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Lecture notes, cheat sheets
Eye diseases. General issues of pathology of the vascular tract (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 14. General issues of the pathology of the vascular tract 1. Questioning the patient Having come into contact with the patient, one should briefly find out the timing and alleged causes of the disease, the nature of its course, the treatment performed, its effectiveness, etc. There are slight transient pains in the eye, redness of the eye, and sometimes a decrease in vision. Pain in the eye with iridocyclitis in children, unlike adults, is very weak and intermittent, so seeking medical attention is often belated. If the history reveals that the eye disease arose after or against the background of some general changes in the child’s condition, then it should be borne in mind that most often iridocyclitis in children develops with influenza, tuberculosis, rheumatism, diseases of the paranasal sinuses, teeth, and toxoplasmosis , childhood infections, etc. Anomalies and tumors are predominantly congenital in nature. 2. External examination of the eye and examination of the cornea Examination of the patient should begin with checking the field acuity and color vision. Next, a general external examination of the face and eyes is performed. Pay attention to the position of the eyes and their appendages, their mobility and comparative sizes. With the help of lateral illumination, the nature of the injection of the vessels of the eyeball is determined. A mixed injection of the eyeball may be indicative of iridocyclitis. To make sure that there is a mixed injection, an adrenaline test is performed. Pericorneal injection for anterior uveitis is the same as for patients with keratitis. In young children, the injection of the eyeball is slightly expressed. After determining the nature of hyperemia of the eyeball using lateral illumination, the state of the cornea is examined using a combined method. As a rule, in side lighting it appears normal. However, when examined by a combined method, especially in the light of a slit lamp, peculiar deposits are often found on the corneal endothelium. These are precipitates, glued lumps of pigment, lymphocytes, macrophages, plasma cells, sometimes fibrin, etc. In the process of their study, attention is paid to the size, shape and color (small, medium and large, gray, yellowish, "fat", etc.) , since these signs can suggest one or another nature of the pathological process. Be sure to determine the state of the depth of the anterior chamber (it may be uneven due to a change in the position of the iris), the presence of its adhesions to the cornea (anterior synechiae) or to the anterior lens capsule (posterior synechiae). Particular attention is paid to the contents of the anterior chamber, since with iridocyclitis the moisture may become cloudy, and depending on the etiology and severity of the process, hyphema, hypopyon, gelatinous or serous exudate may appear. 3. Examination of the iris of the pupil and lens When examining the iris of a diseased eye, it should be compared with the iris of a healthy eye. At the same time, it is possible to detect a change in its color (gray, brownish, yellowish, reddish, etc.), blurring of the pattern (smoothness of crypts and lacunae), the presence of separate dilated and newly formed vessels. By changing the color of the iris, we can conclude that the expansion of its vessels, the appearance of transudate and exudate in it. A very important diagnostic sign of iritis is the condition of the pupil. It is almost always narrowed, reacts sluggishly to light, and often has an irregular shape due to the formation of posterior synechiae. Changes in the pupil area are especially clearly visible after instillation of mydriatics (scopolamine, homatropine, etc.) into the conjunctival sac. It should be remembered that in cases where there is fusion and infection of the pupil and there is no outflow of moisture from the posterior chamber to the anterior chamber, the iris protrudes (bombing), the anterior chamber becomes small and uneven, and an increase in ophthalmotonus is observed. When examining the lens on its anterior capsule, it is often possible to detect brown clumps of remnants of the pigment epithelium after rupture of the posterior synechiae, but gray, yellowish, crumbly or membranous deposits of exudate can be detected, the type and severity of which depend on the nature of the process. To clarify their location, to identify the type and nature of the exudate, an examination with a slit lamp is necessary. 4. Fundus examination and ophthalmoscopy The eye is examined in transmitted light, attention is paid to the nature of the reflex from the fundus. If there are precipitates on the posterior surface of the cornea, sweating of the endothelium, exudate deposits on the anterior and posterior capsules of the lens, the moisture of the anterior chamber is turbid, or opacities in the vitreous body are determined, then the reflex from the fundus will be unevenly pink. In cases where there are opacities of the vitreous body, they are detected by shadows that have a different shape, size, intensity and mobility. These opacities are due to the presence of transudate or exudate. Next, ophthalmoscopy is performed and the state of the retinal vessels (expansion, narrowing, uneven caliber, etc.), the optic nerve head (size, color, clarity of contours), the central zone and periphery of the retina (foci of various sizes, shapes, colors and localizations) are ascertained . After examining the fundus, be sure to palpate the eye. If the child pulls his head back, this indicates the appearance of pain in the ciliary body. At the same time, intraocular pressure is palpated, which is often below normal, however, as already mentioned, in the presence of posterior and anterior synechia, intraocular pressure can be increased as a result of a violation of the outflow of intraocular fluid. 5. Identification of inflammatory processes Thus, if a child has a mixed or pericorneal injection of the eyeball, clouding of the moisture of the anterior chamber, precipitates, changed color and pattern of the iris, the shape and size of the pupil, posterior synechia and opacities in the vitreous body, and some pain in the eye during palpation and reduced ophthalmotonus, there is every reason to diagnose iridocyclitis (anterior uveitis). However, not always all of the above symptoms are expressed in iridocyclitis. Sometimes such a characteristic symptom as the presence of precipitates is enough to diagnose iridocyclitis. In contrast to the indicated ophthalmological picture, which is characteristic of inflammation of the iris and ciliary body, with an inflammatory process in the choroid itself (choroiditis, posterior uveitis), the eye is usually calm and there are no changes in its anterior section. Depending on the localization of the process, patients may present various complaints. Sometimes they complain about the curvature of straight lines (metamorphopsia), flashes before the eye (photopsia), the surrounding objects seem to them either small (with micropsia) or large (with macropsia), there is a loss of visual field (central scotomas, absolute and relative). These complaints are characteristic of central posterior uveitis maculitis. There may be complaints of poor twilight vision (this is how night blindness, or hemeralopia, manifests itself) with many lesions in the periphery. Ophthalmologically, inflammatory foci are detected in the fundus. If the lesion is fresh, then it has a grayish or yellowish-white color, its boundaries are not too distinct, and there is no pigment in the lesion around it. Patients should be examined using an electric ophthalmoscope and a slit lamp. Biomicroscopy allows you to detect a variety of changes in the vitreous body, different in shape, intensity and color of cloudiness. Patients with posterior uveitis, in addition to visual acuity, should check the field of view, determine the nature of the cattle and examine the color perception. In cases where changes characteristic of iridocyclitis (anterior uveitis) and choroiditis (posterior uveitis) are found in the eye, we can talk about the presence of panuveitis (iridocyclochoroiditis). If the process captures only the iris, it is iritis, if the ciliary body is cyclitis. Sometimes, with ophthalmoscopy, focal changes are detected in the fundus: it is seen that the retinal vessels pass through the focus, bending along its edge, there is an accumulation of pigment along the retinal vessels, in front of them and in the focus area. All this is a sign of chorioretinitis. According to the nature of the ophthalmological picture, focal and diffuse forms of choroiditis are distinguished. Focal changes in the fundus, combined with changes in the optic nerve head, which are manifested in its hyperemia, blurred borders, vein dilation, are characteristic of neurochorioretinitis, most often observed in tuberculosis, lues (syphilis), sympathetic ophthalmia. In such patients, there is an increase in the blind spot. In the clinical course of uveitis in different age groups, a number of features are noted. The phenomena of eye irritation are expressed the weaker, the younger the child. In children under four years of age, the precipitates are small and occur in small numbers. Exudate in the anterior chamber, fusion and infection of the pupil, sequential cataracts and secondary glaucoma are more common in children under five years of age. In children of toddler and preschool age, there is a tendency to generalize the process with spread to all parts of the vascular tract and the absence of characteristic clinical symptoms that help to identify the etiology of the disease. In this regard, laboratory tests and immunological tests are very important to clarify the cause of the disease. So, to make a final clinical diagnosis, not only data on the onset of the disease, the nature of the course of the process, the features of the clinical picture (the nature of precipitates, exudate, posterior synechia), its connection with other diseases, but also laboratory data (bacteriological, virological, immunological, etc.) .) analyzes. The diagnosis of iritis and iridocyclitis is by no means difficult. However, in the initial stages, when pericorneal injection is mild, iritis must be differentiated from conjunctivitis. If a gentle turbidity of the anterior chamber moisture is detected, then an illusion of corneal edema is created, and this, in turn, can lead to a more gross diagnostic error: iritis can be mistaken for glaucoma. An error in diagnosis can lead to undesirable consequences, since with iridocyclitis, atropine should be instilled to dilate the pupil, and with glaucoma, atropine will aggravate the severity of the process. If you skip the onset of the disease, mistaking it for conjunctivitis, and do not prescribe mydriatics, then posterior synechia may form, which subsequently cannot be broken. 6. Detection of congenital anomalies and neoplasms Congenital pathology of the vascular tract is usually associated with various kinds of pathological effects on the organ of vision during the second critical period of intrauterine development. Therefore, it is important to clarify how the pregnancy of the mother of the child being examined proceeded, whether there were any harmful effects on the mother’s body (viral diseases, toxoplasmosis, X-ray exposure, drug therapy, etc.). In the practice of a pediatrician, cases of congenital anomalies of the vascular tract, especially the iris, are possible. In this regard, when examining a child, it is imperative to pay attention to the eyes, since anomalies of the vascular tract can be combined with other malformations, such as cleft lip, cleft palate, microcornea, microphthalmos, etc. With the help of lateral illumination, the anterior part of the eye is examined , pay attention to the pattern and color of the iris, the size, position and shape of the pupil. With such an examination, the following anomalies can be detected: 1) congenital coloboma of the iris; 2) aniridia; 3) polycoria; 4) corectopia; 5) age spots of the iris. To determine the coloboma of the choroid, it is necessary to perform ophthalmoscopy. Patients should determine visual acuity and visual field, which can be impaired to varying degrees. When diagnosing neoplasms in the vascular tract, attention should be paid to the position of the eyes (sometimes a deviation of the eyeball can be detected, which is a sign of a decrease in visual acuity). The eyeball may be enlarged, which indicates a complication of the tumor - secondary glaucoma. Neoplasms of the anterior vascular tract are detected when viewed with side lighting and with a slit lamp. In this case, the following changes in the iris can be detected: 1) cysts; 2) angiomas; 3) neurofibromas; 4) melanomas. Pay attention to the color and pattern of the iris, the displacement of its pupillary edge, which can be observed with a tumor of the ciliary body. Neoplasms of the ciliary body are determined by ophthalmoscopy and gonioscopy. At the beginning of the disease, patients do not complain. Diagnosis is aided by radioisotope studies and luminescent biomicroscopy. Author: Shilnikov L.V. << Back: Pathology of the oculomotor apparatus (strabismus) >> Forward: Iridocyclitis
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