoms characteristic of progressive myopia must begin, as usual, with the collection of patient complaints. Most often, the child notices that his vision from the board has become worse. Teachers note that he makes mistakes when copying information from the board into a notebook or copying it from a neighbor’s notebook. Parents notice that the child bends low over the table while doing homework and squints when looking into the distance. Sometimes what brings them to the ophthalmologist is that he has unusually wide pupils. If a student already uses glasses, the progressive nature of myopia will be indicated by deterioration of vision in glasses, which become “small”.

Sometimes patients complain of short-term darkening of the eyes, a quickly arising feeling of fatigue, pain in the eyes during classes and heaviness in the eyelids at the end of the working day, double vision of letters and words, and blurring of the written text.

Less often, they are bothered by photopsia in the form of lightning, light objects, flashes, twinkling stars, pulsating spots, and so on. As a rule, these complaints occur in patients with cervical osteochondrosis, dysfunction of the spinal cord and cerebral vascular symptoms. Complaints about impaired focusing of vision and rapid onset of eye fatigue while working at close range are due to a violation of the accommodative function of the eyes.

When collecting anamnesis, it is necessary to pay attention to other manifestations of cerebral vascular changes and pathology of the spinal cord. Most children note a coincidence in the timing of the onset of headaches with deterioration of vision or an increase in frequency and intensification of cephalgia during the progression of myopia.

Some children experience dizziness, vestibular disorders, and less often - complaints indicating more severe cerebral ischemia - attacks of fainting with short-term loss of consciousness, temporary weakness in the limbs (the arm weakened and the briefcase fell out, the leg began to twist and walk poorly), phenomena of hypoesthesia body, choking when eating and others. It is clear that the deterioration of vision and the progression of myopia against this background are due to a decrease in the accommodative function of the eyes during an increase in the inferiority of cerebral hemodynamics.

Many children note a connection between headaches and head turns, neck pain after sleeping in an uncomfortable position, or prolonged activities with the head tilted. Sometimes there is a feeling of anesthesia of the skin in the neck area, “running” goosebumps, crunching and crackling sounds when turning the head.

For the clinical differential diagnosis of “vascular” and “hypertensive” (associated with increased ICP) headaches, it is important to clarify the nature of cephalgia, accompanying symptoms, time of onset and therapeutic measures that bring relief. “Vascular” headaches are often localized in the temples, forehead and back of the head, and are pulsating or squeezing in nature.

They typically appear in the morning after sleeping in a position that is uncomfortable for the neck, working at close range with head anteflexion, and after school in the afternoon (neurologists call them “school” headaches). At the height of the headache, nausea and even vomiting may appear, which does not bring relief. Such pain goes away after rest, massage or applying a heating pad to the neck area, or taking vasodilator drugs.

Hypertensive cephalgia most often occurs at night, when venous stagnation impairs the flow of cerebrospinal fluid and increases ICP. They are bursting in nature, accompanied by vomiting, which gives a diuretic effect and leads to relief of the general condition. In addition to analgesics, hypertensive headaches are relieved by diuretics.

Myopic people are characterized by “vascular” headaches with a neurological symptom complex, indicating their connection with pathology in the school.

Ophthalmological examination

Refraction and visual acuity

Determining the degree of myopia, contrary to established tradition, must be carried out without cycloplegia. Our research has confirmed numerous works of recent years, the authors of which are convinced that in most cases the results of autorefractometry and skiascopy in conditions of cycloplegia with myopia coincide with the data of a subjective examination of patients.

Among our patients, this coincidence was recorded in 57% cases. U 25% children after atropinization, myopia decreased by 0,5 diopter, and 18% - has increased just as much. O.G. Levchenko explains this phenomenon by a violation of the interaction of two sections of the autonomic innervation of the ciliary muscle as a result of weakened accommodation.

Currently, the use of cycloplegia in patients with myopia is advisable only if it is necessary to determine the degree of myopia to resolve the issue of vision status for service in the Armed Forces, naval, aviation and other schools. It is now clear that the refraction of the eye under conditions of atropinization does not in fact always correspond to reality, as was previously thought. The fact is that in this case the part of the ciliary muscle responsible for its contractile function is artificially paralyzed.

Naturally, in this case, the action of the antagonistic part begins to predominate, providing accommodation for the distance and innervated by the sympathetic nerve. The true value of refraction can only be obtained under conditions of resting accommodation, when the tone of the accommodative muscle is balanced.

That part of the tone that atropine eliminates is now commonly called the habitual or physiological tone of the ciliary muscle. Many old ophthalmologists still mistakenly call it “spasm of accommodation” and try unsuccessfully to rid patients of it by regularly instilling atropine. This not only does not help cure myopia, but often leads to paralysis of accommodation. In myopic people, there is already paresis of the ciliary muscle, manifested by weakness of the contractile function of accommodation, and atropine weakens it even more.

As for a true spasm of accommodation, it occurs extremely rarely with myopia. According to our data - in 0,2% cases. Accommodation spasm is more typical for weak refraction - hypermetropia in children with astigmatism, especially mixed. In these cases, it compensates for the refractive error. Therefore, the correct prescription of glasses for these patients requires the use of cycloplegics. The value of the physiological tone of a healthy emmetropic eye is. according to various authors, from 1.0 before 1,42 diopter, in myopic people it is reduced to 0,33-0,5 diopters, therefore it is logical to consider the difference between refraction before and after cycloplegia as a spasm of accommodation more 1,5 diopter

It is well known that visual acuity in myopia does not always correspond to its degree. However, most often with myopia - 0,5 diopters patients see 0,8, -1,0 diopter - 0,6 , at - 1,5 diopter - 0,3. Myopia - 2,0 diopters and higher allows you to see more often 0,1. However, there are cases when, with moderate and even high myopia, patients can consider 0,2-0,3 . and vice versa, they see the same amount with myopia -1,0 diopter

As is known, when correcting myopic refraction, its value is determined by the minimum negative glass that gives maximum visual acuity. Most often this visual acuity corresponds to 1,0 , less often - 1,5. U 19% in patients with progressive myopia, it can decrease to 0,6-0,9 .

In some cases, this is due to uneven contraction of the fibers of the paretic ciliary muscle and functional astigmatism, sometimes - organic congenital astigmatism, and in some cases - dysfunction of the visual analyzer. As a rule, treatment aimed at restoring accommodation and cerebral circulation can improve visual acuity in all these patients.

In the first case, elimination of paresis of the ciliary muscle eliminates functional astigmatism and restores vision. In the second, the strong accommodative ability of the eye compensates for organic astigmatism. In the third, improving the blood supply to the visual analyzer increases its function.

U 55% Myopic people have anisometropia (different refraction of the two eyes). Sometimes one eye is first ahead of the other in terms of myopia, and then the vision levels out. It happens that the worst eye becomes the best. Comparison of the degree of refraction with the state of cerebral hemodynamics revealed a clear correlation of the magnitude of myopia with volumetric blood flow in the vessels of the VBB.

The VAs are located at a short distance from each other, but with dislocation of the cervical vertebrae they can suffer to varying degrees. This explains the frequent anisometropia. Interestingly, ophthalmologists note that the degree of myopia is often higher in the right eyes (according to our data, in 58% patients, according to I.L. Ferfilfain - in 61,7%), and pediatric neurologists and pathomorphologists consider the right VA to be more vulnerable and more likely to suffer from compression.

Accommodative function of the eyes

The state of the accommodative function of the eyes in myopic people is given special importance, since it is the weakness of accommodation under conditions of intense visual load that is the first link in the three-factor theory of the pathogenesis of myopia development according to E.S. Avegisov. Among all indicators of ciliary muscle function, the positive part or POA is of greatest importance. Professor E.S. Avetisov believed that it is precisely the decrease in the value of the POA that is the closest criterion for the threatening progression of myopia.

As is known, to determine the state of relative accommodation of the eyes, it is necessary to insert lenses into the patient’s frame that optimally correct his distance vision. Then at a distance 33 see the doctor shows him the text №4 (visual acuity 0,7 ) tables for testing near vision. If the patient can read it, negative glasses are first inserted one by one over the glasses that correct his ametropia until the patient can no longer see him.

The last negative glass, with which reading is still possible, is an indicator of the magnitude of the accommodation reserves or the positive part of the relative accommodation. The negative (spent) part of it is determined similarly. The maximum positive lens with which the patient reads the reference text corresponds to this indicator. As a rule, if all conditions of an accommodation study are met, the negative part is +3,0 diopter It is by this value that the refraction of the eye should increase during convergence at a distance 33 cm ( 100 cm: 33 cm=3.0 ).

Progressive myopia is characterized by a decrease in VA compared to the age norm. Usually, to assess this indicator, we are guided by data from the Research Institute of GB named after. Helmholtz. The ZOA is:

V 7-10 years - 3,0 diopter, in 11-12 - 4,0 dp gr, in 13-20 - 5,0 diopter, 21-25 - 4.0 diopter, 26- 30 - 3.0 diopter 31-35 - 2,0 diopter, 36-40 - 1,0 diopter, older 40 years - 0 diopter

In patients with myopia, both distance accommodation suffers (so they begin to see poorly in the distance) and near. However, it is precisely the violation of the contractile function of the ciliary muscle that leads to the need to turn on the vicious mechanism of focusing closely located objects by bringing them closer to the eyes and lengthening the PZO of the eye.

If the accommodative function of the eyes is restored before the appearance of its axial deformation (and a myopic scleral crescent on the temporal side is formed in the fundus around the optic nerve head), then visual acuity will also be completely restored. This myopia is called functional, or “false” myopia. Previously, it was explained by a spasm of accommodation and “treated” with atropine.

In case of functional myopia, the BTN is removed due to a decrease in the contractility of the ciliary muscle, and in organic myopia, due to the elongation of the PZO of the eye, it moves closer to the eye. DTYAZ is approaching in both cases. Therefore, with functional myopia, the volume of absolute accommodation is less than with organic myopia.

As mentioned in the previous chapter, accommodation paresis in myopic people is most often one of the symptoms of nuclear paresis of the oculomotor nerve. Therefore, during a macroscopic examination of the eyes, it is often possible to detect slight asymmetry in the position of the upper eyelids, anisocoria, and a smaller range of movements of one eyeball compared to the other. Convergence often suffers.

When trying to focus vision on an approaching finger, one or both eyes move outward. Muscle imbalance leads to heterophoria. The most characteristic of eyes with progressive myopia is the inferiority of the internal, inferior and, somewhat less frequently, external rectus muscles.

Therefore, exophoria is most often observed, and inphoria is less often observed. Interestingly, all symptoms of paresis of the oculomotor muscles (especially ptosis, mydriasis and disturbance of accommodation) are most pronounced in low light conditions. This is due to the existence of a reflex arc between the optic and oculomotor nerves (direct and conjugate pupillary reactions).

To illustrate, I will give an example from my own practice. Once, during an ophthalmological examination of a child treated in a children's neurological clinic for chronic cerebral vascular insufficiency, I noted more pronounced ptosis and mydriasis in one eye. Other symptoms of paresis were present at the same time III pairs of cranial nerves of both eyes.

The next day the boy was brought for a consultation with Professor A.Yu. Ratner, and he did not detect any of the symptoms I described. When I was invited to re-examine the child, the professor’s office, where the consultation took place, was flooded with bright sunlight. Looking at the patient, to my shame, I also did not see any ptosis or anisocoria in him and agreed with the neurologists that I had overdiagnosed him.

However, as soon as I brought the child back into the dark room where ophthalmologists traditionally examined children, all these disappeared symptoms reappeared. Only then did it become obvious that low illumination could help identify minimal phenomena of nuclear paresis of the oculomotor nerve.

Light is thus a powerful stimulator of oculomotor nerve function. This is why it is so harmful for patients with weakened accommodation to exercise in the dark.

Biomicroscopy of myopic eyes

Examination of the conjunctiva of the eyeball under a slit lamp reveals a whole range of symptoms indicating a violation of the regional hemodynamics of the eye.

The anterior segment is usually not changed, although the size of the pupils due to hypofunction of the sphincter attracts attention.

As a rule, in young patients, when myopia progresses, no changes in the lens and vitreous body are observed. Brown cataracts and destruction of the vitreous body, so typical for myopia, appear after forty years. Changes in the vitreous body are characteristic of high degrees of myopia and are dystrophic in nature. When examining the patient under a slit lamp, filamentous destruction with floating flakes and diffuse opacities in the liquefied substrate is visible in the vitreous. Individual cavities filled with liquid can be biomicroscoped. Initially, these changes are localized in the posterior part of the eyeball, and then spread to the entire vitreous body.

Destruction of the vitreous body in some cases leads to its detachment. In this case, the posterior limiting membrane breaks away from its place of fixation around the optic nerve and floats in front of it in the form of a round ring. Vitreous detachment is best seen when examined with a Goldmann lens under a shel lamp. The detached posterior membrane resembles a translucent curtain, separated from the retina by a dark optical shell filled with liquid.

The cause of changes in the vitreous body, apparently, on the one hand, is the axial stretching of the posterior parts of the eyeball, and on the other hand, regional ischemia of the eye and metabolic disorders, the synthesis of mucopolysaccharides and other changes in metabolism associated with ischemia of the hypothalamic-pituitary region.

Condition of the optic nerve and retinal vessels

Features of the fundus in acquired myopia depend on the degree and severity of hemodynamic disturbances in the vessels of the ophthalmic artery. The color of the optic disc is determined by the state of the capillary network covering it, extending from the retinal vessels. Therefore, with spasm of the ophthalmic artery and retinal vessels, the color of the disc becomes paler, especially its temporal half.

Often, with severe vascular disorders, a slight blurring of the nasal borders appears. Such symptoms were described by Associate Professor of our department V.M. Krasnova and A.Yu. Ratner in patients with cervical osteochondrosis during the period of its exacerbation and intensification of cerebral vascular insufficiency. For differential diagnosis of such vascular changes in the optic nerve head with incipient optic nerve atrophy, it is necessary to perform fundus ophthalmoscopy using the Vodovozov method in purple light.

With true aphophia, the disc acquires a more pronounced blue color, and with symptomatic blanching it remains pink. It is characteristic that the field of view to white light can be concentrically narrowed in both cases. We explain this in patients with myopia by spasm of the retinal vessels and hypoxia of the peripheral parts of the retina. Visual field testing to red light reveals a significant increase in concentric narrowing in patients with optic atrophy, in contrast to patients with symptomatic pallor.

Studies of the critical flicker fusion frequency (CFF) and visual evoked potentials (VEP) help to assess the functional state of the optic nerve and visual analyzer even more subtly. Research by our graduate student G.R. Tazieva revealed in children with mild and moderate myopia a significant decrease in CFSM and VEP amplitudes while maintaining normal latency time indicators. These changes were somewhat more common in patients with moderate myopia, but correlated even more clearly with the state of cerebral hemodynamics.

Interestingly, she observed exactly the same deviations in VEP in emmetropics with chronic cerebral vascular insufficiency. It is important to note that such electrophysiological symptoms of “vascular” pathology in patients with myopia were noted throughout the entire path of the visual analyzer.

Apparently, this explains the decrease in corrected visual acuity in some of these patients and, possibly, a narrowing of the visual field. At the same time, the profession of these vascular disorders of the optic nerve and analyzer can explain the fairly high frequency of optic nerve aphophia that develops in myopic patients at an older age.

In the practice of ophthalmologists, there is already an established opinion that in myopic eyes, narrowing of the vessels of the central retinal artery is normal. Meanwhile, working with neurologists, we drew attention to their extremely scrupulous attitude towards the condition of the caliber of the retinal vessels. In this situation, of course, our colleagues are right.

The fact is that our description of the fundus and, especially, the condition of the arteries and veins helps them differentiate, for example, vascular headaches from hypertension. The former are characterized by spasm of the retinal arteries and pallor of the optic nerve head, slight blurring of its fania, and for the latter - the phenomenon of venous stagnation with dilation and tortuosity of the veins, a picture of a congestive nipple.

In the clinic, diagnosis, of course, is facilitated by additional research methods - DG, REG. echoencephalophapia, cranial radiophaphy. A comparison of all the data convinces us that the fundus picture is highly informative for explaining the nature of cerebral pathology. We consider spasm of retinal vessels to be normal in myopia only on the basis of the high frequency of these symptoms in myopic people. The true cause of this phenomenon, as our studies have shown, is a compensatory spasm of the orbital arteries when SA steal syndrome occurs, which develops in response to a reduction in blood flow in the VB system.

Previously, ophthalmologists tried to explain the narrowing of retinal vessels in myopia by a stronger refraction of the eye, which, with reverse ophthalmoscopy, led to a decrease in all the details of the fundus, including the caliber of the vessels.

Other authors believed that this symptom is caused by stretching of the retinal vessels simultaneously with stretching of the membranes of the eyeball in high myopia. However, O.G. Levchenko proved that regional eye disorders and narrowing of retinal vessels appear already at the earliest stages of the development of myopia, when there is still no talk of a significant increase in refraction or stretching of the eyeball.

Our research revealed that from 450 children with mild myopia had narrowing of the retinal arteries 236 Human ( 52,4%), from 216 patients with moderate myopia - in 132 (61,1%). Other researchers also noted a slight increase in the number of patients with spasm of the retinal arteries as the refraction of the eye increased.

Our analysis of the results of rheoencephalographic and ophthalmoscopic correlations also showed that narrowing of retinal vessels occurs in patients with a decrease in volumetric blood flow in the ICA and VA. At the same time, these children develop and become more frequent headaches and the accommodative function of the eyes weakens, resulting in the progression of myopia. Therefore, this symptom in the fundus should be considered as a manifestation of cerebral vascular insufficiency and a harbinger of the progression of myopia.

In addition to changing the caliber of the arteries, in some cases the diameter of the veins changes. Dilatation of the retinal veins was observed in 28,4% children with low myopia and 26,4% patients with moderate myopia. This symptom is typical for patients with hypotension and minor disturbances of venous outflow. Often, in the fundus of patients with myopia, one can notice manifestations of VSD in the form of different calibers of retinal arteries in one eye.

Myopic scleral crescent, cone and staphyloma

As a rule, the development of low degree myopia is accompanied by the appearance of a myopic crescent, bordering the optic nerve on the temporal side and having a width of up to 1/3 DC. Increased refraction by 3 diopter is associated with an elongation of the eye's PZO by 1 mm. Therefore, the stretching zone of the sclera around the optic nerve is even insignificant. However, there may be a dissociation of this symptom with the degree of myopia. For example, the absence of a scleral falx in myopia - 3,0 diopter or, conversely, the presence of a scleral cone with a width of 1/3 DD of the optic nerve.

This discrepancy is due to the initial refraction and the associated shape of the eyeball.

The first option (absence of the sickle) is typical for children with hereditary myopia, which is explained by the large size of the eyeball. As a rule, there is no axial elongation of the eye and ultrasound echobiometry indicates the preservation of normal proportions of the eyeball when the PZ is less than horizontal. With this type of myopia, there will be no other symptoms of stretching of the choroid, characteristic of complicated myopia.

The second option, when the myopic cone is too large for a given degree of myopia, develops in children who initially had hypermetropic refraction. It is no secret that similar “myopic” temporal scleral falxes can also be found in hypermetropes. The nature of their development is exactly the same as during the progression of myopia. Only in this case there is not an increase in myopia, but a decrease in the degree of hypermetropia.

Patients who have crossed the zero refraction mark then become myopic. Naturally, the degree of axial elongation of the eye will be greater in them than in children with initial emmetropic refraction, and complications will correspond to a greater degree of myopia. In our practice, there were patients who had moderate hypermetropia, found in 6 -years of age, to 10 over the years it was replaced by myopia.

It is clear that no experienced doctor can share the joy of mothers about such a rapid “getting rid” of hypermetropia, since it is accompanied by stretching of the membranes of the eye and promises only complications. Naturally, such patients with a rapid decrease in the degree of hypermetropia (and in them the cause of this is also visual loads disproportionate to weakened accommodation and inferior cerebral hemodynamics) should be treated according to all the principles of therapy for progressive myopia.

As a rule, in patients with initial manifestations of myopic changes in the fundus (series up to 1/3 DC) there is no other pathology in childhood. However, with age, vascular disorders can progress and cause dyspigmentation in the macular region, disappearance of the macular reflex, and subsequently lead to other central chorioretinal dystrophies (CVRD) and peripheral vitreochorioretinal dystrophies (PVCRD) of vascular origin. The development of the latter explains the possibility of retinal tears and detachment in eyes with low myopia.

Further progression of axial elongation of the eye leads to the development around the optic nerve, first of a small cone, the width of which does not exceed 1/2 DD, then middle cone - up to 1 DD and a large cone whose width exceeds 1 DD. In this case, the optic nerve head may acquire an inclined, oblique position. Pronounced axial elongation also leads to so-called supertraction of the membranes on the inside of the eye.

With high degrees of myopia, the entire optic nerve head is located in a depression formed by the stretched sclera. This is a myopic staphyloma.

It can involve the entire posterior pole of the eye, leading to gradual atrophy of the vessels of the choroid. First, the choriocapillaris disappear, and then the medium and large vessels. The border of the staphyloma is visible in the form of an arcuate line through which the retinal vessels bend, concentrically located in relation to the optic nerve head.

The cause of the development of the myopic cone is a change in the course of the optic nerve (sclerochoroidal canal), as well as atrophy of the choroid.

Causes

With an increase in the degree of myopia and further stretching of the eye, the size of the myopic cone increases, which gradually surrounds the optic disc on all sides. As a result, the cone takes the shape of a ring. This condition is called myopic staphyloma. If the severity of myopia is significant, then staphyloma can affect a large area of ​​the optic nerve head and even spread to the macula. Staphyloma itself is the result of degeneration of the choroid, which becomes quite rigid and cannot stretch. In this area, the retina also changes, which does not have plastic properties similar to. The term staphyloma usually refers to any protrusion, but this symptom does not occur very often with true myopia.

Classification

Posterior myopic staphyloma is divided into two types: false and true. With false myopic staphyloma, degeneration of the choroid occurs, which affects the entire circumference of the optic nerve head.

With true staphyloma during myopia, a limited protrusion of the substance of the eye occurs, which is associated with stretching of the posterior segment of the sclera in the area adjacent to the optic nerve and its disc.

The most typical type of myopia is false posterior staphyloma. Quite rarely, and only with a high degree of myopia, such a pronounced stretching of the sclera occurs in the area of ​​its posterior segment (next to the optic nerve) that a true protrusion of the eye is formed (true posterior staphyloma).

With an increase in the degree of myopia and further stretching of the eye, the size of the myopic cone increases, which gradually surrounds the optic disc on all sides.

Symptoms

With pronounced stretching of the membranes of the eyeball during the progression of myopia, increased fragility of blood vessels occurs, which leads to recurrent hemorrhages in the area and in the retina. With slow resorption of hemorrhages, persistent opacities of the vitreous develop, and chorioretinal lesions form directly on the fundus. When pigmented lesions form in the area, a significant decrease in central vision is noted.

Sometimes a decrease occurs as a result of a large number of cloudy spots in the vitreous area, as well as during its detachment and the formation of a complex one. The most severe complication of high myopia is myopia, which is a consequence of its rupture in different parts when the shape of the eye is disturbed.

is a pathological protrusion of the posterior surface of the sclera. Clinically manifested by decreased visual acuity and narrowing of the visual field. The fundus reveals diffuse atrophy of the pigment epithelium of the retina, and the presence of peripheral vitreochorioretinal dystrophy or retinal traction is possible. For diagnosis, an external examination is used, visual acuity and the nature of vision are examined, tonometry and biomicroscopy are performed. Additional methods include ultrasound of the eyeball, computer perimetry, and electroretinography. Treatment of staphyloma is conservative (drugs and physical procedures to improve blood supply to the retina, strengthen the sclera and relax the accommodation of the eye) and surgical (aimed at strengthening the posterior surface of the sclera).

General information

Staphyloma (staphyloma; Greek staphylē – bunch of grapes + -ōma) – severe deformation of the sclera with pathological prolapse and elongation of the eye axis. Scleral staphyloma occurs with high myopia. Myopia is the most common disease and the leading cause of blindness in developed countries. In Russia, 15% of the population suffers from refractive errors, 3% of them have a complicated form with pronounced changes in the fundus. Myopic staphyloma develops between the ages of 20 and 40 years. It is often accompanied by other pathological changes in the structure of the eye and is a cause of disability in young working age. Rehabilitation of patients with high myopia and prevention of complications still remain important problems in modern ophthalmology.

Causes and symptoms of staphyloma

The scleral membrane is the outer opaque capsule of the eyeball and contains in its structure cellular elements that are immersed in a ground substance consisting of glycosaminoglycans, protein, and polysaccharide complexes. 70% of the sclera consists of collagen protein, its bundles - fibrils - form a special plexus with elastic fibers. Thanks to this structure, the scleral membrane performs its main functions - maintaining the strength and elasticity of the eyeball. With the development of high myopia, loosening of the collagen fibers of the sclera occurs. In the posterior pole, the number of proteases increases, which destroy adhesive bonds in elastic fibers and lead to the formation of staphyloma.

Clinically, staphyloma manifests itself when complications develop in a patient with high myopia. Most often, there is a significant decrease in visual acuity, fatigue, and a feeling of heaviness in the eyes. There may be a narrowing of the field of vision in one eye. During examination, an ophthalmologist may detect extensive staphyloma in the fundus (a white focus of atrophy in the form of a ring at the posterior pole), diffuse atrophy of the pigment epithelium, “albinotic” color of the fundus, the presence of peripheral vitreochorioretinal dystrophy or traction. The lesion is often bilateral. Complications of myopic staphyloma include the occurrence of retinal dystrophy, the formation of hemorrhagic retinal detachment, destruction of the vitreous body, the development of cataracts, and open-angle glaucoma.

Diagnosis and treatment of staphyloma

Diagnosis of staphyloma begins with the collection of anamnestic information. Then the ophthalmologist performs an external examination, examines visual acuity and the nature of vision, and conducts tonometry. Biomicroscopy using a slit lamp is the main method for diagnosing staphyloma. A refractive examination using cycloplegia is required. Additional methods include ultrasound of the eye with measurement of the anterior-posterior axis and computer perimetry (to identify paracentral visual field defects). Optical coherence tomography is used to diagnose the condition of the macular area. Electroretinography helps to identify functional disorders in the retina and choroid of the eyeball.

Treatment of myopic staphyloma is complex and includes both surgical and conservative techniques. The primary goal of therapeutic measures is to reduce the progression of myopia. Conservative therapy for staphyloma includes the use of drugs that affect the relaxation of accommodation, help strengthen the scleral membrane, improve the hemodynamics of the eye, metabolic processes in the retina and choroid and increase visual functions.

With the development of hemorrhages in the retina, the use of hemostatic, absorbable and desensitizing agents is necessary. Physiotherapeutic treatment is also indicated. Electrophoresis, laser stimulation or magnetophoresis are prescribed. Rigid orthokeratology lenses can be used to reduce the rate of myopia progression. Surgical treatment of staphyloma is aimed at preventing further stretching of the sclera. Various techniques are used to strengthen the posterior pole of the eyeball.

Prognosis and prevention of staphyloma

The prognosis is most often doubtful. Prevention of myopic staphyloma is aimed at reducing the progression of myopia. Includes activities to promote health and physical development in childhood and adolescence, teaching children and adults the rules of visual hygiene. It is necessary to organize high-quality lighting in schools and workplaces, monitor compliance with sleep and rest schedules, limit the use of tablets and phones by children, and regularly visit an ophthalmologist for preventive examinations.

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Definition

The prevalence of myocardial degeneration varies among different races and ethnic groups and is more common in women than men.

Anamnesis

Important clinical signs

The optic disc itself may be oblique or elongated in the vertical direction, both of these signs may be present (Fig. 2-14, B). Changes in the macular area may cause decreased vision.

Such changes include tortuous areas of atrophy in the posterior pole of the eyeball, which may involve the area of ​​the central fovea. Lacquer cracks are spontaneous linear ruptures of Bruch's membrane (see Fig. 2-14, B) and develop in 4% of patients with high myopia; varnish cracks are considered the cause of spontaneous subretinal hemorrhages, not associated with CNV (Fig. 2-14, B).

Fuchs spots are rounded areas of subretinal hyperpigmentation, occasionally with surrounding areas of atrophy, which are considered to result from subretinal hemorrhage or CNV. Fuchs spots are detected in 10% of cases with high myopia in patients over 30 years of age.

Rice. 2-14, A. Mystical degeneration, myopic cone. Myopic cone from the temporal side. The “thinning” of the retinal pigment epithelium is determined (the true boundaries of the optic nerve head are visible in the enlarged image).
B. Myopic degeneration, obliquely entering the optic disc. Marked oblique entry of the optic disc with a temporal cone and a varnish crack superior to the fovea (arrow).
B. Myopic degeneration, retinal hemorrhage. Spontaneous subretinal (foveal) hemorrhage from a varnish crack without choroidal neovascularization.
D. Myopic degeneration, choroidal neovascularization. Subretinal choroidal neovascularization (arrow) with pigmentation and a small amount of subretinal fluid.

Associated clinical signs

Rice. 2-14, D. Myopic degeneration, posterior staphyloma. A staphyloma around the optic disc is shown.
E. Myopic degeneration. Extensive chorioretinal atrophy in the posterior pole and periphery of the retina of the right eye.
G. Myopic degeneration, Extensive chorioretinal atrophy in the posterior pole and periphery of the retina of the left eye.

Differential diagnosis

Diagnostics

Fluorescein angiography is indicated to evaluate CNV.

Prognosis and treatment

Laser coagulation should be recommended with caution in patients with myopic CNV. Without treatment, CNV often remains small in size, and expansion of atrophic areas after photocoagulation can lead to further progression of vision loss. For subfoveal CNV, the use of photodynamic therapy with verteporfin may be advisable. Without treatment, CNV in myopic degeneration may remain stable without a significant decrease in visual acuity, unlike age-related macular degeneration.

S.E. Avetisova, V.K. Surgucha