Eye diseases. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets
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Eye diseases. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets

Table of contents

1. The structure of the eye. Orbit

The eye as an integral part of the so-called opto-vegetative (OVS) or photoenergetic (FES) system of the body is involved in the adaptation of the internal environment of the body to external conditions. The vast majority of information about the world around comes to the child through the organ of vision. The eye is in a figurative and literal sense a part of the brain, placed on the periphery.

When studying the anatomy of a child, it must be remembered that the orbit in children under the age of one year approaches a trihedral prism in shape. Later it takes the form of a truncated tetrahedral pyramid with rounded edges. The base of the pyramid faces outwards and anteriorly, the apex inwards and backwards. In newborns and children of the first year of life, the angle between the axes of the orbits is sharper, which creates the illusion of convergent strabismus. However, this imaginary strabismus gradually disappears, as the angle between the axes of the orbits increases. The upper wall of the orbit borders the cranial cavity and is formed in front by the orbital part of the frontal bone, and behind by the lesser wing of the sphenoid bone. In the outer corner of the wall, a recess for the lacrimal gland is revealed, and at the place where the upper wall passes into the inner wall, a notch (or hole) for the superior orbital vein and artery is determined. There is also a spike block through which the tendon of the superior oblique muscle is thrown. In the process of comparing the orbits in terms of age, it is revealed that in children the upper wall of the orbit is thin, there is no pronounced superciliary tubercle.

When studying the outer wall of the orbit, it is noted that it borders on the temporal cranial fossa. The orbital process of the zygomatic bone separates the orbit from the maxillary sinus, and the sphenoid bone of the inner wall separates the contents of the orbit from the ethmoid sinus. The fact that the upper wall of the orbit is simultaneously the lower wall of the frontal sinus, the lower upper wall of the maxillary sinus, and the inner side wall of the ethmoidal labyrinth, explains the relatively unhindered and rapid transition of the disease from the paranasal sinuses to the contents of the orbit and vice versa.

At the top of the orbit in the lesser wing of the sphenoid bone, a round opening for the optic nerve and ophthalmic artery is defined. The superior orbital fissure is located outside and below this opening between the large and small wings of the sphenoid bone and connects the orbit with the middle cranial fossa. All the motor branches of the cranial nerves pass through this gap, as well as the superior ophthalmic vein and the first branch of the trigeminal nerve, the ophthalmic nerve.

The inferior orbital fissure connects the orbit to the inferior temporal and pterygoid fossae. The maxillary and zygomatic nerves pass through it.

The entire orbit is lined with periosteum; in front of the bony edge of the orbit to the cartilage of the eyelids is the tarsoorbital fascia. With closed eyelids, the entrance to the orbit is closed. Tenon's capsule divides the orbit into two sections: the eyeball is located in the anterior section, and the vessels, nerves, muscles, and orbital tissue are located in the posterior section.

2. The structure of the soft tissues of the eye

The superior, inferior, external and internal rectus and superior and inferior oblique muscles related to the oculomotor muscles, as well as the muscle that lifts the upper eyelid, and the orbital are located in the orbit. Muscles (except for the inferior oblique and orbital) start from the connective tissue ring that surrounds the visual opening, and the inferior oblique muscle from the inner corner of the orbit. The muscles are separated from the limbus by an average of 5,58,0 mm. In newborns, this value is 4,05,0 mm, and in children aged fourteen years, 5,07,5 mm. The superior and inferior oblique muscles are attached to the sclera 16 mm from the limbus, the external rectus turns the eye outward, the internal inwards, the superior moves upwards and inwards, the inferior downwards and inwards.

The eyelids cover the front of the eye socket. The connection of the free edges of the lower and upper eyelids with each other occurs through external and internal adhesions. There is a variation in the width and shape of the palpebral fissure. Normally, the edge of the lower eyelid should be 0,51,0 mm below the corneal limbus, and the edge of the upper eyelid should cover the cornea by 2 mm. The skin of the eyelids is thin, delicate, poor in fatty tissue, loosely connected with the underlying parts, the underlying vessels shine through it.

The muscles of the eyelids are poorly developed. The muscular layer of the eyelids is represented by a circular muscle, innervated by the facial nerve and providing closure of the eyelids. Under the muscle is cartilage, in the thickness of which the meibomian glands are located, translucent in the form of yellowish radial stripes. The back surface of the eyelids is covered with a connective sheath. On the front edge of the eyelids there are eyelashes, near the root of each eyelash there are sebaceous and modified sweat glands. The lifting of the upper eyelid is carried out with the help of the muscle of the same name, which is innervated by the branches of the oculomotor nerve.

The blood supply to the eyelids is carried out by the external branches of the lacrimal artery, the internal arteries of the eyelids and the anterior ethmoidal artery. The connective sheath, the conjunctiva, covers the eyelids from the inside, passes to the sclera and continues in an altered form to the cornea. There are three sections of the conjunctiva: cartilage (or eyelids), transitional fold (or fornix) and the eyeball. All three sections of the conjunctiva with closed eyelids form a closed slit cavity, the conjunctival sac.

The blood supply of the conjunctiva is carried out by the arterial system of the eyelids and the anterior ciliary arteries. The veins of the conjunctiva accompany the arteries, the outflow of blood occurs in the system of facial veins and through the anterior ciliary veins of the orbit. The conjunctiva of the eye has a well-developed lymphatic system.

The lacrimal organs consist of a tear-producing and tear-removing apparatus. The tear-producing apparatus includes the lacrimal gland and Krause's glands. The lacrimal gland is located in the bony cavity of the upper outer part of the orbit. Twenty or more (up to thirty) excretory ducts of the gland open into the lateral part of the superior conjunctival fornix.

3. The structure of the eyeball, cornea and sclera

The eyeball has an irregular spherical shape. Its anterior section is more convex. The anteroposterior size of the eye is on average 16 mm in a newborn, 19 mm by one year of life, 20 mm by three, 21 mm by seven, 22,5 mm by fifteen, and 23 mm by age twenty. The weight of the eyeball of a newborn is about 3,0 g, and that of an adult is 8,0 g.

The eyeball has three shells: outer (represented by the cornea and sclera), middle (represented by the vascular tract) and inner (represented by the retina). Inside the eyeball are aqueous humor, lens, vitreous body, blood vessels.

The cornea is the anterior transparent part of the capsule of the eye. Its horizontal size in a newborn is 9,0 mm, by one year 10,0 mm, by three years 10,5 mm, by five years 11,0 mm, and by nine years it acquires the same dimensions as in adults, 11,5 .0,5 mm. The vertical dimension of the cornea is 78 mm smaller. The radius of curvature of the cornea is 1,12 mm. The thickness of this shell in the center in a child is 0,8 mm, in an adult 85 mm. The cornea contains up to XNUMX% water.

The cornea normally has transparency, specularity, shine, sensitivity, and sphericity. The cornea is the most powerful refractive medium in the eye (60,0 D in newborns and 40,0 D in adults).

The cornea is nourished by diffusion of nutrients from the marginal looped network and moisture from the anterior chamber. Sensitive innervation of the cornea is carried out by the trigeminal nerve, and trophic innervation is also due to the branches of the facial and sympathetic nerves.

The sclera is a dense opaque fibrous membrane, occupies 5/6 of the entire outer shell of the eye and anteriorly passes into the transparent cornea, and the surface layer of the sclera passes into the transparent shell later than the middle and deep ones. Thus, at the transition point, a translucent limbus border is formed.

In the posterior pole of the eye, the sclera becomes thinner and has a large number of holes through which the fibers of the optic nerve exit. This area of the sclera is called the lamina cribrosa and is one of its weak points. The plate under the influence of increased pressure can stretch, forming a deep excavation of the optic disc.

Outside, the sclera is covered with episclera, which forms the inner wall of Tenon's space. All oculomotor muscles are attached to the sclera. It has openings for the blood vessels and nerves of the eye.

In newborns and children of the first years of life, the sclera is thin, elastic, the choroid is visible through it, so the sclera has a bluish tint. With age, it becomes white, and by old age it turns yellow due to the degeneration of its tissue. Thin, elastic sclera in children of the first years of life under the influence of high intraocular pressure can stretch, which leads to an increase in the size of the eye (hydrophthalmos, buphthalmos).

The outer shell is the main optical medium, it gives the eye a shape, maintains a constant volume.

4. Vascular tract of the eye

The vascular tract, consisting of the iris, ciliary body and choroid, is located medially from the outer shell of the eye. It is separated from the latter by the suprachoroidal space, which is formed in the first months of a child's life.

The iris (anterior part of the vascular tract) forms a vertically standing diaphragm with a hole in the center of the pupil that regulates the amount of light entering the retina. The vascular network of the iris is formed by branches of the posterior long and anterior ciliary arteries and has two circles of blood circulation.

The iris can have a different color: from blue to black. Its color depends on the amount of melanin pigment contained in it: the more pigment in the stroma, the darker the iris; in the absence or small amount of pigment, this shell has a blue or gray color. In children, there is little pigment in the iris, so in newborns and children of the first year of life, it is bluish-gray. The color of the iris is formed by the age of ten and twelve. On its front surface, two parts can be distinguished: a narrow one, located near the pupil (the so-called pupillary), and a wide one, bordering on the ciliary body (ciliary). The boundary between them is the pulmonary circulation of the iris. There are two muscles in the iris that are antagonists. One is placed in the pupillary region, its fibers are located concentrically to the pupil, with their contraction the pupil narrows. Another muscle is represented by radially running muscle fibers in the ciliary part, with the contraction of which the pupil expands.

The ciliary body consists of a flat and thickened coronal parts. The thickened coronal part consists of 70 to 80 ciliary processes, each of which has vessels and nerves. The ciliary, or accommodative, muscle is located in the ciliary body. The ciliary body is dark in color and covered with retinal pigment epithelium. Zinn ligaments of the lens are woven into it in the interprocesses. The ciliary body is involved in the formation of intraocular fluid that nourishes the avascular structures of the eye. The vessels of the ciliary body depart from the large arterial circle of the iris, which is formed from the posterior long and anterior ciliary arteries. Sensitive innervation is carried out by long ciliary fibers, motor parasympathetic fibers of the oculomotor nerve and sympathetic branches.

The choroid, or the choroid itself, is composed mainly of short posterior ciliary vessels. In it, with age, the number of pigment cells of chromatophores increases, due to which the choroid forms a dark chamber that prevents the reflection of rays entering through the pupil. The basis of the choroid is a thin connective tissue stroma with elastic fibers. Due to the fact that the choriocapillary layer of the choroid is attached to the retinal pigment epithelium, a photochemical process is carried out in the latter.

5. The structure of the retina and optic nerve

The retina contributes to the lining of the entire inner surface of the vascular tract. It is also a peripheral part of the visual analyzer. Under microscopic examination, ten layers are distinguished in it. At the place corresponding to the transition of the choroid itself into the flat part of the ciliary body (the region of the dentate line), only two layers of epithelial cells are preserved from its ten layers, passing to the ciliary body, and then to the iris. In the region of the dentate line, as well as at the exit of the optic nerve, the retina is tightly fused with the underlying formations. For the rest of its length, it is held in a constant position by the pressure of the vitreous body, as well as the connection between the rods and cones and the retinal pigment epithelium, which is genetically related to the retina, and anatomically closely related to the choroid.

There are three types of neurons in the retina: rods and cones, bipolar cells, and multipolar cells. The most important area of the retina is the yellow spot, located at the posterior pole of the eyeball. The macula has a central fossa. In the area of the central fovea of the macula, instead of ten layers, only three or four layers of the retina remain: the outer and inner border plates and the layer of cones and their nuclei located between them. However, newborns have all ten layers in the macula area. This, along with other reasons, explains the child’s low central vision. In the central zone of the retina, predominantly cones are located, and towards the periphery the number of rods increases.

Nerve cell fibers (about 100) form the optic nerve, passing through the lamina cribrosa of the sclera. The inner part of the optic nerve is called the disc (nipple). It has a somewhat oval shape, its diameter in newborns is 000 mm, in adults it reaches 0,8 mm. In the center of the disc are the central retinal artery and vein, which branch and participate in feeding the inner layers of the retina. Topographically, in addition to the intraocular one, the intraorbital, intracanalicular and intracranial parts of the optic nerve are distinguished. In the cranial cavity, the optic nerve forms a partial decussation of the nerve fibers of the chiasm. The optic tracts emerge from the chiasm in the form of two separate trunks, ending in the primary visual centers (external geniculate bodies, visual tuberosities). Through the internal capsule in the form of a bundle, the optic fibers go to the cortical visual centers, ending in the occipital lobe, in the region of the avian spur furrow (field seventeen to nineteen according to Brodmann). It is in this area that the visual image of the surrounding world is formed.

6. The structure of the lens and vitreous body

The transparent contents of the eyeball are represented by aqueous humor, the lens and the vitreous body.

Aqueous moisture is enclosed in the anterior and posterior chambers of the eye. Its quantity in children does not exceed 0,2 cm³, and in adults it reaches 0,45 cm³.

The anterior chamber is the space bounded by the posterior surface of the cornea in front, the iris behind, and in the region of the pupil by the lens. The chamber has the greatest depth in the center, to the periphery it gradually decreases. In a newborn, mainly due to the greater sphericity of the lens, the anterior chamber is smaller than 1,5 mm.

The place where the cornea passes into the sclera, and the iris into the ciliary body, is called the angle of the anterior chamber of the eye. Through the angle of the anterior chamber, aqueous and anterior ciliary veins, aqueous humor is drained.

The posterior chamber is the space bounded anteriorly by the iris and posteriorly by the anterior surface of the lens. Through the region of the pupil, the posterior chamber communicates with the anterior one.

The lens is a transparent elastic body, has the shape of a biconvex lens. In newborns, the lens is almost spherical in shape. With age, the lens flattens somewhat, the radius of curvature of the anterior surface increases from 6 to 10 mm, and the posterior surface from 4,5 to 6 mm. The anteroposterior size of the lens of a newborn is 4 mm, and the diameter is 6 mm; the lens of an adult is 44,5 and 10 mm, respectively.

The lens has anterior and posterior surfaces, anterior and posterior poles, a sagittal axis and an equator. The lens is held in place by the ciliary body using the ligament of cinnamon. The lens contains a capsule and lenticular, or cortical, fibers. In children, the fibers are elastic; with age, the center of the lens becomes denser, and from the age of twenty-five thirty, a core begins to form, which gradually increases in size. The lens is made up of 65% water. It performs a refractive function; in relation to the average refractive power of the eye, it accounts for up to 40 out of 7780 diopters in newborns, and by the age of fifteen, 20 out of 60 diopters.

The vitreous body is the main supporting tissue of the eyeball. Its weight in a newborn is 1,5 g, in an adult 67 g. The vitreous body is a formation of a gelatinous consistency, 98% consisting of water, containing an insignificant amount of protein and salts. In addition, it has a thin connective tissue skeleton, thanks to which it does not blur, even if taken out of the eye. On the anterior surface of the vitreous body there is a recess, the so-called plate-shaped fossa, in which lies the posterior surface of the lens.

The vitreous body, being a transparent medium, provides free passage of light rays to the retina, protects the inner membranes (retina, lens, ciliary body) from dislocation. This allows you to perform the accommodative function of the eye, one of the main functions of the organ of vision.

7. Method of external examination of the eye

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 openings, 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.

8. Method of examining the eye using side lighting

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.

9. Combined method of eye examination

The method 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. 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, the 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.

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.

10. Technique of examining the eye in transmitted light and ophthalmoscopy

The deep media of the eye (the lens and the vitreous body) are examined in transmitted light using an ophthalmoscope. The light source (matte electric lamp with a power of 60100 W) is placed on the left and behind the patient, the doctor sits opposite. Using an ophthalmic mirror placed in front of the researcher's right eye, a beam of light is directed into the pupil of the examined eye from a distance of 2030 cm. The researcher examines the pupil through the opening of the ophthalmoscope. In cases where the refractive media of the eye are transparent, the reflex from the fundus is uniformly red. Various obstacles in the way of the passage of the light beam, i.e., turbidity of the media, delay part of the rays reflected from the fundus of the eye. Against the background of a red pupil, these opacities are visible as dark spots of various shapes and sizes. Changes in the cornea can be easily excluded when viewed using lateral illumination.

With a significant change in the vitreous body due to inflammation of the vascular tract or hemorrhage, the reflex from the fundus becomes dull or absent.

The fundus of the eye is examined using the ophthalmoscopy method, which is one of the most important methods for studying the organ of vision, allowing one to judge the condition of the retina, its vessels, choroid and optic nerve. The most widely used ophthalmoscopy method is the reverse. The study is carried out in a darkened room. An ophthalmoscopic mirror is placed in front of the right eye of the examiner seated at a distance of 4050 cm from the subject. The light source is positioned behind and to the left of the patient, as in a transmitted light examination. After obtaining a uniform glow of the pupil, the researcher places a magnifying glass (usually 13,0 diopters) 78 cm in front of the patient's eye, resting his finger on his forehead. A true inverse and approximately 5 times magnified image of the fundus is seen hanging in the air at a distance of about 7 cm in front of the magnifying glass. To examine a larger area of the fundus, if there are no contraindications, the patient’s pupil is first dilated with a 1% solution of homatropine or a 0,25% solution of scopolamine.

Examination of the fundus begins with the most visible part of the optic nerve head. Against the red background of the fundus, the optic disc appears as a yellowish-pink, slightly oval formation with clear boundaries. The color, contours and tissue of the optic nerve head change with inflammation and congestion, optic nerve atrophy, damage to the choroid and many common diseases, in particular blood vessels, blood, etc. Pay attention to the state of the retinal vessels emerging from the middle of the optic nerve head, their caliber, color, width of the reflex strip located along the lumen of the larger arteries and eyelids.

A thorough study of changes in the fundus is carried out by direct ophthalmoscopy.

11. Methods for detecting pathological conditions of the eye

Gonioscopy (from Latin gonia "angle") is a special method for examining the angle of the anterior chamber. It can only be carried out with the help of optical gonioscopes. The study of the chamber angle is of great importance for the diagnosis, therapy and prognosis of a number of diseases (glaucoma, uveitis, injuries, etc.). The most important outflow pathway for intraocular fluid begins at the camera angle. The angle can be narrowed, obliterated, foreign bodies, a germinating tumor can be found in it.

Tonometry is a necessary study in all cases when there is a thought that the patient has glaucoma, secondary eye hypertension or hypotension, in various general and local diseases.

Approximate pressure in the eye can be determined by palpation. In this case, it is necessary that the patient looks down, and the researcher, with index fingers located above the level of the cartilage, presses in turn through the upper eyelid (when looking up through the lower) on the eyeball (similar to the study of abscess fluctuation). When analyzing pressure, it is necessary to compare its value in one and the other eye.

If the ophthalmotonus is within the normal range, it is designated as TN if its value is 2835 mm Hg. Art. T + 1, more than 36 mm T + 2, if hypotension of the order of 1522 mm Hg is detected. Art. T 1, less than 12 mm Hg. Art. T 2.

For the quantitative determination of ophthalmotonus in Russia, the Maklakov tonometer is most widely used.

Tonography is a method for studying the hydrodynamics of the eye. It allows you to determine the state of the outflow of intraocular fluid and is used mainly when examining patients with glaucoma or when it is suspected. The degree of reduction is different in healthy individuals and in patients with glaucoma, which is reflected in the nature of the tonographic curve. Graphic registration of changes in ophthalmotonus becomes possible by connecting a recording device. Data is recorded on a moving paper tape.

To study the optical system of the eye, to measure the anteroposterior and other dimensions, the method of ultrasonic echo-ophthalography is used. It consists in the registration of ultrasonic signals reflected from the interfaces between the media and tissues of the eye with different acoustic properties.

Studies are carried out on the diagnostic device echo-ophthalograph.

Ultrasound examination is also used to detect foreign bodies in the eye, for the purpose of diagnosing retinal detachments, tumors, etc., especially in cases where examination of the fundus is impossible due to clouding of the transparent media.

If a patient has exophthalmos or enophthalmos (protrusion or retraction of the eyeball), special devices are used to quantify them and judge the dynamics of the process (orbital tumors, retrobulbar hematoma, orbital bone fractures, etc.). The most common mirror exophthalmometer.

12. Inflammatory eye diseases

Signs of diseases of the eyelids are very characteristic. Patients are often concerned about itching and burning in the eyelids, eye fatigue, and there may be a change in the shape and size of the palpebral fissure, the position of the ciliary edge of the eyelids, etc. The pathology of the eyelids, unlike diseases of the eyeball, is quite easy to determine already with an external examination. Since the symptoms of inflammation of the soft tissues of the eye and the optical structures themselves are not long in coming.

A sharp swelling and hyperemia of the eyelids may indicate the presence of gonoblenorrhea (in children), diphtheria, as well as an abscess of the eyelids, acute meibomitis, barley. Edema, especially in the outer part of the upper eyelid, is noted in cases of inflammation of the lacrimal gland. Pronounced "cold" edema can be with allergic conditions.

When examining the edge of the eyelids, attention is paid to the features of eyelash growth, the presence of skin changes at their base, the condition of the excretory ducts of the meibomian glands. To clarify the diagnosis, carefully examine the eyelids and their position under side lighting and palpation. During the examination, attention is paid to the presence of skin lesions, which can be the entrance gate for infection.

1. Abscess of the century (abscessus palpebrae). On examination, hyperemia of the skin of the eyelids is determined, palpation reveals induration (edema, infiltration) and tissue tension, their soreness.

In addition, the pre-auricular lymph nodes may be enlarged and painful. If, along with all these signs, there is local softening and fluctuation, then opening the abscess (incision) is advisable. In the absence of fluctuations, the administration of antibiotics in the form of injections around the abscess and oral administration of antibiotics or sulfonamides and UHF therapy are indicated.

2. Meibomite (meibomitis, hordeolum internum).

If, when examining a patient, there is limited infiltration in the eyelid area, the eyelid is painful on palpation, and when everted through the conjunctiva, a translucent yellowish focus in the cartilage is visible, then the diagnosis of meibomitis is undoubted acute purulent inflammation of the meibomian gland. Severely leaking meibomitis can lead to the formation of an extensive abscess of the eyelid.

Treatment. Warming procedures, UHF therapy, disinfectants.

3. Chalazion is a tumor-like, limited, somewhat protruding formation, dense to the touch, painful, soldered to cartilage. It usually occurs after acute inflammation of the eyelid (meibomitis) and in some cases gradually increases.

Treatment of chalazion (hailstones) consists in absorbable drug therapy. However, most often it is ineffective, and then surgical removal of the hailstone in the capsule through an incision in the conjunctiva of the eyelid and cartilage is indicated, followed by treatment of the chalazion bed with an iodine solution.

13. Barley

Barley is a purulent inflammation of the hair follicle or sebaceous gland of the edge of the eyelid, located at the root of the eyelash. The causative agent is most often a representative of the pyogenic flora, mainly staphylococcus aureus. Infection is facilitated by blockage of the excretory duct of the gland with a secret, as well as a decrease in the overall resistance of the body and diabetes mellitus.

Clinical picture and diagnosis. It is characterized by the appearance of a circumscribed and sharply painful swelling near the edge of the eyelid, which is accompanied by swelling and redness of its skin and (often) the conjunctiva. The inflammatory formation grows quite quickly, and after two to four days it undergoes purulent melting, which can be determined by the appearance of a yellow head at the top of the stye. On the third or fourth day, its contents (pus, dead tissue) break out, after which the pain immediately decreases and the inflammation subsides. Swelling and redness of the skin disappear around the end of the week.

In some cases, the inflammatory formation consists of several closely spaced or merged heads. In such cases, barley can occur against the background of intoxication, high temperature, and regional lymphadenitis.

A similar clinical picture is observed in acute purulent inflammation of the meibomian gland, meibomite, however, the breakthrough of pus usually occurs from the side of the conjunctiva and cartilage, after which granulations (connective tissue) often grow. Streets with low body resistance barley is prone to recurrence and is often combined with furunculosis.

Complications of stye can occur due to orbital phlegmon, thrombophlebitis of the orbital veins, purulent meningitis, which is most often associated with attempts to squeeze pus out of it.

When examining the eyelids, their hyperemia, swelling, density and pain are revealed, i.e. the picture resembles a limited abscess or acute meibomitis. However, upon closer examination, the inflammatory focus is determined in a limited area of the ciliary edge of the eyelid in the form of swelling and hyperemia at the root of the eyelash. Usually after three to four days the inflammatory focus suppurates and opens.

Treatment. Dry heat and UHF are applied locally. A 23% solution of albucid, a 20% solution of erythromycin, and a 1% solution of dexamethasone are instilled into the conjunctival sac 0,1 times a day. The area of infiltration (inflammation) on the skin of the eyelid is lubricated with a 1% alcohol solution of brilliant green.

After opening the stye, 2% albucidal ointment (sodium sulfacyl), 20% syntomycin emulsion, 1% tetracycline ointment, 1% hydrocortisone emulsion, 1% yellow mercury ointment are applied to the eyelids 1 times a day.

If the disease is accompanied by symptoms of intoxication, sulfanilamide preparations are administered orally 1 g 4 times a day or tetracycline antibiotics (biomycin 100 IU 000 times a day, tetracycline or terramycin 46 g 0,25 times a day).

With recurrent barley, the patient is shown a thorough examination.

14. Infectious and viral lesions of the eyes

Drug intolerance may occur after topical atropine, quinine, antibiotics, and other drugs. At the same time, children go to the doctor with reddening of the skin of the eyelids, vesicles on the eyelids, erosions at the site of the former vesicles, as well as with conjunctivitis. This pathological condition is called eyelid toxicoderma.

Treatment. Cancellation of drugs that can cause the disease, and the appointment of desensitizing agents (calcium chloride, diphenhydramine).

Sometimes, after an infection, a cold, edematous eyelids are observed with the presence of transparent vesicles or crusts that appear after the vesicles dry. The process is accompanied by severe itching and local pain. This is most likely herpes simplex eyelids, caused by a filterable virus (herpessymplex). In some cases, on the skin, more often than the upper eyelid, as with herpes simplex, vesicles of large sizes and in greater numbers are found. The transparent contents of the vesicles may become cloudy, become purulent, crusts, ulcers may form. The process is accompanied by severe local and headaches. This is herpes zoster.

Treatment. Analgesics, B vitamins, brilliant green moxibustions.

Vaccine pustules of the eyelids during external examination reveal cyanotic edges of the eyelids, pustules (cloudy vesicles) and sores with a greasy coating on the skin. The eyelids are painful on palpation, the anterior lymph nodes are enlarged and painful. On the eyelids of children, single and multiple yellowish nodules of various sizes and with a depression in the center are found. This is a typical picture of an infectious mollusk, refers to filterable viruses.

Due to the significant contagiousness of the disease, treatment consists in removing the nodules and treating the bed with iodine (Lugol's solution).

If the patient complains of itching in the eyelids, eye fatigue, and on examination it is found that the edges of the eyelids are hyperemic, thickened, small grayish scales or yellowish crusts are visible at the base of the eyelashes, then this makes it possible to suspect scaly blepharitis.

In cases where the edges of the eyelids are sharply hyperemic, thickened, covered with ulcers and yellowish crusts, after removing which the surface bleeds, one should speak of ulcerative blepharitis. In this case, the hair follicles and sebaceous glands are involved in the process. Treatment of blepharitis is aimed at eliminating its possible cause. In addition, general strengthening agents are prescribed. The edges of the eyelids are degreased with 70% alcohol and treated with disinfectant solutions.

Occasionally (especially in children), when examining the intermarginal space, it is possible to detect abnormal growth of trichiasis eyelashes. Separate eyelashes face the eye, irritate the conjunctiva and cornea, causing tearing, pain, contributing to the development of corneal ulcers.

Treatment. Diathermocoagulation of eyelash bulbs with a needle electrode; with gross changes, plastic surgery is indicated.

15. Inflammation of the lacrimal gland

With the pathology of the lacrimal gland, there may be increased tearing or, conversely, dry eyes. However, pain and size change are more often determined. There are dacryadenitis in the form of sharp inflammatory changes in the eyelids and conjunctiva or cysts of the lacrimal gland, resembling translucent tumors of various sizes.

Palpation of the lacrimal gland area is performed through the skin of the upper eyelid, while determining its consistency, size and location.

More often, changes are noted in the lacrimal ducts. The study of their condition begins with examination of the lower lacrimal opening. It usually faces the eyeball and becomes visible if you bend the lower eyelid slightly. Atresia of the lacrimal openings, their dislocation, and narrowing may be detected, which is accompanied by impaired absorption of tears and the appearance of lacrimation. In old age, inversion of the lacrimal punctum is often observed. If there are no changes in the lacrimal opening, then lacrimation may be due to pathology of the lacrimal canaliculi or other parts of the lacrimal ducts. To determine the state of the main function of the lacrimal ducts (the passage of tears through the lacrimal canaliculi and its discharge into the nose), a color test is used. Passing a blunt needle or conical probe into the lacrimal sac before washing it also serves as a diagnostic technique, as it allows one to judge the presence of narrowing of the tubule or obstacles in it. Rinsing is carried out after instillation of a 0,5% solution of dicaine (1% lidocaine) into the conjunctival cavity. Dacryoadenitis is inflammation of the lacrimal gland.

It can be both acute and chronic. It occurs mainly due to endogenous infection with measles, scarlet fever, mumps, typhoid fever, rheumatism, tonsillitis, influenza. The process is often one-sided.

If in the lateral part of the upper eyelid, according to the localization of the lacrimal gland, there is swelling and the upper eyelid acquires an S-shape, palpation in this area is marked by compaction and pain, swelling of the mucous membrane of the eyeball is noted (chemosis), sometimes yellowish areas of suppuration of the gland or opened abscesses on the side of the conjunctiva, purulent contents are released into the conjunctival cavity, and upward and outward mobility of the eye is limited, regional lymph nodes are enlarged and painful, this indicates dacryoadenitis. Sharp swelling, pain, redness of the outer part of the upper eyelid. The palpebral fissure takes on a changed shape. Redness and swelling of the conjunctiva of the eyeball in the upper outer region are noted. There may be a downward and inward displacement of the eye and a limitation of its mobility. The preauricular regional lymph nodes are enlarged and painful. However, more often the disease is benign.

The goal of treatment is to combat the common disease. In an acute process, antibiotics are prescribed (ampicillin, oletethrin, metacycline in four to six doses), sulfonamides, and symptomatic agents.

16. Inflammation of the tubules and lacrimal sac

With canaliculitis, there is a slight swelling in the area corresponding to the lacrimal openings and tubules. In addition, hyperemia of the skin, lacrimation and purulent discharge are revealed, and when pressing on this swelling with a finger or a glass rod, a mucous or purulent plug is released from the lacrimal opening. In some cases, the squeezed out contents of the tubule is a crumbly yellowish secret containing grains of fungal calculus. It is necessary to subject the discharge to bacteriological examination.

Treatment. Antibiotics and sulfonamides are used locally; sometimes dissection of the affected tubule is used, scraping out the contents with a sharp spoon, followed by treatment of the cavity with a 12% solution of lapis, iodine tincture.

Dacryocystitis inflammation of the lacrimal sac. It occurs in acute and chronic form.

When examining children in the first weeks of life, a slight lacrimation and lacrimation are sometimes detected, and in some cases a purulent discharge is detected. If, moreover, when pressing on the area of the lacrimal sac, the mucous or purulent contents of the sac are released from the lacrimal puncta into the conjunctival cavity, then the diagnosis of neonatal dacryocystitis becomes obvious. If dacryocystitis exists for a long time, then a strong stretching (dropsy) of the lacrimal sac occurs, swelling is observed, a significant protrusion of tissues in the area of the lacrimal sac.

Often, dacryocystitis is complicated by the development of phlegmon of the lacrimal sac. At the same time, pronounced swelling and a sharp painful infiltration of surrounding tissues appear. The palpebral fissure may close completely.

The development of chronic dacryocystitis occurs due to stenosis of the nasolacrimal duct, leading to stagnation of the tear and the detachable mucous membrane of the lacrimal sac. There is a gradual stretching of the wall of the bag. The contents accumulating in it are a favorable environment for the development of pathogenic microflora (streptococcus, pneumococcus, etc.). The transparent secret of the cavity of the lacrimal sac becomes mucopurulent. The most common damage to the lacrimal openings and tubules in wounds of the eyelids.

Clinical picture and diagnosis. Complaints of persistent lacrimation, purulent discharge from the eye. There is an excess of tears along the edge of the lower eyelid, a soft protrusion of the skin at the inner edge of the eye. When pressing on the area of the lacrimal sac, mucous or mucopurulent contents flow abundantly from the lacrimal openings. The lacrimal sac may be so distended that grayish contents show through the thinned skin. This condition is called dropsy of the lacrimal sac.

For diagnosis, biomicroscopy, tubular and nasal samples are used.

Treatment. Chronic dacryocystitis is treated only surgically. A dacryocystorhinostomy is necessary to create a direct fistula between the lacrimal sac and the nasal cavity.

17. Pathological processes of the orbit

The main symptom of most diseases of the orbit, both inflammatory and non-inflammatory, is exophthalmos, along with which other symptoms can be noted. The eyeball, depending on the localization of the process in the orbit, can be displaced in one direction or another, its mobility can be limited, diplopia occurs. Sometimes there are changes in the condition of the edges and walls of the orbit. In the presence of dense tissue in the retrobulbar space, the reposition of the eyeball is difficult. In inflammatory diseases of the orbit, eyelids are often involved in the process, possibly a serious general condition of the patient.

In children of any age, but more often in the first year of life and at school age, among full health, eyelid edema suddenly and quickly appears, sometimes significant, chemosis is possible. Exophthalmos develops rapidly, but there may also be a shift of the eyeball to the side (with ethmoiditis, periostitis). The mobility of the eyeball, as a rule, is limited due to a mechanical obstacle, damage to the muscles and motor nerves. There is a severe general condition, high fever, headaches and pain in the orbit.

In infants, general symptoms of the disease often prevail over local ones. In children of the first months of life, except for exophthalmos, it is not possible to identify other signs of the disease. A carefully collected history, consultations of an otolaryngologist, a dentist, and radiography of the paranasal sinuses contribute to the establishment of its cause. In infants, orbital phlegmon is more often associated with inflammatory processes in the upper jaw, umbilical sepsis and dacryocystitis, in schoolchildren with orbital injuries and sinusitis.

Treatment. Loading doses of broad-spectrum antibiotics intramuscularly, periorbitally and retrobulbarno.

If necessary, the cells of the ethmoid labyrinth are opened, the maxillary sinus is punctured. At the same time, the phlegmon of the orbit is opened with drainage of the wound cavity with turunda soaked in antibiotics.

Examination of a patient with sarcoma reveals exophthalmos, displacement of the eyeball, limitation of its mobility, diplopia, a painless tumor-like elastic formation, sometimes soldered to the underlying tissues and skin, is palpated. More often the tumor is localized in the upper half of the orbit. The diagnosis becomes even more likely when indicating the rapid growth (weeks and months) of the tumor.

Orbital sarcoma should be differentiated from eosinophilic granuloma, tumor-like forms of leukemia. To clarify the diagnosis, it is necessary: radiography of the orbits, sternal puncture (study of the myelogram), often puncture biopsy.

Treatment consists of exenteration of the orbit followed by x-ray and chemotherapy.

In some types of leukemia (hemocytoblastosis, etc.), tumor-like infiltration nodes appear on the upper or, less often, lower edge of the orbit, developing from the hematopoietic tissue of the flat bones of the orbit, called lymphomas. Exophthalmos, displacement of the eyeball are noted.

18. Conjunctivitis

Conjunctivitis is an inflammation of the mucous membrane that lines the back of the eyelids and the eyeball.

Due to the occurrence, bacterial conjunctivitis (staphylococcal, streptococcal, gonococcal, diphtheria, pneumococcal), viral conjunctivitis (herpetic, adenovirus, epidemic keratoconjunctivitis), chlamydial conjunctivitis (trachoma), allergic and autoimmune conjunctivitis (drug, hay fever, tuberculosis-allergic) are distinguished. According to the nature of the course, conjunctivitis is divided into acute and chronic.

General symptoms characteristic of all conjunctivitis include subjective complaints of the patient and objective signs. Subjective symptoms include a burning sensation and itching in the eye, a feeling of blockage, and photophobia. Acute infectious conjunctivitis (the most common of all bacterial conjunctivitis) is caused by staphylococci and streptococci. Both eyes are involved in the pathological process, but more often not simultaneously, but sequentially. In addition to the symptoms common to all conjunctivitis, this type is characterized by the presence of purulent discharge that sticks the eyelashes together. Pneumococcal conjunctivitis: pinpoint hemorrhages in the conjunctiva, swelling of the eyelids and the formation of whitish-gray films.

Acute epidemic conjunctivitis of Koch Wicks is characterized by a very high contagiousness. The disease begins suddenly with a sharp swelling of the eyelids, redness of the conjunctiva of the eyelids and the eyeball. The discharge is at first meager, then becomes abundant and purulent. Gonococcal conjunctivitis (gonoblennorrhea) is caused by gonococcus and is clinically subdivided into gonoblenorrhea of newborns, children and adults. Clinically, gonoblenorrhea is manifested by a sharp reddening of the conjunctiva with profuse bloody discharge (the color of meat slops).

Corneal ulceration is a complication of gonoblenorrhea.

Gonoblenorrhea in adults occurs with severe general symptoms: fever, damage to the joints and the cardiovascular system. In adults, complications of gonococcal conjunctivitis are quite common.

Diphtheria conjunctivitis is rare (if the diphtheria vaccination regimen is not followed) and is accompanied by severe intoxication, high body temperature, swollen lymph nodes and their soreness. Local hallmarks of diphtheria conjunctivitis are gray membranous plaques on the conjunctiva of the eyelids and the eyeball. Their removal is painful and accompanied by bleeding. Most often, herpetic conjunctivitis is unilateral and has a long course. Adenovirus conjunctivitis is caused by adenoviruses and is accompanied by fever and pharyngitis. Allergic and autoimmune conjunctivitis develops with increased sensitivity of the body to a wide variety of substances.

Treatment. For acute infectious conjunctivitis, antimicrobial drugs are prescribed: 30% sodium sulfacyl solution, antibiotic solutions, furatsilin solution at a dilution of 1:5000. On the first day of illness, drops are instilled into the conjunctival sac every hour.

19. Features of the course of conjunctivitis of various ethnologies

Acute epidemic conjunctivitis occurs in children, mainly toddlers, more often in the morning, after sleep, against the background of general symptoms characteristic of conjunctivitis, pronounced swelling (chemosis) of the lower transitional folds, petechial hemorrhages in the conjunctiva of the eyelids and transitional folds can be observed. In older children, against the background of hyperemic mucous membrane of the eyeball, ischemic densified white areas in the form of two triangles are formed, the base facing the cornea. When examining the cornea, infiltrates can be detected. Recovery occurs within five to seven days.

Sometimes, along with the general symptoms of conjunctivitis in children, pinpoint hemorrhages are found in the conjunctiva of the eyeball and transitional folds, and gentle pinpoint infiltrates are visible on the cornea near the limbus. With such changes, one can think of acute pneumococcal conjunctivitis.

The presence of delicate gray films on the conjunctiva of the eyelids and vaults, weakly associated with the underlying tissue and, when removed, do not leave bleeding surfaces, will indicate a false-membrane form of pneumococcal conjunctivitis.

There is a sharp swelling of both eyes on the second or third day after birth; when the palpebral fissure opens, watery fluid is ejected almost like a fountain from the conjunctival cavity, the conjunctiva is thickened and bleeds slightly. This clinical picture is typical for the initial period of gonoblenorrhea. If the disease lasts more than a week, then a sharp infiltration of the conjunctiva and pyorrhea are observed, swelling and hyperemia of the eyelids decrease at this stage. The discharge is purulent, yellowish-green in color. The conjunctiva of the eyeball is swollen and surrounds the cornea in the form of a shaft. During this period, changes in the cornea are possible due to disruption of its nutrition due to severe infiltration of the eyelids and mucous membrane, as well as as a result of the melting effect of pus on its tissue. In the third or fourth week of the disease, papillary hypertrophy of the conjunctiva may be detected. The eyes are almost calm, the swelling of the eyelids and conjunctiva is slight, and a liquid greenish discharge appears again. Papillae form on the conjunctiva, it becomes uneven and rough. The process can be protracted or chronic. However, usually in the second month the phase of reverse development of all signs of the disease begins, resulting in clinical recovery.

Diphtheria conjunctivitis is manifested by the fact that the eyelids resemble plums in appearance, and upon palpation they are dense and painful. The conjunctiva is pale due to compression of the vessels, or there are grayish-yellow films with numerous hemorrhages on it. Removal of films is accompanied by bleeding. When the disease lasts seven to ten days, sloughing films and granulation tissue with a large amount of pus are visible. Subsequently, star-shaped scars form at the site of granulation. Sometimes less pronounced symptoms of eyelid edema, more delicate films on the conjunctival cartilage and scanty discharge are observed.

20. Trachoma

Trachoma is a chronic infectious eye disease. The causative agent of infection is the microorganism chlamydia, which causes damage to the conjunctiva and cornea with an outcome in scarring, destruction of the cartilage of the eyelids and complete blindness. The causative agent of trachoma in its properties and cycle of intracellular development is similar to other chlamydia.

The incubation period is seven to fourteen days. The onset of the disease is acute, but in many patients it develops gradually, and the course of the infection is chronic. Both eyes are usually affected. With the acute onset of the disease, symptoms of acute conjunctivitis are observed (redness of the skin of the eyelids, photophobia, copious mucopurulent discharge, the conjunctiva is swollen and hyperemic).

There are four stages during the trachomatous process:

1) the development of a follicular reaction, lymphoid subconjunctival infiltration, limbitis (inflammation of the limbus) and pannus of the cornea;

2) the appearance of scars replacing follicles;

3) the predominance of scarring of the conjunctiva and cornea;

4) ending scarring, covering the conjunctiva, cornea, cartilage of the eyelids.

There are four forms of the disease:

1) follicular, in which predominantly follicles are observed;

2) papillary with a predominance of papillary growths;

3) mixed, when both follicles and papillary growths are found;

4) infiltrative, characterized by predominant infiltration of the conjunctiva and cartilage of the eyelids.

The clinical picture of trachoma when infected in early childhood is similar to neonatal blenorrhea. Repeated exacerbations in these patients cause the development of corneal cicatricial changes characteristic of trachoma.

The consequences of trachoma are due to the process of scarring, which leads to the appearance of adhesions between the conjunctiva of the eyelid and the eyeball. Pronounced scarring of the conjunctiva in combination with trichiasis (improper growth of eyelashes) and inversion of the eyelids leads to a decrease in vision, and scarring and clouding of the cornea to partial or complete loss of vision.

The diagnosis of trachoma is established when at least two of the four cardinal signs of the disease are detected, such as follicles on the conjunctiva of the upper eyelid, follicles in the region of the upper limb or their consequences (fossae), typical conjunctival scars, pannus, more pronounced in the upper limbus.

Treatment. Topically apply 1% ointments or solutions of tetracycline, erythromycin, oletethrin, 10% solutions of sodium sulfapyridazine, 5% ointments or 3050% solutions of etazol 36 times a day. If necessary, after one to two weeks from the start of treatment, follicle expression is performed.

21. Strabismus

Strabismus is the deviation of one or both eyes from a common point of fixation, while normal vision is disturbed (the coordinated work of both eyes).

Paralytic strabismus is observed with weakness of the muscular apparatus of the eyeball, which may be due to trauma, tumor, neuroinfections, concomitant strabismus develops in childhood.

Clinically, paralytic strabismus is manifested by the limitation or absence of movements of the squinting eye in the direction of the affected muscle, while there is a feeling of doubling of objects. With a long-term strabismus, vision may be reduced. Concomitant strabismus develops in childhood, while the movements of the eyeballs are preserved in full, and there is no doubling. Deviation of the eye to the nose is referred to as convergent strabismus; when the eye deviates to the temple, strabismus is considered divergent. In addition, there are deviations of the eyeball up and down, as well as a combination of horizontal and vertical deviation of the eyes.

With a constant deviation of one eye, strabismus is considered one-sided, both eyes are bilateral, alternate deviation of one or the other eye is intermittent.

In all patients with strabismus, both the anterior segment of the eye and the fundus of the eye are carefully examined with a dilated pupil.

It is also necessary to examine the visual acuity of the child, first without correction, then with existing glasses. If the vision is below 1,0 in glasses, an attempt is made to correct it.

If even with correction it was not possible to achieve full vision, this may indicate (in the absence of morphological changes in the eye) a steady decrease in vision without visible organic changes as a result of the existing strabismus of dysbinocular amblyopia. The division of amblyopia according to severity:

1) light 0,80,5;

2) average 0,40,3;

3) severe 0,20,05;

4) very severe 0,04 and below.

Then the nature of fixation is determined. This means that non-central fixation is accompanied by very low visual acuity.

In all patients with strabismus, to decide whether they need to wear glasses, examine the clinical refraction by skiascopy or refractometry.

In cases where the correction of ametropia does not completely eliminate the deviation of the eye, the strabismus should be considered partially accommodative.

If the strabismus does not decrease under the influence of correction, therefore, it is of a non-accommodative nature.

The next step in the study is the determination of the angle of strabismus. It is determined by various methods, the simplest of which is the Hirshberg method.

In examining a child with strabismus, it is important to determine the functional state of the oculomotor muscles.

22. Detection of pathology of the vascular tract of the eye

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. Most often, iridocyclitis in children develop with influenza, tuberculosis, rheumatism, diseases of the paranasal sinuses, teeth, toxoplasmosis, childhood infections, etc. 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. 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. 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.

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. 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.

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. 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 those cases where there are opacities of the vitreous body, they are detected by shadows that have a different shape, size, intensity and mobility. 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 .

23. Iridocyclitis

Iridocyclitis is an inflammation of the anterior choroid (iris and ciliary body).

The causes of the disease are general diseases of the body, often of an infectious nature, viral infections, rheumatism, tuberculosis, focal infections, eye injuries, syphilis, toxoplasmosis, diabetes, gout, gonorrhea, brucellosis. There are two forms of iridocyclitis acute and chronic.

Acute iridocyclitis is the cause of severe pain in the eye, photophobia, lacrimation, blepharospasm, and headache. Diffuse hyperemia of the sclera around the cornea with a purple tint (pericorneal injection), discoloration and blurring of the iris pattern, narrowing and deformation of the pupil, and its poor reaction to light are characteristic.

The moisture in the anterior chamber becomes cloudy, and a gelatinous exudate forms in the area of the pupil. So-called grayish-white precipitates, round-shaped deposits of exudate, appear on the posterior surface of the cornea. In severe cases, purulent exudate is visible and clouding is detected in the vitreous body. The disease is long-term, with relapses.

Influenza iridocyclitis occurs and proceeds acutely, the pain syndrome is expressed slightly. The pathological process is manifested in a sharp pericorneal reaction, the appearance of serous exudate.

Rheumatic iridocyclitis begins acutely and proceeds rapidly. Hemorrhage is observed in the anterior chamber, as well as under the conjunctiva, there is a sharp mixed injection of the eyeball. Exudation has a gelatinous character, insignificant, but there are numerous pigmented posterior synechia. Iridocyclitis in collagen diseases. The most studied is iridocyclitis in infectious nonspecific polyarthritis. The earliest signs are small precipitates on the posterior surface of the cornea near the inner and outer limbus. The course of chronic iridocyclitis is sluggish, sometimes with slight pain, moderate hyperemia, but exudation often occurs, which leads to the formation of coarse adhesions of the iris with the lens, the deposition of exudate in the vitreous body, and atrophy of the eyeball. An important role in the development of chronic iridocyclitis is played by the herpes simplex virus, tuberculosis, penetrating wounds of the eye.

Tuberculous iridocyclitis has a sluggish course, occurs gradually, is characterized by the appearance of new vessels in the iris, which sometimes fit and surround single or multiple tuberculomas. There may be flying nodules along the edge of the pupil. The precipitates are large, have a greasy appearance, contain a lot of exudate.

Treatment. Treatment of iridocyclitis is reduced to the treatment of the underlying disease and special ophthalmic treatment. The latter includes dilation of the pupil with mydriatics. With the formation of posterior adhesions, the introduction of fibrinolysin and a mixture of mydriatics by electrophoresis is recommended.

Anti-inflammatory and antiallergic drugs are prescribed: corticosteroids in the form of instillations of a 5% cortisol solution 56 times a day or subconjunctival injections.

24. Irit

Iritis is an inflammatory process in the iris.

The introduction of infection into the eye during injuries, various diseases (flu, diseases of the teeth and tonsils, tuberculosis, rheumatism, brucellosis, etc.). The inflammatory process in the iris begins with aching pains in the eye, which subsequently spread to the temporal region. At the same time, photophobia, lacrimation, blepharospasm appear, vision deteriorates.

On examination, there is dilation of the passing vessels and pericorneal injection. In this case, a pinkish-violet corolla appears around the cornea. A characteristic sign of iritis is a change in the color of the iris. To get a clear picture of this change, it is recommended to examine the iris in natural light, comparing the color in one eye and the other. The gray and blue iris takes on a green or rusty tint, and the brown iris turns yellow.

Changing color, the iris becomes cloudy and loses the characteristic pattern of depressions (iris crypts). Hyperemia of the vessels in iritis causes a narrowing of the pupil, which can be easily seen by comparing the diseased eye with a healthy one.

A characteristic feature of iritis are the so-called adhesions (synechia). The adhesions of the iris to the anterior surface of the lens are called posterior iris commissures. They can be detected when mydriatics are instilled into the eye (1% solution of platyphylline, 1% solution of homatropine hydrobromide or 1% solution of atropine). Under their influence, the pupil dilates unevenly, its shape becomes irregular. When mydriatics are instilled into a healthy eye, the pupil, expanding unevenly, retains its regular round shape.

Posterior adhesions pose a certain danger in iritis, since their large accumulation can serve as an obstacle to the penetration of intraocular fluid through the pupil into the anterior chamber, which leads to the formation of excess fluid and, consequently, to an increase in intraocular pressure. If it is not reduced, blindness may occur.

Treatment. Emergency care in the treatment of the inflammatory process of the choroid consists primarily of preventing the formation of posterior adhesions of the iris or their ruptures, if they have already appeared. For this purpose, repeated instillation of mydriatics is used. It should be remembered that mydriatics can only be used when intraocular pressure is low (if intraocular pressure is elevated, it is better to use a 0,1% solution of adrenaline or a 1% solution of mesatone instead of these drugs). A swab moistened with one of these solutions is placed behind the lower eyelid. Then, repeated instillations of a solution of ofthandexamethasone or a 12% suspension of hydrocortisone are performed. At the same time, antibiotics are required.

Treatment depends on the etiology of the disease, with appropriate antibiotic therapy and topical corticosteroids.

25. Uveitis

Uveitis is inflammation of the choroid (uveal tract) of the eye. Distinguish between the anterior and posterior sections of the eyeball. Iridocyclitis, or anterior uveitis, is inflammation of the anterior iris and ciliary body, and choroiditis, or posterior uveitis, is inflammation of the posterior, or choroid. Inflammation of the entire vascular tract of the eye is called iridocyclochoroiditis, or panuveitis.

The main cause of the disease is infection. The infection penetrates from the external environment with eye injuries and perforated corneal ulcers and from internal foci with general diseases.

In the mechanism of development of uveitis, the protective forces of the human body play an important role. Depending on the reaction of the choroid, atopic uveitis associated with the action of environmental allergens (pollen, food, etc.) is distinguished; anaphylactic uveitis caused by the development of an allergic reaction to the introduction of immune serum into the body; autoallergic uveitis, in which the allergen is the choroid pigment or lens protein; microbial-allergic uveitis, which develops in the presence of a focal infection in the body.

The most severe form of uveitis is panuveitis (iridocyclochoroiditis). It can occur in acute and chronic forms.

Acute panuveitis develops due to the entry of microbes into the capillary network of the choroid or retina and is manifested by sharp pains in the eye, as well as decreased vision. The process involves the iris and ciliary body, and sometimes the vitreous body and all the shells of the eyeball.

Chronic panuveitis develops as a result of exposure to brucellosis and tuberculosis infections or herpes viruses, and occurs in sarcoidosis and Vogt-Koyanagi syndrome. The disease lasts a long time, with frequent exacerbations. Most often, both eyes are affected, resulting in decreased vision.

When uveitis is combined with sarcoidosis, lymphadenitis of the cervical, axillary and inguinal lymphatic glands is observed, and the respiratory mucosa is affected.

Peripheral uveitis affects people in their twenties and is usually bilateral. The disease begins with decreased vision and photophobia. With peripheral uveitis, the following complications are possible: cataract, secondary glaucoma, secondary retinal dystrophy in the macular region, swelling of the optic nerve head. The basis for the diagnosis of uveitis and its complications is eye biomicroscopy. Conventional research methods are also used.

Treatment. For the treatment of acute uveitis, it is necessary to administer antibiotics: intramuscularly, under the conjunctiva, retrobulbar, into the anterior chamber of the eye and vitreous body. Provide rest to the organ and put a bandage on the eye.

In chronic uveitis, along with specific therapy, hyposensitizing drugs and immunosuppressants are prescribed, and, according to indications, vitreous body moorings (adhesions) are excised.

26. Clinical picture of individual forms of uveitis

Influenza uveitis is characterized by an acute onset during and after influenza. Serous exudate is determined in the anterior chamber, posterior synechiae are easily torn.

Treatment is general: oral long-acting (prolonged) preparations of broad-spectrum antibiotics (tetracycline series) and sulfonamides in age-related doses, as well as antibiotics and sulfonamides.

Rheumatic uveitis begins acutely, often against the background of a rheumatic attack; its seasonality is very characteristic. Both eyes are often affected. A jelly-like exudate and a lot of easily ruptured posterior synechiae are found in the anterior chamber. The disease lasts five to six weeks, and there is a tendency to relapse. Positive immune reactions to Reactive protein, high titers of ASG and ASLO help in making a diagnosis.

General treatment: inside aspirin (pyramidone, salicylic sodium, butadione), prednisone, injections of cortisone, ACTH (intramuscularly), penicillin durant preparations.

With tuberculosis infection, various forms of damage to the vascular tract are observed. Tuberculous lesions of the vascular tract are characterized by an inconspicuous onset, a sluggish course, the presence of "sebaceous" precipitates, "guns" along the pupillary edge of the iris, tuberculous tubercles, powerful, difficult to tear posterior synechiae. Sometimes the cornea is involved in the process. Additional research methods clarify the diagnosis: Pirquet, Mantoux tests, detection of focal reactions to tuberculin tests, biochemical studies of protein blood fractions before and after tuberculin tests.

Treatment. Complex therapy, specific antibacterial agents. Uveitis in nonspecific infectious polyarthritis is characterized by damage to connective tissue elements in the stroma of the cornea, conjunctiva, sclera, uveal tract, which is expressed in dry keratoconjunctivitis, corneal dystrophy, scleritis and episcleritis. The vascular tract is primarily affected. The first signs of eye involvement in the pathological process are dry gray precipitates of various sizes on the posterior surface of the cornea. The treatment is comprehensive, restorative: intravenous 40% glucose solution, blood transfusions, physical therapy, joint exercises, electrophoresis of the joint area with calcium chloride, antiallergic and anti-inflammatory treatment (calcium gluconate, aspirin, butadione, chloroquine, delagil, corticosteroids, etc.).

The ophthalmic form of toxoplasmosis occurs as a sluggish serous iridocyclitis with significant clouding of the vitreous body. The central or peripheral exudative chorioretinitis is more often observed.

Diagnostic positive serological reactions (RSK with the patient's blood serum) and a skin test with toxoplasmin help.

Treatment. According to the scheme, in a certain dosage, depending on age, chloridine is prescribed in combination with sulfa drugs and cortisone. Local symptomatic therapy.

27. Choroiditis

Choroiditis is an inflammation of the choroid itself.

The cause of the inflammatory process of the choroid is an infection (tuberculous, streptococcal, staphylococcal, viral, syphilitic, brucellosis). Choroiditis can be endogenous and exogenous. Endogenous are caused by tubercle bacillus, viruses, the causative agent of toxoplasmosis, streptococcus, brucellosis infection, etc. The occurrence of exogenous choroiditis occurs as a result of involvement in the inflammatory process of the choroid in traumatic iridocyclitis and diseases of the cornea. Choroiditis is divided into focal and diffuse.

Patients with choroiditis do not have eye pain and visual disturbances. Therefore, it is detected only with ophthalmoscopy. When involved in the process of adjacent parts of the retina (chorioretinitis), visual impairment occurs. When the chorioretinal focus is located in the central parts of the fundus, there is a sharp decrease in vision and distortion of the objects in question, and the patient notes a sensation of flashes and flicker (photopsia). With damage to the peripheral parts of the fundus, twilight vision decreases, sometimes "flying flies" are observed before the eyes. With inflammation in the fundus, grayish or yellowish foci with fuzzy contours are visible, protruding into the vitreous body; retinal vessels are located above them, without interruption. During this period, hemorrhages in the choroid, retina and vitreous body are possible. Under the influence of the treatment process, the chorioretinal focus flattens, becomes transparent, acquires clearer contours, the choroid becomes thinner, and the sclera shines through it. With ophthalmoscopy, a white focus with large vessels of the choroid and pigment lumps is visible against the red background of the fundus, which indicates the onset of the stage of choroidal atrophy. When the chorioretinal focus is located near the optic nerve head, inflammation may spread to the optic nerve. A characteristic scotoma appears in the field of view, merging with the physiological one; with ophthalmoscopy, blurring of the boundaries of the optic nerve is determined. Peripapillary choreoretinitis develops, or Jensen's parapapillary neuroretinitis. With tuberculous lesions of the choroid, such clinical forms as miliary, disseminated, focal (with central and peripapillary localization of the focus) choroiditis, choroidal tuberculoma, and diffuse choroiditis are more common. With toxoplasmosis, focal choroiditis develops, with congenital toxoplasmosis, central focal choroiditis develops. With acquired syphilis, diffuse choroiditis occurs.

The treatment complex includes pathogenetic, specific and non-specific hyposensitizing agents, physiotherapeutic and physical methods of influence (laser coagulation, cryocoagulation).

Specific hyposensitization is carried out in order to reduce the sensitivity of sensitized eye tissues in tuberculosis, toxoplasmosis, viral, staphylococcal and streptococcal choroiditis. Antibacterial therapy plays an important role in the treatment of choroiditis. With an unknown etiology (cause) of choroiditis, broad-spectrum antibiotics are used.

28. Signs of choroid tumors

In the iris, single thin-walled or multiple blisters of various shapes and sizes are determined, which grow and can cause secondary glaucoma. Pearl cysts can occur in the iris due to the germination of the corneal epithelium into it after perforated wounds or surgical interventions.

Cysts of the ciliary body are determined by cycloscopy and gonioscopy. At the extreme periphery, at the dentate line, yellow-gray bubbles are visible, protruding into the vitreous body. Ciliary body cysts should be differentiated from retinal detachment, which is characterized by the presence of light gray or pink blisters, retinal swelling, and changes in the course and color of blood vessels. Treatment is carried out, as a rule, when secondary glaucoma occurs and consists of diathermocoagulation of the ciliary body, sometimes in excision of the cyst.

Choroidal angioma. Most often localized in the paracentral parts of the fundus, they are round in shape, yellowish-cherry in color, and their boundaries are unclear. According to the location of the angiomas, a defect in the field of view is observed.

Pigment tumors. Benign melanomas in children can be localized in different parts of the vascular tract. Benign melanomas ("birthmarks") of the iris are of different sizes, slightly rise above its surface and have a dark color of varying intensity. Melanomas of the ciliary body are almost never detected in vivo and do not cause noticeable changes in the functions of the eye.

Choroidal melanomas have the appearance of spots of varying sizes and localization, dark with a gray tint, round in shape, with fairly clear boundaries. The retina under these spots is not changed or, due to the pronounced thickness of the melanoma, is somewhat protruded into the vitreous body. The state of eye function depends on the severity and location of melanomas.

Melanoblastoma of the vascular tract in children is almost never registered. It is more common in people over thirty years of age.

Treatment. Surgery, diathermo, photo or laser coagulation.

Neurofibromatosis. If, during examination using lateral illumination and biomicroscopy, the unevenness of the anterior chamber is determined, multiple nodules of a brownish-yellowish round shape with clear boundaries are found in the iris, slightly rising above the surrounding unchanged tissue of the iris, you should find out whether the patient has changes on the skin (pigment spots café-au-lait color, tumors along the skin nerves), which is characteristic of neurofibromatosis, or Recklinghausen's disease.

29. Diagnosis of fundus pathology

If patients complain of deterioration in visual acuity, changes in peripheral vision, loss in visual fields (scotomas), blurred vision at dusk (hemeralopia, or night blindness), impaired color perception, then pathology of the retina can be assumed.

When clarifying the data on the picture of the fundus in children and adults, it should be borne in mind that in newborns the fundus is light, the optic nerve head is grayish-pink, its boundaries are not entirely clear, there may be pigment deposits at the optic nerve head, the macular reflex is absent, the ratio the caliber of arteries and veins is 1:2.

In pathological conditions of the retina, due to various reasons, a variety of changes can be observed in the fundus:

1) edema and retinal detachment;

2) clouding and ischemia;

3) atrophic foci;

4) tumor formations;

5) change in the caliber of vessels;

6) preretinal, retinal and subretinal hemorrhages.

To judge the location in the retina of foci of hemorrhages, one should be guided by their shape, size, color, location in relation to the vessels of the retina.

The foci located in the layer of nerve fibers have the form of strokes or an oblong (linear) shape. In the region of the macula, in the layer of Henle, the foci are arranged radially, form a "star" pattern, and have a yellowish-white color. In the middle layers of the retina, the foci have a rounded or irregular shape, a yellowish or bluish tint. If the focus is located so that it covers the vessels of the retina, then it is located in the inner layer of the retina. In cases where the focus is located behind the vessels of the retina, it is located in the middle or outer layers of it.

The presence of pigment in the focus speaks in favor of damage to the neuroepithelial layer and choroid. The defeat of the inner layers of the retina is accompanied by swelling of the optic disc, its hyperemia. At the same time, the disk tissue is opaque, its borders are blurred, the retina in the peripapillary zone is opaque.

Retinal hemorrhages have the form of lines, strokes located radially around the optic nerve head. Larger hemorrhages are triangular in shape with the apex facing the optic nerve head.

Dotted hemorrhages of round and oval shape are located in the middle and outer layers of the retina. Hemorrhages in the area of the optic nerve head or in the area of the macula, which are ovoid, dark in color, or cup-shaped with a dark lower half and a lighter upper layer, are characteristic of preretinal localization. The ischemic retina is matte white, without a sharp border. The edematous retina looks dull, cloudy, and the retinal vessels are not clearly visible. For a detailed examination of the fundus, patients should dilate their pupils with mydriatics.

30. Possible pathological processes in the retina

Pigmentary degeneration (degeneration) of the retina.

From the anamnesis of patients with retinitis pigmentosa, characteristic complaints of poor vision at dusk are revealed. Objectively determined concentric narrowing of the field of view, impaired dark adaptation. The optic disc is waxy, the retinal vessels, especially the arteries, are constricted. On the periphery of the fundus, there is an accumulation of pigment in the form of "bone bodies". The field of view gradually narrows to a tubular one, the process always ends in blindness due to the death of photoreceptors and atrophy of the optic nerve. The disease is often bilateral and may present in early childhood; in half of the cases is hereditary.

Retinal macular degeneration. Patients complain of a decrease in visual acuity, they note that they are better oriented in the evening than in the afternoon. With ophthalmoscopy in the area of the macula, pigmented and yellowish dotted foci are determined. When examining the visual field, a relative central scotoma is determined, as well as a violation of color perception for red and green colors.

The disease is bilateral and often has a family-hereditary nature.

Macular degeneration in Tay Sachs disease is a systemic disease that is detected in children four to six months old, manifested by mental retardation, seizures, and muscle weakness due to fatty degeneration of ganglion cells in the retina and brain. In the area of the macula, such children have a degenerative white lesion with a bright red round spot in the center. The child, as a rule, goes blind and dies before reaching the age of two.

retrolental fibroplasia. Every premature newborn, especially if he was in an oxygen tent, should be examined by an optometrist. These children may develop retrolental fibroplasia of retinopathy of prematurity.

It occurs in both eyes of children in incubators already in the second to fifth week after birth.

There are three periods of the course of the disease. The first period (the acute phase lasting from three to five months) is characterized by the presence of retinal edema, vasodilation, and gentle diffuse opacification of the vitreous body on the periphery of the fundus.

The second period (regression period) is characterized by the spread of newly formed vessels with their supporting tissue from the area of retinal changes into the vitreous body, the appearance of hemorrhages, and retinal detachment.

In the third period (cicatricial phase), a significant mass of opaque tissue, foci of proliferation covering most of the retina, are determined in the vitreous body. Fibrous masses gradually fill the entire vitreous body up to the lens.

31. Types of vascular pathologies of the retina

External exudative hemorrhagic retinitis, or Coates' disease. The disease is characterized by varicose veins in the central zone of the fundus. Exudative and hemorrhagic foci of white, gray or yellowish (golden) color with fuzzy contours, bumpy or smooth surface are found near the optic nerve head. The retina prominates in these places.

The vessels “climb” onto the lesions, make bends, form loops, aneurysms, resembling the picture of angiomatosis. Exudation can be so pronounced that it appears as if there is a retinal detachment, as in retinoblastoma. Exudate accumulates between the choroid and the retina and penetrates the vitreous body. The fundus becomes poorly visible due to exudate and repeated hemorrhages. Gradually, the vitreous body takes on the appearance of a homogeneous grayish mass with hemorrhagic inclusions. Over time, the exudate is replaced by connective tissue, powerful moorings are formed that extend from the retina into the vitreous body and lead to retinal detachment. Gradually, starting from the posterior sections, the lens becomes cloudy. Visual functions decrease depending on the severity of the process.

Treatment. The etiology of the disease is not yet known, so treatment is usually ineffective. Given the similarity of the process with retinal tuberculosis, specific anti-tuberculosis therapy is often used in combination with non-specific anti-inflammatory and resolving agents (corticosteroids and enzymes).

Acute obstruction of the central retinal artery. Patients complain of a sudden sharp deterioration in vision, a typical picture is determined in the fundus: against the background of an ischemic retina of a milky white color, the central fovea stands out in the form of a cherry-red spot (the “cherry pit” symptom), the arteries are sharply narrowed, intermittency of blood flow is determined in the narrow arteries of the retina . Gradually, the optic disc becomes pale and atrophies, and the patient becomes blind.

In adults, the causes of embolism are hypertension, rheumatism, endarteritis.

Thrombosis of the central retinal vein. The disease develops more often in older people on the basis of sclerotic changes, vascular changes in hypertension, in children with blood diseases.

Patients complain of a rapid decrease in vision in one eye, the appearance of fiery flashes, fog before the eyes. The picture of the fundus: the optic disc and retina are edematous, the size of the disc is enlarged, it is red, protrudes into the vitreous body, the vessels are lost in the edematous tissue, the veins are dilated, tortuous, reminiscent of leeches. Therapy of the main suffering, the appointment of heparin, fibrinolysin, antispasmodics and vasodilators, and later absorbable drugs, physiotherapy.

32. Retinoblastoma and its causes

Retinoblastoma (retinoblastoma) is a malignant neoplasm that develops in the retina of the eye. It refers to congenital tumors. It occurs in children as young as two to four years of age. Retinoblastoma can be either unilateral or bilateral. The disease is found more often in the first year of life.

The etiology has not been reliably established. A possible cause is considered to be a mutation of the chromosomes of germ cells due to internal and external factors. Retinoblastoma consists of neuroglia, that is, it is a glioma in its structure. Glia develops from the ectoderm and has great energy to reproduce and form new elements. Glial tissue permeates all layers of the retina and optic nerve.

There are differentiated and undifferentiated forms of the tumor. In undifferentiated forms, small cells with a large nucleus and a narrow rim of the cytoplasm are found.

There are five stages of tumor development:

1) latent;

2) primary;

3) developed;

4) far gone;

5) terminal.

The latent stage of retinoblastoma is characterized by such early indirect signs as unilateral dilation of the pupil, slowness or absence of its reaction to light. The initial stage is characterized by the fact that ophthalmoscopy reveals a yellowish-white lesion with unclear contours in the fundus, often covered with retinal vessels. Small satellite lesions are observed around the lesion. Tumor growth leads to amaurosis (blindness). The tumor can spread into the vitreous body in the form of grayish-white, sometimes yellowish or greenish masses with blurred boundaries, on the surface of which hemorrhages are visible. The process can spread across the retina (exophytic growth) and towards the vitreous body (endophytic growth). The advanced stage (glaucoma stage) is characterized by tumor growth and an increase in the volume of eye contents, which often leads to increased intraocular pressure. In this case, pain in the eye, stagnant injection, corneal edema, decreased depth and clouding of the anterior chamber fluid (pseudohypopyon) are possible.

Advanced stage (germination stage). This stage of retinoblastoma is characterized by tumor growth beyond the eyeball, more often through the sclera, along the vessels, through the sheaths of the optic nerve, etc. Posterior growth of the tumor is manifested by exophthalmos with limited eye mobility, the spread of the process into the cranial cavity causes an expansion of the optic nerve canal, which is detected on radiograph.

In the terminal stage (stage of metastases), enlarged cervical, submandibular lymph nodes are determined, further gross changes are observed from the side of the eye, up to the collapse of the membrane and the sharpest exophthalmos.

33. Clinical picture and treatment of retinoblastoma

Retinoblastoma can be unilateral or bilateral. Bilateral tumors are often combined with microcephaly, cleft palate and other embryonic developmental defects. The onset of the disease usually goes unnoticed. The first clinical symptom may be decreased visual acuity. Sometimes an early clinical sign of a unilateral lesion may be strabismus. Then there will be a change in eye color (yellowish reflex), observed in the depths of the eyeball and visible through the pupil (the so-called amaurotic cat's eye). This phenomenon occurs due to the presence of gliomatous nodes on the retina and forces the child’s parents to consult a doctor. The tumor is characterized by slow growth.

In the clinic of retinoblastoma, with an objective examination of the fundus, four stages are distinguished.

At the first stage, retinal whitish-pink lesions with smooth or uneven relief, newly formed vessels and gray areas of calcifications are visible. Their dimensions do not exceed one quadrant of the fundus, the surrounding tissues are not changed.

In the second stage, intraocular dissemination occurs. Whitish inclusions of various sizes are already observed in the vitreous body, precipitate-like deposits are noted in the angle of the anterior chamber of the eyeball and on the posterior surface of the cornea. Secondary glaucoma, buphthalmos (hydrophthalmos) appear. When a tumor grows into the retina, the accumulation of exudate under it leads to retinal detachment. Vision is reduced to complete blindness.

The third stage is characterized by extraocular spread of the tumor. Accompanied by exophthalmos, tumor growth into the cranial cavity, most often along the optic nerve, gives symptoms of brain damage (headache, nausea, vomiting). Germination of retinoblastoma in the choroid leads to hematogenous dissemination and an unfavorable outcome. As a result of tumor necrosis, toxic uveitis may develop.

In the fourth stage, symptoms due to metastasis join the eye symptoms. Metastasis occurs to lymph nodes, bones, brain, liver and other organs.

Treatment and prevention. At the first and second stages of the disease, organ-preserving cryoapplication is possible. At later stages, treatment consists in the timely surgical removal of the tumor (enucleation of the affected eye in a unilateral process or both eyes in a bilateral process). Enucleation of the eyeball is performed with resection of the optic nerve at a distance of 1015 cm from the posterior pole of the eyeball. In the future, radiation therapy is carried out in combination with chemotherapy or alone. Photocoagulation may also be performed. Cyclophosphamide, prospedin, methotrexatebeve are used as antitumor drugs.

Prevention. Timely genetic examination of those families whose relatives were treated for retinoblastoma in the past.

34. Optic nerve

In the diagnosis of diseases of the optic nerve, a decisive role belongs to functional studies, which also make it possible to judge the dynamics of the process. In addition to functional studies, X-ray of the skull, lumbar puncture, consultations of a neuropathologist, otolaryngologist and other specialists are of great help. For effective treatment, it is important to establish an etiological diagnosis, to find out the cause of the disease.

The most common causes of optic neuritis in children are infectious diseases, arachnoiditis, sinusitis, multiple sclerosis, etc. Lesions of the optic nerve are observed in the intraocular part of it (papillitis), behind the eye (retrobulbar neuritis) and in the intracranial region (opticochiasmatic arachnoiditis).

With papillitis, patients complain of a rapid drop in visual acuity, which is also established during the examination. Disturbances in color perception, changes in the field of vision, an increase in the blind spot are determined, and in the fundus there is hyperemia of the disc, blurring of its borders, vasodilation, deposition of exudate along the vessels and in the vascular funnel, as well as hemorrhages in the tissue and retina. Such changes may be absent at the beginning of retrobulbar neuritis, then visual acuity suffers first of all. There may be pain when moving the eyeball. With retrobulbar neuritis, the papillomacular bundle is more often affected, which is then manifested by blanching of the temporal half of the disc. After retrobulbar neuritis, descending atrophy of the optic nerve develops.

Characteristic of damage to the optic nerve in its intracranial part (opticochiasmal arachnoiditis) are complaints of a decrease in visual acuity (which is confirmed during examination), a change in the visual field of the chiasmatic type, manifested in the loss simultaneously in both eyes of the corresponding or opposite parts of the visual field (hemianopsia) . On the fundus of the pathology is not detected.

The disease is usually bilateral, prolonged, and may be accompanied by headache. With the development of the process in the fundus, there may subsequently be phenomena of stagnation of the optic nerve head and its atrophy. Pneumoencephalography, lumbar puncture help the diagnosis.

Treatment of neuritis etiological. It is necessary to prescribe antibiotics in combination with B vitamins, urotropin, glucose infusions, tissue therapy, nicotinic acid, angiotrophin, dibazol, aloe, FIBS.

Treatment should be long, repeated courses, since part of the visual fibers may be functionally inhibited or be in a state of parabiosis, i.e., have the ability to recover. If a patient has optic-chiasmatic arachnoiditis, the intervention of a neurosurgeon is possible. The operation is indicated for persistent progressive loss of vision, as well as an increase in the central scotoma, and consists in dissecting the moorings around the optic nerve and chiasm.

35. Congestive nipple (disc) of the optic nerve

Causes of a congestive disc are volumetric processes in the brain that lead to an increase in intracranial pressure: tumors, brain abscesses, gummas, tuberculomas, cysticercosis, meningiomas, hydrocephalus, injuries of the skull and orbits. Diagnosis is aided by targeted examinations.

Attention should be paid to the data of the anamnesis indicating hypertension syndrome, x-ray of the skull, diagnostic lumbar puncture, bilateral process in the fundus.

Changes in the fundus, characteristic of a congestive nipple, vary depending on the stage of the process. Initially, the patient does not complain, visual acuity is not changed. In the fundus, congestive hyperemia of the disc, blurring of its borders due to retinal edema, which spreads along the vessels and increases it in the upper and lower sections, are noted. As a result, an increase in the blind spot is determined, which is of great importance for diagnosis. Subsequently, the optic nerve disk increases in size, its marginal edema increases, the disk protrudes into the vitreous body, the veins expand, and the arteries narrow, the vessels sink in the edematous retina, hemorrhages appear from the dilated veins on the disk, and white foci of transudate are determined near the disk. Visual acuity gradually decreases, the blind spot increases even more.

In the future, a significant increase and blanching of the optic nerve is determined in the fundus, which mushroom-like protrudes above the level of the retina by 23 mm, which is determined using direct ophthalmoscopy. In the macular area, a "star" pattern may be observed. Patients complain of a significant decrease in vision. Vision changes depend on the localization of the pathological process in the brain.

Bitemporal and binasal hemianopsia are observed when the process is localized in the chiasm region, for example, with pituitary tumors, craniopharyngiomas. Homonymous hemianopsia is a consequence of the impact of the pathological focus on the visual tracts.

With a long-term congestive disc, the edema gradually decreases, the disc becomes grayish, its contours are indistinct, the caliber of the veins normalizes, and the arteries remain narrow. Subatrophy of the optic disc develops. Visual functions are still partially preserved.

If the process progresses, secondary atrophy of the optic nerve develops, which is expressed in the fact that the disc becomes white, its boundaries are fuzzy, the vessels narrow, especially the arteries, and the patient goes blind. This process is long, so the patient does not notice it immediately, but gradually over several years.

36. The concept of atrophy and glioma of the optic nerve

The disease occurs as a result of an inflammatory or congestive process in the optic nerve, accompanied by a progressive decrease in visual acuity and a characteristic picture of the fundus (blanching of the optic nerve head, vasoconstriction).

With primary atrophy of the optic nerve, the borders of the disc are clear, and with secondary indistinct. Secondary atrophy of the optic nerve is observed after papillitis or congestive nipple, primary after retrobulbar neuritis, optochiasmal arachnoiditis, with spinal tabes.

In addition, secondary atrophy of the optic nerve can occur as a result of many diseases of the retina of an inflammatory, dystrophic and post-traumatic nature, as well as angiocirculatory disorders. Possible congenital atrophy of the optic nerve.

Treatment. Means aimed at improving blood circulation and stimulating the remaining depressed nerve fibers (nicotinic acid injections, oxygen under the conjunctiva, vitamins B1, B12, B6, tissue therapy, intravenous glucose, glutamic acid, ultrasound treatment, cysteine iontophoresis, etc.). Unfortunately, such therapy is not always effective, since the process is irreversible.

optic nerve glioma

Glioma is a primary tumor of the optic nerve. It occurs rarely and only in preschool children. The disease is characterized by three main features:

1) slowly increasing unilateral exophthalmos;

2) decreased visual acuity;

3) a picture of a stagnant disc in the fundus.

The leading symptom is an irreducible (not decreasing with pressure on the eyeball) exophthalmos, which does not change with head tilt, tension, crying. The protrusion of the eye is, as a rule, straight forward, and only sometimes there is a slight outward deviation, which is due to the localization of the tumor of the optic nerve in the region of the muscular funnel.

The tumor may spread along the optic nerve into the skull, and then there may be no exophthalmos. In such cases, X-ray examination helps to diagnose.

Glioma should be differentiated from exophthalmos in thyrotoxicosis, orbital angioma, and cerebral hernia.

The diagnosis is helped by such studies as radiography of the orbit, skull, optic nerve canal, angiography. Radioisotope diagnostics helps to exclude a malignant process in the orbit. What is important in determining the further tactics of the patient.

37. Perforated wounds of the eyes

Due to the nature of the injuring objects, wounds are more often infected and are always severe.

Corneal perforation wounds are characterized by the presence of a wound that passes through all layers of the cornea. The anterior chamber is small, but with good adaptation of the wound edges, especially with stab wounds, it can recover by the time of examination by an ophthalmologist. Ophthalmotonus is reduced. In connection with damage to the intraocular vessels, hyphema can be observed. If there is damage to the anterior capsule of the lens, then a cataract appears.

Scleral perforated wounds are often not visible and are indirectly manifested by a deep anterior chamber and hypotension of the eye. The lens is damaged less frequently than with corneal injuries. Simultaneously with the injury of the sclera, the choroid and retina are injured. In the fundus, retinal ruptures and hemorrhages can be determined, respectively, at the site of injury to the sclera.

Corneoscleral wounds can combine in their clinical picture signs of corneal and scleral wounds. With penetrating wounds of the eyeball, along with the inlet in the cornea or sclera, there may also be an outlet. In addition, in some cases, there is hemorrhage into the retrobulbar space, manifested by exophthalmos, soreness, and limited mobility of the eyeball.

For simple perforated wounds of various localization, adapted edges are characteristic without loss of the internal contents of the eye; for complex (more common in children) prolapse and infringement of the membrane. Complications of penetrating wounds are manifested in the form of metallosis (siderosis, chalcosis, etc.), purulent and non-purulent inflammation, as well as sympathetic ophthalmia.

Treatment. For cut or puncture wounds with adapted edges no longer than 2 mm, surgical treatment is not performed. Antibiotics are prescribed intramuscularly or orally, instillation of a 30% solution of sulfacyl into the conjunctival sac. When the wound is localized in the center of the cornea, mydriatics are indicated, while myotics are indicated in the periphery or in the limbus area. A sterile bandage is applied to the eye. The administration of tetanus toxoid is mandatory.

For more extensive and especially complicated wounds, surgery is performed under anesthesia. Before the operation, a culture of the conjunctiva is taken to determine the flora and its sensitivity to antibiotics. In the postoperative period, conservative treatment is carried out using antibiotics, corticosteroids, vitamin absorption therapy according to indications (oxygen under the conjunctiva, ultrasound).

Intraocular magnetic foreign bodies, after establishing their localization, are removed using an electromagnet. If the foreign body is in the anterior chamber or iris, it is removed through the corneal wound, in other cases diasclerally, along the shortest path, followed by suturing the scleral wound and diathermocoagulation around it. Unremoved metal magnetic and amagnetic foreign bodies cause metallosis.

38. Contusion of the eye

Blunt injuries of the first degree are characterized by reversible damage to the appendages and the anterior part of the eye, visual acuity and field of vision are completely restored.

With blunt injuries of the second degree, damage to the appendages, anterior and posterior parts of the eyeball is observed, mild residual effects are possible, visual acuity is restored to at least 0,5, the boundaries of the visual field can be narrowed by 10-20°.

With blunt injuries of the third degree, more pronounced residual effects are possible, a persistent drop in visual acuity within 0,40,05, narrowing of the visual field boundaries by more than 20 °.

Blunt injuries of the fourth degree are characterized by irreversible violations of the integrity of the membranes of the eye, hemophthalmos, damage to the optic nerve. Visual functions are almost completely lost.

Treatment. For intraocular hemorrhages, oral administration of rutin (vitamin P), ascorbic acid, and calcium chloride is indicated; in case of retinal concussion, dehydrating agents are prescribed (25% solution of magnesium sulfate intramuscularly, 40% solution of glucose intravenously, etc.), vitamin therapy (orally and parenterally, especially B vitamins). After a few days, oxygen injections under the conjunctiva of the eyeball, ionogalvanization with dionine or potassium iodide, and ultrasound are prescribed to resolve the hemorrhages.

With dislocation and subluxation of the lens, accompanied by constant eye irritation or hypertension, its prompt removal is indicated, with retinal detachment diathermo, cryo or photocoagulation with shortening (filling, depression, corrugation) of the sclera. With subconjunctival ruptures of the sclera, the wound is sutured, followed by conservative therapy with antibiotics and corticosteroids.

A metal magnetic foreign body is removed from the cornea with a magnet, they are removed using a spear-shaped needle, and disinfectants are prescribed (30% sulfacyl solution, 1% synthomycin emulsion).

Multiple small foreign bodies in the conjunctiva of the eyeball must be removed only if the eye is irritated. Large foreign bodies are removed with a lance-shaped needle in the same way as corneal foreign bodies, after instillation of a 1% dicaine solution.

Orbital injuries can be the result of blunt trauma and wounds. In some cases, they are accompanied by subcutaneous emphysema, which most often occurs when the lower inner wall is damaged and is characterized by crepitus, bone defects.

Fractures of the outer wall of the orbit may be accompanied by ruptures of the outer parts of the eyelids, hemosinus of the maxillary sinus, lockjaw. With fractures of the inner wall, various changes are observed in the lacrimal ducts, tears of the inner corner of the eyelids and severe damage to the eyeball. Injuries to the lower wall are complicated by hemosinus and fractures of the zygomatic bone.

39. Eye burns

The most common in children are thermal burns, burns with lime, potassium permanganate crystals, stationery glue. In children, burns are more severe than in adults. Particularly severe damage (colliquation necrosis) occurs with chemical burns, mainly with alkalis. Acid burns, especially sulfuric acid, are also very severe, but the acid does not penetrate deep into the tissue (coagulative necrosis).

According to severity, burns are divided into four degrees, taking into account their localization, size and condition (hyperemia, bladder, necrosis) of burned tissues. First-degree burns are characterized by edema and hyperemia of tissues, second-degree burns are blisters, erosions, and superficial, easily removable necrotic films. The burn of the third degree is characterized by necrosis, which captures the thickness of tissues with the formation of a grayish folded scab, and the fourth degree by necrotic changes in almost all membranes of the eye.

Third-fourth degree burns can be complicated by aseptic uveitis and endophthalmitis and end with eye atrophy. Another terrible complication of these burns is perforation of the necrotic capsule of the eye with prolapse of the membranes and subsequent death of the entire eye.

The consequences of damage to the skin and conjunctiva are cicatricial eversion and inversion of the eyelids, their shortening, leading to non-closure of the palpebral fissure and the formation of adhesions between the conjunctiva of the eyelids and the eyeball, symblepharon, which, unlike trachomatous, is anterior.

A burn can be caused by a chemical substance and hot foreign bodies that have entered the eye, as well as exposure to radiant energy, electric welding without goggles, and prolonged exposure to snow. Bright sunlight causes ultraviolet burns of the cornea and conjunctiva. There is a sharp photophobia, lacrimation, blepharospasm, edema and hyperemia of the mucous membrane. Biomicroscopy shows vesicles and erosions in the corneal epithelium. Watching a solar eclipse or molten glass or metal without protective goggles can cause infrared burns. The patient complains of the appearance of a dark spot before the eye.

Treatment. First aid for chemical burns of the eyes consists in abundant and prolonged washing of the burn surface of the conjunctival cavity with water, removing particles of the substance that has entered the eye. Further treatment is aimed at fighting the infection (local disinfectants are prescribed), improving the trophism of the cornea (subconjunctival injections of autologous blood with penicillin, vitamin drops and ointments are indicated. Due to insufficient oxygenation of the cornea, unithiol and cysteine are indicated. In order to prevent adhesions in severe burns, daily massage of the conjunctival arches with a glass rod after dicaine anesthesia.In case of burns of the third and fourth degree, urgent hospitalization in an eye hospital is indicated, plastic surgery is often recommended.

40. Frostbite and other eye injuries

Frostbite of the eyeball is extremely rare, since the protective apparatus protects the eye from exposure to low temperatures. However, under unfavorable conditions (workers of Arctic expeditions, pilots, athletes, etc.), as a result of the absence of cold receptors in the cornea, cases of frostbite of the cornea are possible.

Subjective sensations during frostbite are manifested in the feeling of a foreign body under the eyelids. Since in such cases, medical workers do not detect foreign bodies, anesthesin (dicaine, lidocaine) is instilled as first aid. This, in turn, aggravates the conditions of frostbite, since the eye loses all sensitivity, and the protective reflex of closing the eyelids and moistening the cornea stops.

Objectively, during frostbite, tender subepithelial vesicles appear in the cornea, on the site of which erosions subsequently form: eye irritation is absent at first and occurs only 68 hours after frostbite (like ultraviolet burns). According to the severity of frostbite are divided in the same way as burns.

Treatment. Instillation of miotics, vitamin drops, application of 1% synthomycin emulsion or sulfacyl ointment.

Combat damage to the organ of vision

Combat injuries of the organ of vision have a number of significant features compared to peacetime injuries. Unlike household injuries, all combat injuries are gunshot wounds. More often, eye injuries are caused by shrapnel, bullet wounds are rare. Wounds, as a rule, are multiple and are combined with powder gas burns.

A characteristic feature of combat injuries is a high percentage of perforated wounds and severe contusions of the eye, damage to the orbit, combined wounds, combined with skull and brain injuries.

The main principle of treatment is the phasing with the evacuation of the patient as directed. First aid (the application of a bandage from an individual package) is provided to the wounded on the battlefield by a comrade or medical personnel. The first medical (eye) aid (dressing and drug treatment) is provided on the day of injury in the SME or on the PHC. On the same day, the wounded is sent to the PPG, GLR or evacuation hospital, where he is assisted by an ophthalmologist.

The first ophthalmic care unit is the Army Ophthalmic Reinforcement Group, part of the ORMU. These groups, together with groups in other specialties, are transferred to the KhPPG, where wounds are treated for the wounded. Slightly wounded soldiers finish treatment in these hospitals and return to the front. Seriously wounded soldiers are sent to the evacuation hospital of the first and second echelons of the GBF. They provide full-scale ophthalmosurgical care.

The wounded, who need long-term treatment, are evacuated from the GBF to the evacuation hospitals of the inner region.

Children often experience damage to the eye, similar to combat: when launching rockets, explosions of capsules, cartridges, which are produced without adult control.

41. Myopia

Myopia (myopia) is one of the variants of the refractive power (clinical refraction) of the eye, which is formed simultaneously with a decrease in distance vision due to a mismatch in the position of the back main focus in relation to the central zone of the retina.

Myopia is congenital (hereditary, intrauterine origin), with age it progresses and can be malignant. Acquired myopia is a type of clinical refraction. Often, with age, it increases slightly and is not accompanied by noticeable morphological changes in the eyes. This process of refractogenesis is considered as a biological option. But under certain conditions, the frequency of both congenital and acquired myopic refraction is pathological: the so-called progressive myopia is developing. Such myopia progresses in most children in the early school years, so it is often called "school", although this is not entirely correct, since myopia can progress at a more mature age.

Myopia usually appears in childhood, progressing with age. The following factors are of great importance in the development of myopia:

1) genetic, in which myopic parents often have myopic children. Factors such as weakness of the accommodative muscle, weakness of the connective tissue (the sclera becomes extensible, resulting in an increase in the length of the eyeball) can be inherited;

2) adverse environmental conditions, especially during prolonged work at a close distance from the eye. This is a professional, school myopia, easily developing with an incomplete development of the organism;

3) weakness of accommodation, leading to an increase in the length of the eyeball, or, on the contrary, tension of accommodation (inability of the lens to relax), which leads to spasm of accommodation. In contrast to true myopia, with false myopia, vision is restored to normal with drug treatment (i.e., seven-day instillation of a 1% atropine solution). This requires careful observation and skiascopy with the participation of an ophthalmologist. Spasm of accommodation can be eliminated with the help of special therapeutic exercises for the eyes.

The initial signs of false myopia, or spasm of accommodation, a person may suspect in himself:

1) during visual work at close range, rapid eye fatigue, pain in the eyes, in the forehead, in the temples may occur;

2) near visual work can often be facilitated by using weak plus lenses (in this case, this does not mean that a person has farsightedness);

3) it may be difficult or slow to "set" the eyes to different distances, especially when looking from a close object to a distant one;

4) distance vision deteriorates.

Spasm of accommodation, if left untreated, becomes persistent over time, difficult to treat and can lead to true myopia.

42. The concept of progressive myopia

Progressive myopia is any type of nearsightedness that is a deterioration in distance vision. There is information about the antecedent of false myopia true, i.e., this is a condition in which there is a more or less rapid and pronounced drop in visual acuity at a distance due to spasm, or tension, of accommodation. Nevertheless, after the spasm is eliminated with the help of cycloplegic agents (atropine, scopolamine, homatropine), vision is restored to normal, and refractometry reveals emmetropia or even farsightedness.

In recent decades, myopia (myopia) more often began to develop in preschoolers who, during their upbringing, had a high visual load in combination with a sedentary lifestyle, poor nutrition and weakening of the body due to frequent illnesses (tonsillitis, dental caries, rheumatism, etc.). Among students in first and second grades, myopia occurs in 36%, in third and fourth grades in 6%, in seventh and eighth grades in 16%, in ninth and tenth grades in more than 20%. Severe (high, advanced) myopia causes over 30% of low vision and blindness from all eye diseases; it is an obstacle to the choice of many professions.

The mechanism of development of myopia that occurs during childhood consists of three main links, such as:

1) visual work at close range (weak accommodation);

2) burdened heredity;

3) weakening of the sclera, violation of trophism (intraocular pressure).

Consequently, according to the predominance of certain causes of development, myopia can be conditionally divided into accommodative, hereditary and scleral.

The development of each of these forms of myopia over time leads to irreversible morphological changes in the eyes and a pronounced decrease in visual acuity, which often does not improve much or does not improve at all under the influence of optical correction.

The main reason for this is a significant lengthening of the eye axis: instead of 22-23 mm, it reaches 30-32 mm or more, which is determined using an echo-ophthalmograph. If myopia progresses over the course of a year by less than 1,0 diopters, then it is conditionally considered benign, and if the increase is 1,0 diopters. and more malignant. However, it is not only a matter of progression, but also of the size and changes in the intraocular structures (vitreous body, choroid, retina, optic nerve).

A large stretching of the eyes during myopia leads to an expansion of the palpebral fissure, as a result of which a kind of bulging is created. The sclera becomes thinner, especially in the area of attachment of the lateral muscles and near the edge of the cornea. This can be determined with the naked eye by the bluish tint of the cornea due to translucence of the choroid, and sometimes by the presence of anterior staphylomas of the sclera. The cornea also stretches and thins. The anterior chamber of the eye deepens. Mild iridodonesis (trembling of the iris), destruction or liquefaction of the vitreous body may occur. Depending on the genesis and magnitude of myopia, changes in the fundus occur.

43. Treatment of myopia

The beginning of the prevention of myopia or its development should occur with the clarification of heredity and the determination of clinical refraction in children under one year old, but not later than 12 years of age. At the same time, there should be a differentiated attitude to the upbringing of the child, taking into account the state of his heredity and refraction. To do this, divide the children into two groups:

1) children with heredity aggravated by myopia, regardless of the detected size and type of refraction, with congenital myopia, with emmetropia;

2) children with farsighted refraction without heredity burdened by myopia.

Treatment of myopia can be conservative and surgical. Conservative treatment begins with vision correction with glasses or contact lenses.

It is necessary to have the convenience of glasses and their compliance with the configuration and size of the face, ensuring visual acuity in both eyes within 0,91,0-2,03,0 and the presence of stable binocular vision. Glasses should be used constantly. In cases of moderate or high myopia, bifocal glasses can be used in such a way that the lower hemisphere of the lens is weaker than the upper one by an average of 3,0 diopters. With high myopia and anisometropia (more than XNUMX diopters), correction with hard or soft contact lenses is recommended.

Treatment of rapidly progressive and severe myopia is a serious and often difficult task. The development of changes in the area of the retinal spot, the appearance of recurrent hemorrhages in the retina and vitreous body require the cessation of visual work, the creation of rest for the eyes, protection from harsh light and vigorous treatment. Both local and general treatment with calcium chloride, cysteine, preparations of Chinese magnolia vine, ginseng, mezaton, ethylmorphine hydrochloride (dionine), as well as subconjunctival oxygen injections, reflex therapy are recommended. It is necessary to prescribe rutin with ascorbic acid, riboflavin, thiamine, vitamin E, intermedin, adenosine triphosphoric acid, taufon, etc.

If correction with glasses or contact lenses, conservative treatment methods, as well as reflexology do not stop or significantly reduce the rate of progression of the process, then surgical treatment is indicated. The decision on the timing and method of surgery is made depending on a number of factors. The younger the child, the faster the annual (over two to three years) progression of myopia (more than 1,0 diopters per year), the more significant the increase in the sagittal size of the eye, the greater the indications for strengthening the eye capsule with scleroplasty. The choice of scleroplasty technique is made in accordance with the stage of myopia, i.e., the location and magnitude of morphological changes. It is necessary to take into account that the less myopia, the more effective scleroplasty. Prevention of rapid progression of myopia through scleroplasty is effective in almost 90% of cases. Within two to three years after surgery, myopia often increases by 1,0 diopters. versus 3,04,0 diopters. with a conservative method of treatment.

44. Astigmatism

Astigmatism is a refractive error in which different types of ametropia or different degrees of one type of ametropia are combined in one eye.

Etiopathogenesis of astigmatism and its forms. The development of astigmatism is based on the unequal refraction of light rays in different meridians of the eye, which is associated with differences in the radius of curvature of the cornea (less often the lens). On the two main mutually perpendicular meridians, the strongest and weakest refractive power is observed. As a result of this feature, the image on the retina always turns out to be fuzzy, distorted. As a rule, the cause is an anomaly in the structure of the eye. However, such changes can occur after operations, eye injuries, diseases of the cornea.

There is a simple astigmatism, in which emmetropia is noted in one of the main meridians, and ametropia (myopia or hypermetropia) in the other; complex astigmatism, when ametropia of the same type, but of varying degrees, is noted in both main meridians of the eye; mixed astigmatism, in which myopia is noted in one of the main meridians, and hypermetropia in the other.

In astigmatic eyes, there are main meridians with the strongest and weakest refractive power. If the refractive power is the same throughout the meridian, then astigmatism is called correct, if different, incorrect.

With direct astigmatism, the vertical main meridian has the strongest refraction, with the reverse horizontal. When the main meridians pass in an oblique direction, one speaks of astigmatism with oblique axes. Correct direct astigmatism with a difference in refractive power in the main meridians of 0,5 diopters. considered physiological, not causing subjective complaints.

Clinical picture and diagnosis of astigmatism. Patients complain of a decrease in visual acuity, rapid eye fatigue during work, headache, and sometimes vision of objects twisted. Spherical convex and concave glasses do not improve vision. The study of refraction reveals the difference in the refractive power of the eye in different meridians. The basis of the diagnosis is to determine the refraction in the main refractive meridians.

Treatment of astigmatism. Spectacles with cylindrical or spherical-cylindrical lenses (astigmatic lenses) are prescribed. The constant wearing of such glasses maintains high visual acuity and good performance. That is why patients with such a pathology for a long time can do without surgery.

45. Glaucoma

Glaucoma is a chronic eye disease that manifests itself as a constant or periodic increase in intraocular pressure, a special form of optic nerve atrophy, and significant changes in the visual field.

Etiopathogenesis and classification. There are primary, secondary and congenital glaucoma. The development of primary glaucoma is influenced by both local and general factors. Local factors include changes in the drainage system and microvessels of the eye, general hereditary predisposition, neuroendocrine and hemodynamic disorders. Before an increase in intraocular pressure, trophic changes occur in the drainage system of the eye, which causes a violation of the circulation of aqueous humor and an increase in ophthalmotonus.

Classifying primary glaucoma, it is necessary to take into account the form and stage of the disease, the level of intraocular pressure and the dynamics of visual functions. The state of the iridocorneal angle of the anterior chamber and the site of violation of the main resistance to the outflow of aqueous humor determines the form of glaucoma. There are open-angle and closed-angle forms of glaucoma.

With open-angle glaucoma, dystrophic changes in trabecular tissue and intratrabecular canals of varying severity occur, as well as blockade of Schlemm's canal. Types of open-angle glaucoma include pigmentary, pseudoexfoliation and glaucoma with low intraocular pressure. In pigmentary open-angle glaucoma, the pigment completely covers the trabecular zone, which leads to impaired outflow of aqueous humor and increased intraocular pressure. Pseudoexfoliative glaucoma results in the deposition of pseudoexfoliation on the posterior surface of the cornea, iris, ciliary body and in the iridocorneal angle of the anterior chamber. Pseudoexfoliative glaucoma is often combined with cataracts. Glaucoma with low intraocular pressure is characterized by typical symptoms of primary glaucoma: changes in the visual field and partial atrophy of the optic nerve with glaucomatous excavation of the optic nerve head. Angle-closure glaucoma is characterized by blockade of the iridocorneal angle of the anterior chamber by the root of the iris, as well as the development of goniosynechia. Glaucoma occurs with pupillary block, shortening of the iridocorneal angle of the anterior chamber, flat iris and vitreolenticular block. With a mixed form of glaucoma, the signs of open-angle and closed-angle glaucoma are combined.

There are four stages of the disease: initial, advanced, advanced and terminal, and at the same time an acute attack of angle-closure glaucoma. The designation of each stage is carried out by a Roman numeral for a brief record of the diagnosis. The staging of glaucoma is determined by the state of the visual field and the optic disc. The initial stage is characterized by the absence of marginal disc excavation and changes in the peripheral boundaries of the visual field. For advanced and far advanced stages of glaucoma, the presence of marginal excavation is characteristic.

46. Clinical picture of glaucoma

Open-angle glaucoma usually occurs after the age of forty. The onset of the disease is often asymptomatic. 1520% of patients complain about the appearance of iridescent circles around the light source, periodic blurred vision. Often there is an early, age-inappropriate weakening of accommodation. There are minor changes in the anterior part of the eye. The depth of the anterior chamber in the case of open-angle glaucoma is usually not changed. The clinical picture of open-angle glaucoma is characterized by the development of glaucomatous atrophy of the optic nerve in the form of marginal excavation. In this case, a whitish or yellowish ring (halo) may appear near the optic nerve head.

In gonioscopic examination, the iris angle of the anterior chamber is always open, and is usually quite wide and only in rare cases somewhat narrowed. Corneoscleral trabeculae are sclerotic. There is exogenous pigmentation of the iris angle of the anterior chamber. With open-angle glaucoma, there is a slow and gradual increase in intraocular pressure as resistance to the outflow of aqueous humor increases. The deterioration of visual functions may be a consequence of the growing phenomena of glaucomatous atrophy of the optic nerve head. Early changes in the visual field are characterized by the expansion of the blind spot and the appearance of small scotomas in the paracentral region, later turning into Bjerrum's arc scotoma.

Further development of the glaucomatous process characterizes the detection of defects in the peripheral visual field. The narrowing of the visual field occurs mainly on the nasal side (in the upper nasal sector). The late stages of the disease are characterized by concentric narrowing of the visual field and a decrease in visual acuity.

Primary open-angle glaucoma is typical for middle-aged and elderly people. Changes occurring in the body are characteristic of this age group. A number of negative factors such as low blood pressure, the presence of cervical osteochondrosis, sclerotic changes in extracranial vessels affect the course and prognosis of primary open-angle glaucoma. All these factors lead to a deterioration in the blood supply to the brain and eyes. Angle-closure glaucoma accounts for 20% of primary glaucoma cases. It usually progresses over the age of forty. It most often manifests itself in individuals with hypermetropia, since the anatomical features of eyes with such refraction (small anterior chamber and large lens) are predisposed to its development. The course of angle-closure glaucoma is characterized by periods of exacerbations and remissions. An acute attack of angle-closure glaucoma is provoked by emotional arousal, pupil dilation, copious fluid intake, overeating, cooling, body position that causes venous stasis in the eye area (with prolonged head tilt down, neck compression, etc.), drinking in a significant amount. Patients have pain in the eye, radiating along the trigeminal nerve to the forehead and temples, blurred vision, the appearance of iridescent circles when looking at a light source. Characterized by a slow pulse, nausea, and sometimes vomiting.

47. Diagnosis of glaucoma

Early diagnosis of primary glaucoma is extremely important. It is based on the patient's complaints, the history of the disease, the clinical picture, the results of the study of the functions of the eye, especially the central region of the visual field, the state of intraocular pressure and tonography data.

Tonometry is the main method for determining intraocular pressure. The pressure is measured in the supine position of the patient with a tonometer with a load of 10 g, while the tonometric pressure is determined, which normally should not exceed 27 mm Hg. Art. Intraocular pressure in the right and left eyes normally differ by about 5 mm Hg. Art. Daily tonometry is considered very important for the diagnosis of glaucoma. Measurement of intraocular pressure is usually made at 68 o'clock in the morning and at 68 o'clock in the evening, it is desirable to measure it in the middle of the day. Determination of daily changes in ophthalmotonus occurs in a hospital or in a glaucoma dispensary: morning measurement of intraocular pressure is carried out in a patient still in bed. The normal study duration is 710 days, with a minimum of 34 days. There is a calculation of the average morning and evening indicators of the level of intraocular pressure and the amplitude of the ophthalmotonus. The optimal range of ophthalmotonus fluctuations during the day should not be higher than 5 mm Hg. Art. The difference in fluctuations exceeding 5 mm Hg. Art., is the reason for suspicion of glaucoma. Of great importance is the absolute value of the rise in ophthalmotonus (more than 27 mm Hg). If they occur repeatedly, then this is a reliable sign of glaucoma.

Elastotonometry is a method for determining ophthalmotonus in the case of measuring intraocular pressure with tonometers of various masses. With elastotonometry, it is necessary to use a set of Maklakov tonometers weighing 5, 7,5, 10 and 15 g, with the help of which, in ascending order of their mass, intraocular pressure is measured 4 times. The readings of tonometers of different masses are plotted on a graph.

Tonography is a method for studying the dynamics of aqueous humor with graphic recording of intraocular pressure. Electronic tonographs help to conduct tonographic studies. A guaranteed confirmation of the diagnosis is a combination of the results of tonography, daily tonometry and perimetry of the central part of the visual field. The diagnosis of glaucoma is not in doubt if the outflow easiness coefficient is less than 0,15, and the diurnal curve is pathological, in addition, scotomas are noted in the central part of the visual field.

Glaucoma is suspected in the following cases: intraocular pressure equal to 27 mm Hg. Art. and higher; complaints characteristic of glaucoma; shallow anterior chamber; blanching of the optic disc (or part of it) or the beginning development of glaucomatous excavation; asymmetry in the condition of the two eyes (differences in the level of intraocular pressure, the depth of the anterior chamber, the condition of the optic discs); the presence of small paracentral relative and absolute scotomas in the field of view.

48. Principles of glaucoma treatment

In the case of developing a drug treatment regimen for a patient with glaucoma, an observation period is established (at least two to three weeks), after which it is necessary to use the drug. In the future, the effectiveness of treatment is monitored once every 1 months.

Treatment of patients with primary glaucoma usually begins with the administration of instillations of solutions of cholinomimetic agents, most often a 1% solution of pilocarpine hydrochloride 23 times a day. If normalization of intraocular pressure is not observed, instillation of a 2% solution of pilocarpine is prescribed 3 times a day. These drugs are used 3 times a day. Pilocarpine hydrochloride 12 times daily and 2% pilocarpine ointment at night are also prescribed in ophthalmic film.

Other cholinomimetic agents (13% solutions of carbacholine or 25% solutions of aceclidine) are used much less frequently. If cholinomimetic drugs are insufficiently effective, one of the miotic agents with anticholinesterase action (prozerin, phosphakol, armin, tosmilen) is additionally prescribed. The frequency of instillation of these drugs is no more than twice a day. For patients with open-angle glaucoma with low or normal blood pressure and insufficient effectiveness of pilocarpine hydrochloride, instillations of 12% solutions of adrenaline hydrotartrate, dipivalyl epinephrine, isoptoepinal are added or adrenopilocarpine is prescribed 23 times a day.

It is possible to use instillations of a 0,5% solution of clonidine (hemitone). The hypotensive effect of clonidine leads to inhibition of aqueous humor secretion, as well as improvement of its outflow. The effectiveness of treatment is monitored 23 times a month.

β-adrenergic blocking agents are also used in the form of eye drops (1% anaprilin, 1% propranolol, 0,25-0,5% optimol). In case of insufficient effectiveness of local antihypertensive therapy for open-angle glaucoma, it is supplemented with short-term prescription of general antihypertensive drugs: carbonic anhydrase inhibitors (diamox, diacarb), osmotic (glycerol) and neuroleptic drugs (aminazine). The main indications for surgery are a persistent and significant increase in intraocular pressure, despite the use of various antihypertensive drugs; progressive deterioration of the visual field; negative dynamics of clinical data (condition of the iris, anterior chamber angle, optic nerve).

In recent years, laser methods have been used to treat primary glaucoma. The most effective in the drug treatment of angle-closure glaucoma are miotic drugs, mainly cholinomimetic drugs (pilocarpine, carbacholine, aceclidine). It is also possible to prescribe a 0,250,5% solution of timolol. In this form of glaucoma, adrenomimetic drugs (adrenaline, fethanol, clonidine) are also contraindicated. General agents for reducing intraocular pressure include diacarb and glycerol used orally.

With insufficient drug therapy, surgical and laser treatment is also used.

49. Treatment of an acute attack of glaucoma

An acute attack of glaucoma requires urgent specialized care, the main purpose of which is to reduce intraocular pressure and thus normalize impaired blood circulation in the eye, restore metabolism in the tissues of the eye and the optic nerve.

In an outpatient setting, treatment begins with instillations of a 1% (preferably 2%) solution of pilocarpine hydrochloride every 15 minutes for 1 hour, then every 30 minutes for the next 2 hours and then every hour. Instead of pilocarpine, a 1,53% solution of carbocholine can be administered. A 0,5% solution of Optimol is also instilled. Simultaneously with miotics, 0,5 g of diacarb or glycerol (50% glycerol solution) is prescribed orally at the rate of 11,5 g of glycerol per 1 kg of body weight. The decrease in intraocular pressure after taking glycerin begins after about 30 minutes, and after 11,5 hours its maximum decrease is achieved. Upon completion of emergency measures, the patient is sent to inpatient treatment. In the hospital, if the effect of previous treatment is insufficient after 23 hours and in the absence of arterial hypotension, the administration of chlorpromazine, which produces a pronounced sedative effect, is indicated. The drug reduces blood and intraocular pressure. The decrease in intraocular pressure under the influence of chlorpromazine is due to a decrease in the production of aqueous humor. Aminazine is administered as part of a lytic mixture containing a 2,5% solution of aminazine (1 ml), a 1% solution of diphenhydramine (2 ml) and a 2% solution of promedol (1 ml). Solutions of these medications are collected into one syringe, after which they are administered intramuscularly. After administration of the lytic mixture, patients must remain in bed for 34 hours in a horizontal position to prevent orthostatic collapse. In cases of severe corneal edema, eye baths with a 2040-810% glucose solution are indicated. If the described drug treatment does not stop an acute attack of glaucoma within XNUMX hours, anti-glaucoma surgery is performed.

General drug treatment for primary glaucoma includes the prescription of drugs that improve metabolic processes in the retina and optic nerve. Of these drugs, the most widely used orally are nicotinic acid (0,05 g 23 times a day for two to three weeks), nikoshpan (1 tablet 23 times a day for two to three weeks), noshpa (0,04 g 23 times a day), nigexin (0,25 g 34 times a day for the first 23 weeks and 2 times a day for another two weeks), aminalon (0,5 g 3 times a day for a month or more), Cavinton (0,005 g 23 times a day), Complamin (0,15 g 23 times a day), Trental (0,1 g 23 times a day), Riboxin (0,2 g 23 times a day), glio6, or pyridoxylate (0,1 g 23 times a day), biogenic stimulants, 1% solution of sodium salt of ATP (1 ml intramuscularly daily, 3 injections per course), 0,25% solution of cytochrome C, B vitamins.

50. Congenital glaucoma

There is hereditary congenital glaucoma (about 15% of cases) and intrauterine (about 85% of cases), which occurs as a result of exposure to various pathological factors on the fetal eye, which is a consequence of malformations of the anterior part of the eye. An increase in intraocular pressure occurs due to a violation of the outflow of intraocular fluid due to the closure of the iridocorneal angle of the anterior chamber by unresolved embryonic mesodermal tissue. Less common causes of aqueous humor retention are the anterior attachment of the iris and intratrabecular and intrascleral changes.

Congenital glaucoma manifests itself in three forms: simple (actual hydrophthalmos) with changes in the angle of the anterior chamber of the eye (the most common); congenital glaucoma with anomalies in the anterior part of the eye or the entire eye (aniridia, ectopia of the lens, microphthalmos, etc.); congenital glaucoma with phakomatoses (angiomatosis, neurofibromatosis).

Often, congenital glaucoma appears in newborns or in the first six months of a child's life, as well as in the first year of life. Congenital glaucoma is characterized by a progressive course. There are the following stages of the disease: initial, advanced, advanced, almost absolute and absolute. According to the state of intraocular pressure, it is possible to distinguish compensated, uncompensated and decompensated congenital glaucoma.

The onset of the disease is manifested by photophobia, lacrimation, dullness of the cornea; the length of the sagittal axis of the eye and the diameter of the cornea are normal or slightly enlarged. An increase in the length of the sagittal axis of the eye, the diameter of the cornea and an increase in corneal edema occur in the advanced stage due to further stretching of the membranes of the eyeball. There are ruptures of the Descemet's membrane and clouding of the cornea.

The anterior chamber becomes deeper. Changes occur in the iris in the form of atrophy and stromal hypoplasia, depigmentation. The pupil is dilated. Excavation of the optic nerve head, decreased visual acuity, and narrowing of the field of view on the nasal side to 45-35° are observed (if the child’s age allows them to be examined). The progressive stage of the disease is determined by a sharp increase in the length of the sagittal axis of the eye and the diameter of the cornea. The limbus is stretched. The sclera becomes thinner, and the choroid appears through it in a bluish-bluish color. The anterior chamber is deep. There are degenerative changes in the cornea. The pupil is wide. The optic disc is grayish in color, its excavation increases. There is a sharp decrease in visual acuity, a concentric narrowing of the field of vision, mainly on the nasal side (up to 15°). Treatment of congenital glaucoma is surgical. In order to eliminate embryonic tissue and improve the outflow of intraocular fluid into Schlemm's canal, in most cases, operations are performed in the area of the anterior chamber angle, as they are the most effective. Despite the age of the child, the operation must be performed urgently.

51. Juvenile and secondary glaucoma. Criteria for difference

It develops at a young age due to congenital defects in the structure of the iridocorneal angle of the iris, there is a hereditary transmission of these defects. Usually people older than thirty years are ill. For some patients, changes in the iris are characteristic (hypoplasia, large crypts or their almost complete absence, eversion of the pigment sheet, coloboma), for others, the first symptoms appear in the second decade of life, develop slowly, the cornea is of normal size, the anterior chamber is deep.

In the diagnosis of erased forms, gonioscopic and tonographic studies are important. Many patients with juvenile glaucoma have a remnant of germinal mesodermal tissue in the anterior chamber angle. Topical application of various miotic drugs (pilocarpine, carbacholin, aceclidine, phosphakol, armin), as well as clonidine and optimol, is shown, diacarb is prescribed orally. In the absence of compensation for the glaucomatous process and the deterioration of visual functions, an operation is indicated.

The increase in intraocular pressure that occurs with secondary glaucoma is the result of another disease of the eye (or the whole body) or damage to the eye.

Glaucoma can develop at various times after cataract removal. An increase in intraocular pressure in the early stages after cataract extraction is associated with pupillary block as a result of obstruction of the pupil by the vitreous body, residual lens masses, or air introduced into the eye.

The reason for the increase in ophthalmotonus in the later stages after cataract removal may be pupillary or angular blockade, which developed as a result of postoperative complications (iridocyclitis, goniosinechia). Occasionally, glaucoma in an aphakic eye may be a manifestation of primary open-angle glaucoma not identified prior to cataract extraction.

The differential diagnosis is based on the data of tonometric, tonographic studies and gonioscopy of both eyes.

Treatment consists of dilating the pupil, reducing ophthalmotonus, reducing the production of intraocular fluid, eliminating the inflammatory reaction, and also depends on the cause of the increase in intraocular pressure. A 12% solution of pilocarpine hydrochloride, preparations of timolol maleate (0,250,5% timoptik, 0,250,5% oftan timolol, 0,250,5% proxodolol, etc.), combined preparations (fotil, timpilo), Diacarb is prescribed orally at 0,125-0,25 g 23 times a day. If ineffective, surgical intervention is indicated. This consists of adequately reducing intraocular pressure, optimizing the visual functions of the eye, and most importantly, eliminating, if possible, the cause that caused the development of glaucoma.

52. Cataract

Cataract - partial or complete clouding of the substance or capsule of the lens with a decrease in visual acuity up to its complete loss. There are primary and secondary cataracts, acquired and congenital. Congenital cataracts can be hereditary or result from intrauterine developmental disorders, such as infections in the mother, such as rubella, etc.

Depending on the etiological factor, several groups of cataracts are distinguished: senile, traumatic, complicated, radiation, toxic and metabolic.

Complicated cataracts often form against the background of chronic uveitis of various origins due to the toxic effects of inflammatory products on the lens.

The lens is very sensitive to radiation exposure: infrared radiation, which causes damage to the anterior lens capsule in the form of peeling of the surface layers, ultraviolet radiation (290329 nm), ionizing radiation.

As a result of exposure to a number of chemicals (naphthalene, dinitrophenol, thallium, mercury, ergot), toxic cataracts develop. The entry of alkali into the conjunctival cavity causes damage to the conjunctiva, cornea and iris and often leads to the development of cataracts. Cataracts occur in certain metabolic diseases: diabetes mellitus, galactosemia, hypocalcemia, Westphal-Wilson-Konovalov disease, myotonic dystrophy, protein starvation.

In diabetes mellitus, with an increase in blood sugar levels, the glucose content in the chamber moisture and the lens increases. Water then enters the lens, causing the lens fibers to swell. Edema affects the refractive power of the lens. In 75% of patients with classical galactosemia, cataracts usually develop within the first weeks after birth. Cataract can form in any condition that leads to a decrease in the level of calcium in the blood: tetany, spasmophilia, rickets, kidney failure. In Westphal-Wilson-Konovalov's disease, copper metabolism is disturbed. With miotic dystrophy, patients have multicolor iridescent crystals in the posterior intracapsular layers of the lens. The disease is hereditary.

With a polar cataract, changes in the lens are formed in the intracapsular layers of the anterior or posterior pole of the capsule. Suture cataracts are manifested by clouding of the Y-shaped suture of the nucleus. Congenital nuclear cataract is an opacity of any embryonic nucleus. Capsular cataract is a limited clouding of the epithelium and the anterior lens capsule. Zonular cataract is a bilateral symmetrical lesion. A complete cataract is a clouding of all lens fibers. A membranous cataract occurs when the proteins of the lens are resorbed. In this case, the anterior and posterior lens capsules are soldered into a solid membrane.

53. Clinic and treatment of cataract

clinical picture. The clinical picture of cataract in the primary form is manifested by complaints of decreased visual acuity. Sometimes the first symptoms of cataract are distortion of objects, monocular polyopia (multiple vision of objects).

In the clinical course of senile cataract, there are initial, immature, mature and overripe stages. In the initial stage, patients may not have complaints, others note a decrease in visual acuity, the appearance of "flying flies", and sometimes polyopia. In a biochemical study at this stage, the appearance of intracapsular blisters, stratification of the lens fibers are determined. After 23 years, the stage of immature cataract begins. At this stage, the phenomena of hydration of the lens increase, and patients complain of a sharp decrease in vision. The stage of immature cataract lasts for years. Gradually, the lens begins to lose water, and the turbidity acquires an intense gray hue, becomes uniform. There is a stage of a mature cataract. At this stage, the figure of a lens star, intense opacification in the region of the lens sutures are visible. Patients complain about the lack of objective vision. With an overripe cataract, the cortical substance is converted into a liquefied milky mass, which undergoes resorption, the volume of the lens decreases.

With a nuclear cataract, central vision is disturbed early, far vision suffers more. Temporary nearsightedness may occur. In side light, the lens in these cases has a light green tint.

Complications of cataracts are phacolytic glaucoma, phacogenous iridocyclitis. Phacolytic glaucoma develops in immature cataracts due to the absorption of a decaying substance during swelling of the lens, an increase in its volume and as a result of a violation of the outflow of intraocular fluid. When cataract masses fall into the anterior chamber of the eye and their resorption is delayed, iridocyclitis may occur, associated with the development of hypersensitivity to the lens protein.

Treatment. Conservative cataract therapy is used for initial lens opacification to prevent its progression. Medicines used to treat cataracts contain a means for correcting metabolic processes, normalizing electrolyte metabolism, redox processes and reducing lens edema (oftankatachrome, soncatalin, vitaiodurol, quinax).

Surgery (cataract removal) remains the main treatment for lens opacities. Indications for surgical treatment are determined individually. This depends on the state of visual functions, the nature and intensity of lens opacification. Removal can be internal or extracapsular. In intracapsular removal, the lens is removed within the capsule. During extracapsular removal, after opening the anterior capsule of the lens, the nucleus is squeezed out and the lens masses are sucked out. A method has been developed to remove cataracts through tunnel incisions, which are sutured.

54. Congenital cataract

By origin, cataracts are divided into: congenital (hereditary, intrauterine); consistent due to local processes (uveitis, congenital glaucoma, injuries, etc.) and due to general diseases (infectious and neuroendocrine diseases, radiation sickness, metabolic diseases, etc.); secondary (postoperative).

By localization, cataracts are: polar, nuclear, zonular, coronary, diffuse, membranous, polymorphic, anterior and posterior (cup-shaped, rosette).

According to the absence or presence of complications and concomitant changes, cataracts are divided into: simple (except for opacities, there are no other changes), with complications (nystagmus, amblyopia, strabismus), with concomitant changes (congenital malformations of the eye, microphthalmos, aniridia, coloboma of the vascular tract, retina, optic nerve, etc., acquired by pathology of posterior and anterior synechiae, subluxation and dislocation of the lens, vitreous hernia).

According to the degree of visual impairment: the first degree of cataract visual acuity is 0,3 and above), the second is 0,20,05, the third is below 0,05.

Anterior and posterior polar cataracts (cataractae polaris anterior etposterior) are diagnosed by their location at the poles of the lens. Opacities are clearly visible in transmitted light and biomicroscopy. Anterior polar cataracts can also be detected on examination with lateral illumination. A polar cataract has the form of a dense white disc with a diameter of no more than 2 mm, quite clearly delimited from the surrounding transparent areas of the lens. When the eyeball moves, the anterior polar cataract is viewed in transmitted light moving in the direction of eye movement, while the posterior polar cataract moves in the opposite direction. These types of cataracts usually do not affect visual acuity and are not subject to surgical treatment.

Zonular (layered) cataract (cataracta zonularis) is the most common congenital pathology of the lens. In transmitted light, a zonular cataract is a gray, lighter in the center disk 56 mm in diameter with radiar processes ("riders") against the background of a pink reflex of the fundus.

In the light of a slit lamp, clouding is visible in the form of a disk located in the central sections and surrounded by a transparent substance of the lens. Along the edge of the disk, which consists of separate opacification zones, additional opacities in the form of protrusions are visible. The degree of vision loss depends on the intensity of the clouding.

Unlike other types of congenital opacities, zonular cataract can progress in the first years of a child's life.

Diffuse (complete) cataracts (cataracta diffusa) are visible even with side lighting. The pupil area is diffusely gray, vision is sharply reduced.

One of the varieties of congenital cataracts is membranous cataract (cataracta membranacea), which has a gray (white). Such cataracts also significantly reduce visual acuity and, like diffuse ones, are subject to removal.

55. Diagnosis of cataracts in children

When examining a child, it is important to find out how the mother’s pregnancy proceeded, whether there were any harmful effects on her body (rubella, influenza, chicken pox, oxygen starvation of the fetus as a result of heart disease in the mother, lack of vitamin A in the pregnant woman’s diet, etc. ), at what weight and whether the child was born full-term, and whether he was kept in an oxygen tent after birth. Find out the presence in the anamnesis of general (tuberculosis, diabetes, infectarthritis, etc.) and local (uveitis, trauma, etc.) processes that can cause the occurrence of sequential cataracts.

In young children, when it is not possible to determine vision by classical methods, one should pay attention to how they orient themselves in the environment, whether they have shaped vision (whether they reach for a toy that is shown at various distances from the eye, whether they move freely) . Visual acuity in older children and adults should be determined according to the tables (up to two units) with both narrow and wide pupils, with and without correction, since this is important in clarifying the indications and choosing the method of surgical intervention. If the patient has light projection, it should be established whether it is correct. If the projection of light on the eye with a cataract is incorrect and it is impossible to examine the deeper parts of the eye (vitreous body, retina, optic nerve, choroid) using visual methods, echo-ophthalography is performed, which allows to detect changes in the vitreous body, retinal detachment, etc.

The study of the visual field in patients with cataracts can be carried out on the projection-registration perimeter with an object of the greatest brightness and magnitude, as well as on the desktop perimeter with a luminous object or a candle.

During an external examination, attention is paid to the position and excursion of the eyeballs (in case of strabismus, the magnitude of the Hirschberg deviation is determined), the presence of nystagmus and other complications, as well as concomitant congenital anomalies.

Next, under conditions of mydriasis (caused by 0,10,25% scopolamine, 1% homatropine, etc.), an examination is carried out with a side lamp, a combined method and in transmitted light. While examining the eyes, you can see clouding of the lens in the form of a gray disk (zonular cataract) or a gray dot (anterior polar cataract), etc. You should pay attention to which direction the clouding shifts when the eye moves. This allows us to judge their topography in the lens. When the lens is subluxated (dislocated), its edge is visible; also, with dislocation, changes in the depth of the anterior chamber, trembling of the iris (iridodonesis), congestive injection of the eye are noticeable, and increased ophthalmotonus can be detected by palpation. When examining the cornea, scars may be detected. Particular attention is paid to the depth and uniformity of the anterior chamber. A deep and sometimes uneven chamber occurs with aphakia, lens dislocations, and iridodonesis (trembling of the iris) is often observed when the eye moves.

56. Senile cataract and principles of cataract treatment

Senile cataracts are characterized by a slow progressive loss of vision. With initial cataracts (cataracta incipiens), visual acuity is usually high. With side illumination, no changes from the side of the lens can be detected. In transmitted light with a dilated pupil against the background of a pink reflex, one can see opacities on the periphery along the equator of the lens in the form of spokes or strokes or in the center if the cataract is nuclear.

If a patient has an immature (swelling) cataract (cataracta nondum matura s. intumescens), he complains of a significant decrease in vision. When illuminated from the side, a gray cloudy lens is visible in the pupil area. The lens may swell, causing the anterior chamber to become shallow. Due to the existing transparent areas in the lens, the shadow of the iris is visible on it in lateral lighting, as well as a reflex from the fundus in transmitted light. Swelling of the lens can cause increased intraocular pressure.

Patients with mature cataracts (cataracta matura) are practically blind. Visual acuity is equal to light perception or hand movement near the face; there is no shadow from the iris, there is no reflex from the fundus.

If the cataract is overripe (cataracta hypermatura), then cholesterol deposits are observed in it in the form of white plaques on the anterior capsule of the lens, the nucleus may descend downwards, as the cortical substance liquefies. White plaques and a drooping nucleus are visible on combined examination and under the slit lamp.

Congenital cataracts that hardly affect visual acuity (for example, polar cataract, suture cataract) cannot be treated. Zonular, diffuse, membranous, nuclear and other cataracts are removed when visual acuity decreases to 0,2, and also if vision does not increase with pupil dilation.

Senile cataracts are treated depending on the stage of the process and the state of the visual function. In the initial stage, the appointment of vitamin drops (cysteine, withiodurol, etc.) is shown, with a mature cataract, intracapsular extraction.

If visual acuity is very low, the patient is almost blind, and the cataract is not quite mature, intracapsular extraction is also performed. Treatment of consecutive cataracts is carried out depending on the etiology of the process and the degree of vision loss. For example, in diabetes, lens opacities may disappear under the influence of insulin therapy.

Before prescribing a patient for surgery, it is necessary to have the following additional data: the conclusion of the therapist to exclude somatic contraindications to surgical intervention, the results of chest x-ray, positive conclusions of the otolaryngologist and dentist, sowing from the conjunctiva, reaction to toxoplasmosis, Wasserman reaction, blood tests (general, coagulability and bleeding time), urinalysis.

On the eve of the operation, it is necessary to cut the eyelashes and shave the eyebrows. On the morning of the operation, a cleansing enema is done, the patient does not eat. Children are operated under anesthesia, adults under local anesthesia. The operating field is treated with alcohol, smeared with iodine, covered with sterile napkins.

Author: Shilnikov L.V.

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