LECTURE No. 3. Methodology for examining the condition of the eye (part I)

Examination of the organ of vision, regardless of complaints and first impressions, should always be carried out sequentially, according to the principle of the anatomical arrangement of its parts. However, it should be an unshakable rule to start the examination with a check of visual functions, especially visual acuity, since after diagnostic interventions the child will no longer give correct indications about the state of vision.

1. External examination of the eye in natural light

The study of the organ of vision begins with an external examination of the eye in natural light. In the region of the orbit, changes can be associated mainly with congenital pathology in the form of dermoid cysts, cerebral hernia or tumors (angiomas, sarcomas, etc.). Pay attention to the condition of the eyelids. In rare cases, there may be a congenital or acquired coloboma of the eyelids, their fusion (ankyloblepharon), congenital or as a result of a gross cicatricial process.

It is not uncommon to see congenital drooping of the upper eyelid (ptosis). There may be changes in the skin of the eyelids (hyperemia, subcutaneous hemorrhages, edema, infiltration) and the edges of the eyelids (scales and crusts at the base of the eyelashes, ulceration, cysts, etc.).

Usually, the eyelids fit snugly against the eyeball, but sometimes in chronic inflammatory processes of the mucous membrane, an eversion of the lower eyelid may occur, and with cicatricial changes in the mucous membrane and cartilage, eyelid torsion may occur. Sometimes in children in the first month of life, a congenital inversion of the lower eyelid is found, while the eyelashes are turned towards the cornea. With eversion of the lower eyelid, the lacrimal point, usually facing the eyeball and immersed in the lacrimal lake, lags behind somewhat, which leads to lacrimation and lacrimation.

On examination, pay attention to the correct growth of eyelashes. With ulcerative blepharitis, trachoma, chronic meibomitis, abnormal growth of eyelashes (trichiasis), baldness of the edges of the eyelids (madarosis) can be observed.

The state of the lacrimal ducts should be judged by the severity of the lacrimal puncta, their position, the presence of discharge from them when pressed on the area of ​​the lacrimal canaliculi (canaliculitis) or the lacrimal sac (dacryocystitis).

Inspection of the lacrimal gland is carried out by pulling the upper eyelid up, while the subject should look at the tip of his nose. In some acute and chronic inflammatory processes (dacryoadenitis), the gland can be enlarged, sometimes through the mucous membrane you can see its cystic degeneration, abscesses, etc.

Pay attention to the position of the eyeballs in the orbit. Anterior displacement of the eye (exophthalmus) is possible, more often observed with retrobulbar hemorrhages, tumors. The value of the protrusion of the eye is determined by the exophthalmometer. The displacement of the eyeball back (enophthalmus) is observed with the degeneration of the bones of the orbit, Horner's syndrome. Most often in children there is a lateral deviation of the eyeball (strabismus). Check the range of motion of the eyeball. To do this, the subject needs to fix the doctor's finger moving in all directions with a fixed head position. This is how paresis of individual oculomotor muscles is detected, nystagmus is detected with extreme abduction of the eyeballs, as well as the predominance of one or another muscle group. In addition, this way they get an idea of ​​the size of the eyeballs (buphthalmos, microphthalmos), the size of the cornea (micro and macrocornea), the depth of the anterior chamber, the size and reaction to light of the pupil, the state of the pupil area (mydriasis, coloboma), etc.

2. Side lighting method

The method of lateral, or focal, illumination is used to study the condition of the mucous membrane of the eyelids and the anterior part of the eyeball (the mucous membrane of the eyeball, sclera, cornea, anterior chamber, iris and pupil), as well as the lens. The study is carried out in a darkened room. The lamp is placed to the left and in front of the patient. The doctor illuminates the patient's eyeball, throwing a focused beam of light from the lamp onto its individual sections using a lens of 13,0 or 20,0 diopters. The mucous membrane of the lower eyelid becomes accessible for inspection when the edge of the eyelid is pulled down. This requires the patient to look up.

When examining the mucous membrane, attention should be paid to all its parts (cartilage, the region of the transitional fold and the lower half of the eyeball). At the same time, the presence of edema, infiltration, cicatricial changes, foreign bodies, films, discharge, color, surface (follicles, papillae, polyposis growths), mobility, translucence of the ducts of the meibomian glands, etc. are determined.

For a thorough examination of the conjunctiva of the upper eyelid, it is necessary to turn it out. At the same time, the patient is asked to look down, and at this time, with the thumb of the left hand, the eyelid is pulled up so that the ciliary edge of the eyelid moves away from the eyeball. With the thumb and forefinger of the right hand, they grab it closer to the base of the eyelashes and try to raise the edge of the eyelid up, while simultaneously pressing the upper edge down with the thumb or forefinger of the left hand. With the thumb of the left hand in this position, the everted eyelid is held until the examination is completed.

When examining the mucous membrane of the upper fornix, which remains invisible during normal eversion, it is necessary to additionally slightly press through the lower eyelid on the eyeball. In this case, in the region of the palpebral fissure, there is a protrusion of the upper transitional fold loosely connected with the underlying tissues. For a more thorough examination of the upper fornix, especially if foreign bodies are suspected in this section of the conjunctiva, a double eversion is performed using an eyelid lifter.

The mucous membrane of the eyeball is also examined under focal illumination. Fix attention on the state of its vessels, transparency, the presence of changes (inflammation, neoplasms, cicatricial changes, pigmentation, etc.). A white or bluish sclera usually shines through the mucous membrane. With the defeat of the cornea, sclera and choroid of an inflammatory nature, the vessels located in the sclera or in the thickness of the sclera around the limbus expand.

Pay attention to the condition of the limb. It can be expanded (with glaucoma), thickened (with spring catarrh), infiltrated (with trachoma). The vessels of the conjunctiva of the eyeball can enter it (with trachoma, scrofula). Especially carefully with the help of focal illumination examine the cornea. Sometimes in children with a sharp blepharospasm (squeezing of the eyelids) or edema (with gonorrhea, diphtheria), it is not possible to push the eyelids apart. In such cases, eyelid lifters must be used to examine the anterior eyeball. The child's mother or nurse tightly hugs the child, clasping his body with one hand with her hands pressed, the other head. The mother clasps the child's legs between her knees. The doctor slightly pulls the upper eyelid and carefully brings the eyelid lifter under it. If the child is very restless, then he is laid on his back, the doctor fixes the child's head between the knees, the mother holds the child's arms and legs. In this case, the hands of the doctor remain free.

3. Combined inspection

For a more detailed examination of the organ of vision, a combined research method is also used. It consists in examining the illuminated place through a strong magnifying glass, with side illumination of the eye. Instead of a second loupe, you can use a binocular loupe that gives a magnification of 610 times. It is especially convenient to use this method in an outpatient setting in the absence of a slit lamp.

When examining the cornea, attention is paid to its size, shape, transparency, etc. If there are changes, the freshness of inflammatory infiltrates, their shape, depth of location, and areas of ulceration are determined. Pay attention to the ingrowth of superficial and deep vessels into the cornea, smoothness, sphericity and luster of its surface. When examining the cornea, it is always necessary to examine its sensitivity. Most simply, it is determined by a piece of cotton wool with a thinned end, which, when touched to the cornea, causes a protective reflex (closing of the eyelids, withdrawal). To objectify the research, specially made hairs are used, as well as algesimetry.

To detect defects in the corneal epithelium, one drop of a 1% fluorescein solution is instilled into the conjunctival sac. After several blinks, the conjunctival cavity is rinsed with saline. The paint, easily washed off from the surface of the cornea, covered with epithelium, colors the eroded areas emerald green. These areas are clearly visible when examined using a combined method.

Then they examine the anterior chamber, fix attention on its depth, uniformity, transparency of moisture, the presence of blood, exudate in it, etc.

When examining the iris, its color is determined (the presence of heterochromia, areas of excessive pigmentation). The radial pattern of the iris, usually depending on the state of its trabecular tissue, is well expressed in light irises. They also clearly visible pigment fringe along the edge of the pupillary area. Detect congenital and acquired defects of the iris, its fusion with the cornea (synechia anterior), anterior lens capsule (synechia posterior). Unions can be single, along the edge of the pupil, and circular (synechia circularis, seclusio pupillae). They usually occur as a result of an inflammatory process in the vascular tract. In case of damage, detachments of the iris at the root (iridodialisis), tears and ruptures of the sphincter of the pupil are observed.

The study of the pupil begins with determining its shape, width, direct and friendly reaction to light. Different width of the pupils of the left and right eyes (anisocoria) is often a pathological phenomenon. The direct reaction of the pupil to light is checked by pointing a beam of light at it with a lens or an ophthalmoscope. In this case, the second eye is tightly closed with the palm of your hand. Pupillary reaction is considered alive if under the influence of light the pupil quickly and distinctly narrows, and sluggish if the pupil reaction is slow and insufficient. A change in the direct pupillary reaction may depend on a violation of the conduction of the motor descending path of the reflex or on disorders in the area of ​​\uXNUMXb\uXNUMXbthe connection of the optical and motor paths.

Examining the friendly reaction of the pupils, one eye is illuminated with an ophthalmoscope, following the reaction of the pupil of the other eye. In conclusion, the reaction of the pupils to the installation at a close distance, which takes place with the participation of accommodation and convergence, is checked. For this, the patient is asked to fix the object with his eyes, gradually approaching the eyes, and follow the reaction of the pupils, which are constricted at the same time. With the defeat of the motor pathway of the reflex, the reaction of the pupils is absent.

There may be congenital changes such as displacement of the pupil (corectopia) or many pupils (policoria), and with iridodialysis, a change in the shape of the pupil.

Author: Shilnikov L.V.

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